Medicare Certification Requirement

(A) Nursing facilities must be certified for participation in the Medicare program pursuant to Title XVIII of the Social Security Act, as amended from time to time, and regulations promulgated thereunder. (B) If a facility or institution has only one unit licensed to provide skilled nursing care, then that unit must be Medicare certified. A facility with more than one unit licensed to provide skilled nursing care may have one non-Medicare-certified unit. (C) A facility that is newly enrolling in MassHealth after a change in ownership, has met the conditions in 130 CMR 456.404(A) or 130 CMR 456.405(A) as applicable, and has accepted assignment of the seller’s Medicare provider number, may enter into a provider agreement with MassHealth for conditional enrollment pending the facility’s Medicare certification for a time period not to exceed nine months from the approval date of the conditional enrollment. At the time that MassHealth receives sufficient documentation from the facility demonstrating that the facility has received Medicare certification, the conditional enrollment will be converted into full enrollment status. If, at the conclusion of the nine-month conditional enrollment, the facility has not yet received Medicare certification, payments to the facility will be suspended until such time as MassHealth receives sufficient documentation from the facility demonstrating that the facility has received Medicare certification. (D) Penalties. (1) For a facility that was a MassHealth provider as of October 1, 1990, failure to comply with 130 CMR 456.406(A) or (B) may result in an imposition of an administrative fine by the MassHealth agency or may result in the facility’s suspension from participation in MassHealth. (2) For any facility applying to be a MassHealth provider after October 1, 1990, including facilities built after October 1, 1990, and facilities participating in MassHealth on October 1, 1990, that subsequently changed owners, failure to comply with 130 CMR 456.406 will preclude that facility from participating in MassHealth.