Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
accordance with and in addition to 42 CFR 455, Subpart B, and 42 CFR 1002,
Subpart A, as amended, the following disclosure requirements apply to all
providers of Medicaid services and shall be disclosed in accordance with this
(1) The name and address of each person
with an ownership or control interest in the disclosing entity or in any
subcontractor in which the disclosing entity has direct or indirect ownership
of five percent (5%) or more.
Whether any of the persons named, in compliance with subdivision (1), is
related to another as spouse, parent, child, or sibling.
The name of any other disclosing entity
in which a person with an ownership or control interest in the disclosing
entity also has an ownership or control interest. This requirement applies to
the extent that the disclosing entity can obtain this information by requesting
it in writing from the person. The disclosing entity must:
(A) keep copies of all these requests and the
responses to them;
(B) make them
available to the office upon request; and
(C) advise the office when there is no
response to a request.
(4) The name, address, and Social Security
number of any agent or managing employee.
(b) Any document or agreement, stipulating
ownership interests or rights, duties, and liabilities of the entity or its
members, required to be filed with the secretary of state, whether it be a
single filing or a periodic filing, shall also be filed with the office or its
fiscal agent. In the case of a partnership, the partnership agreement, if any,
and any amendments thereto, shall be filed with the office immediately upon
creation or alteration of the partnership.
A long term care facility provider shall
comply with notification requirements set forth in 405 IAC 1
for change of
The office may
suspend payment to an existing provider or reject a prospective provider's
application for participation if the provider fails to disclose ownership or
control information as required by this rule and