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Effective Date: 
4/2014

Documents

 

Instructions

Updated: 4/2014

 

Purpose

Complete this form in order to:

  • apply for a Medicaid bed allocation waiver, or
  • assign an existing waiver to a different entity.

 

Procedure

Transmittal

Mail applications with required documents to:

Texas Health and Human Services Commission
Regulatory Services, Mail Code E-342
P.O. Box 149030
Austin, TX 78714-9030

or, for overnight delivery only, deliver applications with required documents to:

Texas Health and Human Services Commission
Regulatory Services, Mail Code E-342
701 West 51st St.
Austin, TX 78751

 

General Instructions

Pursuant to the Texas Administrative Code (TAC), Title 40, Part 1, Section 19.2322, the applicant must complete this application in accordance with these instructions. Full disclosure of the information requested in the application and instructions is mandatory.

Waiver applicants who submit false information will not be eligible for a waiver. Waivers issued based on false information provided by the applicant are void. Pursuant to 40 TAC §19.2322, the applicants for Medicaid bed allocation waivers and any controlling persons must demonstrate a history of providing quality care.

  • HHSC will determine that an applicant has demonstrated a history of quality of care if, within the preceding 24 months, an applicant and its controlling parties have not received any of the following sanctions:
    • termination of Medicaid and/or Medicare certification;
    • termination of Medicaid contract;
    • denial, suspension or revocation of a nursing facility license;
    • cumulative Medicaid and/or Medicare civil monetary penalties totaling more than $5,000 per facility;
    • civil penalties pursuant to §242.065 of the Texas Health and Safety Code; or
    • denial of payment for new admissions; and
    HHSC finds no clear pattern of substantial or repeated licensing and Medicaid sanctions, including administrative penalties and/or other sanctions.

For Assistance: If, after consulting these application instructions, you need further assistance with your application, call the Licensing and Credentialing section at 512-438-2630.

 

Detailed Instructions

Item 1. Community Information

County — Enter the name of the county for which you are requesting the waiver.

Precinct — Enter the number of the precinct for which you are requesting the waiver, if applicable.

City — If the waiver is being requested for a particular city, enter the name of the city.

ZIP Code — If the waiver is being requested for a designated ZIP Code, enter the ZIP Code.

Item 2. Type of Application

Mark one of the following (see Attachment A: Qualifying Requirements, for the definition of, and qualifications for, the different waiver types):

  • Community Needs Waiver Economically Disadvantaged Waiver Small House Waiver Rural County Waiver Alzheimer's Waiver High Occupancy Waiver Waiver Assignments

Item 3. Number of Medicaid Beds Requested

Title 19 Medicaid — Enter the total number of Medicaid beds requested for the waiver.

Item 4. Applicant Information

Name of Applicant (corporation, LLC, partnership, etc.) — Enter the legal name of the business or governmental entity applying for the waiver and/or Title 19 Medicaid certification, as chartered, filed, registered or otherwise legally declared.

Tax ID No. — Enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (Temporary taxpayer identification numbers are not acceptable.)

For an individual who has not been assigned a taxpayer identification number by the Internal Revenue Service, the Social Security number assigned by the Social Security Administration may be used as the taxpayer identification number. Individuals who do not wish to disclose their Social Security number must obtain a taxpayer identification number from the Internal Revenue Service prior to submission of the application.

Name of Applicant (if individual or sole proprietor) — Self-explanatory.

Social Security/Tax ID No. — Self-explanatory.

Applicant Mailing Address (Street or P. O. Box), City, State, ZIP Code — Enter the main office address of the applicant's business entity where all waiver or assignment correspondence will be mailed.

Applicant Email Address — Self-explanatory.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Business Entity Type — Check the applicable business entity type.

Item 5. Contact Information

Name of Contact Person — Enter the full name of the person who has authority to provide information pertaining to Item 4 on behalf of the applicant during the application process.

Contact Title — Self-explanatory.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Email Address — Self-explanatory.

Item 6. Qualifying Requirements

Refer to Attachment A for the qualifications of each waiver type and mark the yes or no box to indicate if the documentation submitted with the application contains evidence of compliance for that waiver type. If no, indicate which required items are either missing or deficient, and state why those items are missing or deficient.

Item 7. Disclosure

Disclose whether any controlling person of the applicant is also a controlling person of a licensed facility. (Note: The definition of "controlling person" is included below in the explanation for Item 8.) Mark the yes or no box. If yes, attach a list of those facilities.

Item 8. Applicant Ownership and Controlling Person Information

The applicant is required to fully disclose all levels of ownership interest in the applicant entity, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the applicant entity to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 8 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure. The total of all of the ownership interests in the applicant entity must equal 100 percent, unless one of the boxes is marked at the bottom of the page to indicate why 100 percent has not been disclosed.

A controlling person (controlling entity) is defined as a person who has the ability, acting alone or in concert with others, to directly or indirectly influence, direct or cause the direction of the management, expenditure of money, or policies of an institution or other person. Thus, a controlling person includes, for purposes of this waiver application and HHSC requirements, any and all shareholders, directors, members, managers and/or partners in the applicant entity.

Legal Name of Applicant (corporation, LLC, partnership, sole proprietorship, etc.) — Enter the legal name of the business or governmental entity applying for the Medicaid bed allocation, as chartered, filed, registered or otherwise legally declared.

Disclose each entity and individual with an ownership interest in the applicant according to the entity type and then disclose each entity and individual who is a controlling entity/person, as specified in Attachment B: Ownership and Controlling Person Information According to Business Entity Type.

Legal Name of Business Entity (if other than individual) — Enter the legal name of the business entity with an ownership interest or other role as a controlling entity in the applicant entity.

Business Entity Type — Enter the applicable type of business entity.

Taxpayer Identification No. — For a business entity, enter the nine-digit taxpayer identification number of the legal business entity assigned by the Internal Revenue Service. (Temporary taxpayer identification numbers are not acceptable.)

Last Name (if an individual), First Name, MI, Jr., Sr., etc. — Enter the full name of the individual with an ownership interest or other role as a controlling person in the applicant entity.

Date of Birth — For an individual, enter the person's date of birth.

Driver License No. (DLN) — For an individual, enter the person's driver license number.

DLN State of Issue — For an individual, enter the state where the person's driver license was issued.

Social Security No. — For an individual, record the person's Social Security number (United States) or Social Insurance Number (Canada). HHSC requests voluntary disclosure of the Social Security number in order to conduct the evaluation specified in 40 TAC §19.2322. If the individual chooses not to furnish his Social Security number, the application process may be delayed, and additional information may be requested to validate the individual's identity.

State/Country of Residence — If the individual being disclosed is a resident of the United States of America, enter the state of the individual's legal permanent residence. If the individual is not a U.S. resident, enter the country of residence.

% Ownership — Record the percentage of shares, membership shares, etc., owned by the individual/entity being disclosed in this block.

Physical Address — Street, City, State/Province, ZIP/Postal Code, Country — For an individual, enter the physical address of the person's home. For a business entity, enter the physical address of the business.

Mailing Address — Street or P.O. Box, City, State/Province, ZIP/Postal Code, Country — Enter the mailing address, if different from the physical address.

Title or Position Held (with the entity being disclosed on this page) — Enter the title or position this individual/entity holds with the applicant. (Examples: shareholder, president, secretary, treasurer, member, manager, general partner, limited partner, trustee, etc.)

Start Date of Association (with the entity being disclosed on this page) — Enter the date on which the individual/entity's association with the entity identified on this page began.

Follow-up Questions for All Business Entity Types — Check yes or no to the questions below.

Has 100 percent ownership interest been disclosed in this section? — Check yes or no. If yes, proceed to the next section. If no, answer the following questions:

Does each of the remaining individual shareholders own less than 5 percent? — Check yes or no. If yes, proceed to the next section. If no, disclose all ownership owning 5 percent or more.

Note: All partnerships must be disclosed fully.

Are the shares publicly traded? — Check yes or no. If yes, proceed to the next section. If no, disclose all ownership owning 5 percent or more.

Publicly traded is defined as shares of a company that are traded on the open market, such as a stock market.

Are all remaining ownership shares unassigned? — Check yes or no. If yes, proceed to the next section. If no, disclose all ownership owning 5 percent or more.

Are all remaining shares held in treasury of the company? — Check yes or no. If yes, indicate in a statement that the remaining shares are held in the company's treasury. Proceed to the next section. If no, disclose all ownership owning 5 percent or more.

Are all remaining ownership percentage investment funds? — Check yes or no. If yes, identify the investment fund. Next to the entity name add the following statement: "Investment Fund." Further disclosure is required for investment funds. Identify the investment fund and list the fund advisor or fund manager. Provide proof that the entity is functioning as an investment fund. If no, disclose all ownership owning 5 percent or more.

Investment fund is defined as an entity that invests the funds of silent investors. These investors do not have influence or control over the operation of the facility.

Item 8. Applicant Ownership and Controlling Person Information: Next Level, if Multiple Tiers of Ownership

Based on the first level of ownership information in Item 8, complete the next level(s) of ownership and controlling person information. Complete this section for each business entity previously disclosed in Item 8 and each successive entity.

The applicant is required to fully disclose all levels of ownership interest in the applicant entity, and is required to disclose all entities and all individuals at each level of ownership, from the ownership of the applicant entity to the ownership of each successive ownership entity.

If additional entries are required for disclosure of all owners and controlling entities/persons, copy this section of Item 8 to use as an attachment for multiple entries. Use a separate page for each business entity disclosed at any level of the ownership structure.

Item 9. Affidavit for Application

The applicant, or controlling person if the applicant is an entity, must attest that the information included in the application, all accompanying documents, and related compliance history is true and correct. The application must be notarized and must include the notary's seal or stamp.

Attachment A: Qualifying Requirements
Attachment B: Ownership and Controlling Person Information According to Business Entity Type