Disclosure of Ownership, Control Interest Statement, Licensure, Certifications, Governmental Programs, Investigations, Liability, Legal and Criminal Information

TO: All Providers

RE: Disclosure of Ownership, Control Interest Statement, Licensure, Certifications, Governmental Programs, Investigations, Liability, Legal and Criminal Information

To facilitate this transition, Medicaid will enforce the new Disclosure Form on October 1, 2024, and after.

This ALERT is a reminder for providers regarding information about mandatory disclosures according to the Code of Federal Regulations Title 42, Part 455, Sections 100-107.

Who must provide disclosures.

Any group or facility enrolling with the Medicaid program must complete the Disclosure of Ownership, Control Interest Statement, Licensure, Certifications, Governmental Programs, Investigations, Liability, Legal and Criminal Information.

What disclosures must be provided.

Medicaid must require that disclosing entities, fiscal agents, and managed care entities provide disclosures. Below are some examples of disclosures:

1. The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing entity, fiscal agent, or managed care entity. The address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address.

2. Date of birth and Social Security Number (in the case of an individual).

3. Other tax identification number (in the case of a corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) or in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a five percent or more interest.

4. Whether the person (individual or corporation) with an ownership or related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a five percent or more interest is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling.

5. The name of any other disclosing entity (or fiscal agent or managed care entity) in which an owner of the disclosing entity (or fiscal agent or managed care entity) has an ownership or control interest.

6. The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity (or fiscal agent or managed care entity).

When the disclosures must be provided.

1. Disclosure from any group or facility or disclosing entity is due at any of the following times:

a. Upon the group or facility or disclosing entity submitting the provider application.

b. Upon the group or facility or disclosing entity executing the provider agreement.

c. Upon request of the Medicaid agency during the re-validation of enrollment process at least every five years.

d. Within 35 days after any change in ownership of the disclosing entity.

2. Disclosures from managed care entities (MCOs, PIHPs, PAHPs, and HIOs), except PCCMs are due at any of the following times:

a. Upon the managed care entity submitting the proposal in accordance with the State's procurement process.

b. Upon the managed care entity executing the contract with the State.

c. Upon renewal or extension of the contract.

d. Within 35 days after any change in ownership of the managed care entity.

Where can the form be obtained.

To complete the form, please visit www.medicaid.alabama.gov, select the 'Providers' tab across the top of the page, then click on 'Provider Enrollment' link, 'Forms for Provider Enrollment and Revalidation' link, 'Disclosure Form' link.

To whom must the disclosures be provided.

Consequences for failure to provide required disclosures.

Failure to provide the required disclosures may result in the denial or enrollment, termination of enrollment, and/or the recoupment of payments.