Procedures and Requirements for Registration of a Supplemental Health Care Services Agency

PURPOSE: This rule specifies the minimum requirements for registration and renewal of a supplemental health care services agency in Missouri. (1) No person shall establish, conduct, or maintain a supplemental health care services agency in this state without a valid registration issued by the department. (2) Each supplemental health care services agency providing, procuring, or engaging health care personnel or independent contractors for temporary employment in Missouri health care facilities must submit a registration application and fee. The Application for Registration to Operate a Supplemental Health Care Service Agency (“Application”), included herein, shall be completed and submitted to the department via mail or electronically online with the fee required by 19 CSR 30-105.020. Information provided in the application shall be attested by signature to be true and correct to the best of the applicant’s knowledge and belief. (3) Each separate business location from which the agency operates in Missouri shall have a separate application. (4) The application shall include— (A) Agency information, including— 1. The agency’s legal or registered fictitious name, addresses, telephone number, fax number, email address, and responsible contact person; 2. Indication of whether the application is the result of a new registered agency or renewal of an existing agency’s registration; and 3. The agency’s days and hours of operation; (B) Owner information, including— 1. Owner name(s), federal employer identification number(s) or social security number(s), state tax identification number, mailing address, and contact information. The owner shall be registered to do business with Missouri Secretary of State; 2. Type of owner’s legal entity; 3. All controlling persons in the ownership of the agency, including each individual or entity name, title or position, personal or primary address, telephone number, federal employer identification number or Social Security number, and percentage of ownership; 4. If the owner is a legal entity, include copies of the articles and current bylaws, together with the names and addresses of officers, managers, members, or directors; (C) Operator information, including— 1. Operator name, mailing address, and contact information. The operator shall be registered to do business with Missouri Secretary of State; 2. Type of operator’s legal entity; 3. All controlling persons in the operation of the agency, including each individual or entity name, title or position, personal or primary address, telephone number, federal employer identification number or Social Security number, and percentage of ownership; 4. List any other supplemental health care services agencies in which the operator owns or operates and provide the agency’s name, address, type of registration, and registration number; (D) Financial information, including— 1. Proof of financial responsibility through one (1) of the following methods documenting at least four weeks of back wages per employee: A. Establishing and maintaining an escrow account consisting of cash or assets eligible for deposit; or B. Obtaining and maintaining an unexpired irrevocable letter of credit established. Such letters of credit shall be nontransferable and nonassignable and shall be issued by any bank or savings association organized and existing under the laws of this state or the United States; 2. Name and address of the bank, savings bank, or savings association in which the agency will deposit the agency’s employee’s income tax withholdings. If the agency is not responsible for employee income tax withholding, the agency shall provide the name and address of each personnel for whom income taxes will not be withheld; and 3. Additional proof of stable or satisfactory financial condition, as specifically requested by the department. This additional documentation shall be submitted within ten (10) business days of receipt of the written request; (E) Other information, including— 1. Proof that the agency or health care personnel, including independent contractors, has medical malpractice insurance (professional liability insurance is acceptable), as required by section 198.644.1(4), RSMo; 2. Proof of current worker’s compensation coverage as required by Missouri law and Chapter 287, RSMo or, if the personnel are independent contractors, proof of occupational accident insurance; and (F) Affidavit, including the following attestations— 1. That the individual or operating entity has adequate financial resources to properly operate the agency referred to in the application; 2. That the agency is familiar with the requirements of a supplemental health care services agency as set out in Chapter 198, RSMo, and the regulations of the Department of Health and Senior Services promulgated thereunder; 3. That the agency does not restrict in any manner the employment opportunities of health care personnel and independent contractors; 4. That the agency refrains in any contract with any health care personnel, including independent contractors, or health care facility from requiring the payment of liquidated damages, employment fees, or other compensation should the health care personnel be hired as a permanent employee of a health care facility; 5. That all health care personnel, including independent contractors, meet all licensing or certification requirements and all training and continuing education standards for the position in which the personnel would be working; and 6. That each health care personnel and independent contractor complies with requirements related to background checks in sections 192.2490 and 192.2495, RSMo. (5) An agency’s registration is valid for one (1) year and shall expire on the annual anniversary of the date the registration was originally issued. If renewed, an agency’s registration is valid for one (1) year and shall expire on the annual anniversary of the date the registration was last renewed. (6) An agency’s renewal application must be received at least sixty (60) days prior to the expiration of the current registration. (7) An agency’s registration is valid only for the entity and/ or person identified on the registration issued at the address shown thereon and is not subject to sale, assignment, or other transfer. (8) An agency must send a copy of its current registration to any member of the general public upon request. SENIOR SERVICES MO 580-3424 (08/23) Page 1 of 5 MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES DIVISION OF REGULATION AND LICENSURE SUPPLEMENTAL HEALTH CARE SERVICES AGENCY APPLICATION FOR REGISTRATION TO OPERATE A SUPPLEMENTAL HEALTH CARE SERVICES AGENCY (One application per registered agency location) Applications must be received at least 60 days prior to the expiration of the current registration. Applications will not be considered for review until payment has been received. Agency Information 1. AGENCY INFORMATION – The name of the Agency must be indicated exactly as you want it to appear on the registration. Include the mailing address of the Agency, if different from the street address. Name of Agency/Doing business as (D.B.A) Agency Physical Address City County State Zip Agency Telephone Number Fax Number Mailing Address or Same as above City County State Zip Agency E-mail Address Agency Website (optional) Responsible Person Responsible Person Email and Phone Number (if different from Agency) Indicate if this application is a result of a new registered agency or renewal: New Agency ($830 fee) Renewal ($700 fee) Each application for registration must be accompanied by a registration fee outlined above. Attach a cashier’s check, personal or certified check, company check, or money order payable to the Department of Health and Senior Services. If fee is submitted online, attach fee receipt. This fee is nonrefundable and not proratable. Check box if submitting payment online Check box if mailing payment; add check number here: List the days and hours of regular operation. (NOTE: Inspections by the department will occur during the business hours submitted.) Section not applicable to agencies that operate 24 hours a day and 7 days a week. Check box if agency operates 24 hours a day and 7 days a week DAY OF THE WEEK OPENING TIME (indicate A.M. or P.M.) CLOSING TIME (indicate A.M. or P.M.) Sunday Monday Tuesday Wednesday Thursday Friday Saturday DO NOT WRITE IN THIS SPACE AGENCY REGISTRATION NUMBER RENEWAL NEW AGENCY EXPIRATION DATE DATE FEE REC’D CHECK NO/ JET PAY NO AMOUNT $ MO 580-3424 (08/23) Page 2 of 5 2. OWNER INFORMATION – Please complete the following for each of the agency’s owner(s). Attach multiple copies of this page if necessary. Owner Name(s) The name of the owner must be the exact legal name. If the owner is any entity other than a sole proprietor, the owner name must match the Missouri Secretary of State filing. The owner name should not be the name of any individual stockholder, partner, or member. Federal Employer Identification Number (EIN) State Tax ID # Mailing Address or Same as Agency Mailing Address City State Zip Contact Name Contact Telephone Number Contact E-mail Address Description of Owner (check one): Corporation Limited Liability Company Limited Partnership Individual Sole Proprietor Other-explain A. Individual and/or Entity Ownership of Owner as listed in section 2 above – Provide the information for each controlling person. Attach additional sheets if necessary. FULL NAME of INDIVIDUAL or ENTITY TITLE OR POSITION PERSONAL/PRIMARY ADDRESS TELEPHONE NUMBER EIN (or SSN if sole proprietor) % OWNERSHIP B. Board Members and Officers of Owner – If the owner is a legal entity, provide the information for each individual or entity that serves as an officer or is on the board of directors of the owner, if applicable. Do not include voluntary board members. PERSONAL/PRIMARY ADDRESS TELEPHONE NUMBER Board Member/Officer Board Member/Officer Board Member/Officer Board Member/Officer Board Member/Officer Board Member/Officer C. Articles – If the owner is a legal entity, attach copies of the owner’s articles and current bylaws to this application. Attached 3. OPERATOR INFORMATION – Please complete the following for the entity(s) operating the agency. SENIOR SERVICES MO 580-3424 (08/23) Page 3 of 5 Check mark this box if the operating entity(s) is the same as the owner. If checked, skip ahead to #1 below. Operator Name(s) The name of the operator must be the exact legal name. If the operator is any entity other than a sole proprietor, the operator name must match the Missouri Secretary of State filing. The operator name should not be the name of any individual stockholder, partner, or member. Mailing Address or Same as above City State Zip Contact Name Contact Telephone Number Contact E-mail Address Description of Operator (check one): Corporation Limited Liability Company Limited Partnership Individual Sole Proprietor Other-explain A. Individual and/or Entity Ownership of Operator as listed in section 3 above – Provide the information for each controlling person. Attach additional sheets if necessary. FULL NAME of INDIVIDUAL or ENTITY TITLE OR POSITION PERSONAL/PRIMARY ADDRESS TELEPHONE NUMBER EIN (or SSN if sole proprietor) % OWNERSHIP B. Board Members and Officers of Operator – Provide the information for each individual or entity (corporation, partnership, association) that serves as an officer or is on the board of directors. PERSONAL/PRIMARY ADDRESS TELEPHONE NUMBER Board Member/Officer Board Member/Officer Board Member/Officer Board Member/Officer Board Member/Officer Board Member/Officer 1. Does the operator currently operate or own any other Supplemental Health Care Services Agencies? Yes No If the operator currently operates or owns any other supplemental health care services agencies, then list below or attach a list of such agency or agencies, including their names, address(es), type of registrations and registration number. Attached Previously submitted; no amendment or change MO 580-3424 (08/23) Page 4 of 5 Each registrant must submit financial information demonstrating that the operator has the financial capacity to operate an agency. Other Information 1. Provide proof that the agency or that the health care personnel has medical malpractice insurance (professional liability insurance is acceptable); Attached 2. Provide proof of current worker’s compensation coverage as required by Missouri Statutes, Chapter 287 RSMo, or if any personnel are independent contractors, provide proof of occupational accident insurance. Attached Acceptable forms of worker’s compensation coverage include: a certificate of insurance supplied by an authorized Worker’s Compensation insurance carrier pursuant to Chapter 287, RSMo. The certificate shall include the name of the registrant, the name of the corporation legally responsible for the registrant, or the name the registrant is doing business as. The certificate must be effective prior to the issuance of an initial registration or have an effective date on or after the effective date of a renewal registration. OR provide approval from the MO Department of Labor to be self-insured. You cannot be issued a registration and may not operate as a supplemental health care services agency unless acceptable evidence of compliance with workers’ compensation coverage provisions is provided. Each agency must provide proof of financial responsibility through one of the following methods documenting at least four weeks of back wages per employee: Enter number of all temporary health care personnel or independent contractor employees: • Establishing and maintaining an escrow account consisting of cash or assets eligible for deposit; • Obtaining and maintaining an unexpired irrevocable letter of credit established. Such letters of credit shall be nontransferable and nonassignable and shall be issued by any bank or savings association organized and existing under the laws of this state or the United States. AND Provide the name and address of the bank, savings bank, or savings association in which the agency will deposit the agency’s employee’s income tax withholdings. If the agency is not responsible for employee income tax withholding, the agency shall provide the name and address of each personnel for whom income taxes will not be withheld. Attached Previously submitted; no amendment or change Financial Information SENIOR SERVICES MO 580-3424 (08/23) Page 5 of 5 I attest that I as an individual, or that the operating entity for which I sign, have/has adequate financial resources to properly operate the Agency referred to in this application. I further attest I am familiar with the requirements of a supplemental health care services agency as set out in Chapter 198 of the Missouri Revised Statutes and the regulations of the Department of Health and Senior Services promulgated thereunder. I further attest to refrain in any contract with any health care personnel or health care facility from requiring the payment of liquidated damages, employment fees, or other compensation should the health care personnel be hired as a permanent employee of a health care facility; I further attest that the agency does not restrict in any manner the employment opportunities of its health care personnel; I further attest that each health care personnel meets all licensing or certification requirements and all training and continuing education standards for the position in which the personnel would be working; I further attest that each health care personnel complies with requirements related to background checks in sections 192.2490 and 192.2495. I further attest that all documents and information required by the Department of Health and Senior Services to be provided pursuant to this application are true and correct to the best of my knowledge and belief, that the statements contained in this application and any attached information are true and correct to the best of my knowledge and belief, and that all required documents are either included with the application or are currently on file with the Department of Health and Senior Services. I understand that if it is determined by the Department of Health and Senior Services that the statements contained herein are not true and correct, the application may be denied and any registration issued based on the application may be revoked. I further attest that I have the express authority to sign this application on behalf of the owner and operator. My signature attests to the truth and accuracy of the foregoing attestations. Authorized Signature of Agency Telephone Number Printed or Typed Name and title of Signatory Telephone Number Affidavit AUTHORITY: section 198.648, RSMo Supp. 2022.* Original rule filed Feb. 8, 2023, effective Sept. 30, 2023. *Original authority: 198.648, RSMo 2022.