The MLTC 62 Nebraska form is a critical document required by the Nebraska Department of Health and Human Services, in compliance with the Centers for Medicare and Medicaid Services. It mandates the disclosure of ownership, controlling interests, and any convictions of individuals involved with Medicaid providers at various points, such as enrollment, survey, or upon request. This form plays a vital role in maintaining transparency and accountability within healthcare services.
The MLTC 62 Nebraska form serves a crucial role in establishing transparency and accountability for entities engaging with the Nebraska Department of Health and Human Services. This document, necessitated by the Centers for Medicare and Medicaid Services alongside the Department of Health and Human Services, is instrumental in the disclosure of ownership, controlling interests, and any past convictions relevant to Medicare, Medicaid, Waivers, CHIP, or Title XX services programs. Entities are required to complete this form upon enrollment or contracting with the Department, during surveys, or in response to specific requests from the Department within a set timeframe. The form entails detailed sections that capture the entity’s basic identifying information, a listing of individuals with significant ownership or controlling interests, and details of managing employees among other critical disclosures. This comprehensive approach ensures that any potential conflicts of interest or legal impediments are identified and managed appropriately, safeguarding the integrity of healthcare services and compliance with regulatory requirements. With its emphasis on accuracy and legal compliance, the completion and submission of the MLTC 62 form underscore the commitment of healthcare providers to transparency and adherence to stringent governance standards.
Department of Health & Human Services
N E B R A S K A
Nebraska Department of Health and Human Services
NEBRASKA OWNERSHIP/CONTROLLING INTEREST AND CONVICTION DISCLOSURE
Completion of this form is required as mandated by the Centers for Medicare and Medicaid Services, Department of Health and Human Services and applicable regulations as found at 42 CFR 455.100 through 42. CFR 455.106. Disclosure must be made at the time of enrollment or contracting with the Department, at the time of survey, or within 35 days of a written request from the Department. It is the provider’s responsibility to ensure all information is accurate and to report any changes as required by law by completing a new Ownership and Disclosure form.
IDENTIFYING INFORMATION
Name of Entity: (Legal name as it appears on tax identiication form)
Provider Number (If currently enrolled in NE Medicaid):
Doing Business As:
NPI Number
Street Address:
City:
State:
Zip Code:
Telephone Number:
Fax Number:
E-mail Address:
IF GOVERNMENT ENTITY OR NON-PROFIT ORGANIZATION, PLEASE CHECK THIS BOX AND GO DIRECTLY TO FIELDS C, D AND E.
A. List the name, address, Federal Employer Identiication Number (FEIN) or Social Security Number (SSN) and Date of Birth (DOB) 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 5% or more. If more space is needed attach a separate list including the required information.
Name
SSN/FTIN
Address
DOB
%Interest
B. Are any of the above mentioned persons related to one another as a spouse, parent, child, or sibling? If more space is needed
attach a separate list including the required information.
Yes No If yes, please name and show relationship.
SSN
Relationship
MLTC-62 REV 3/11 (94062)
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C. List any person who holds a position of managing employee within the disclosing entity.
If more space is needed attach a separate sheet with the required information.
SSN Name
Position Title
D. Does any person, business, organization or corporations with an ownership or control interest (identiied in A or B) have an ownership or controlling interest of 5% or more in any other Nebraska Medicaid Provider? If more space is needed attach a
separate sheet with the required information.
Yes
No If yes, please name and show information.
Other Provider Name
E. List any person (identiied in A, B, or C) who has an ownership or control interest in the disclosing entity (provider), or is an agent or employee of the disclosing entity (provider) who has ever been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, Waivers, CHIP or the Title XX services since the inception of these programs.
Conviction Details
PROVIDER STATEMENT. I certify that information provided on this form is true, accurate and complete. I will notify Nebraska Department of Health and Human Services of any additions/changes to the information
Sign Here ____________________________________________________________________________________________________
Signature of Provider/Authorized Representative/Agent and Title (Stamped Signature NOT Accepted)
_____________________________________________________________________________________________________________
Print Name
Date
Phone Number
MLTC-62
PAGE 2/3
42 C.F.R. Sec. 455.101 Deinitions.
Agent means any person who has been delegated the authority to obligate or act on behalf of a provider.
Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a iscal agent.
Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or
XXof the Act. This includes:
(a)Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII);
(b)Any Medicare intermediary or carrier; and
(c)Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under title V or title XX of the Act.
Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.
Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).
Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.
Ownership interest means the possession of equity in the capital, the stock, or the proits of the disclosing entity.
Person with an ownership or control interest means a person or corporation that—
(a)Has an ownership interest totaling 5 percent or more in a disclosing entity;
(b)Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;
(c)Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;
(d)Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;
(e)Is an oficer or director of a disclosing entity that is organized as a corporation; or
(f)Is a partner in a disclosing entity that is organized as a partnership.
Signiicant business transaction means any business transaction or series of transactions that, during any one iscal year, exceed the lesser of $25,000 and 5 percent of a provider’s total operating expenses.
Subcontractor means—
(a)An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or
(b)An individual, agency, or organization with which a iscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.
Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical irm).
Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider.
42 CFR § 455.102 Determination of ownership or control percentages.
(a)Indirect ownership interest. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock of the disclosing entity, A’s interest equates to an 8 percent indirect ownership interest in the disclosing entity and must be reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the disclosing entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported.
(b)Person with an ownership or control interest. In order to determine percentage of ownership, mortgage, deed of trust, note, or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the disclosing entity’s assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60 percent of the provider’s assets, A’s interest in the provider’s assets equates to 6 percent and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider’s assets, B’s interest in the provider’s assets equates to 4 percent and need not be reported.
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Once the MLTC-62 Nebraska form is completed and submitted, it provides essential information to the Nebraska Department of Health and Human Services. This form ensures compliance with the Centers for Medicare and Medicaid Services' requirements. It is used to disclose ownership, control interests, and any criminal convictions related to Medicare, Medicaid, or other federally funded programs. Updated information must be promptly communicated to remain in compliance with applicable laws. Now, let’s go through the steps to complete the form correctly.
After the MLTC-62 form is filled out, it’s vital to review it for accuracy before submission. Accurate and timely submission of this form ensures compliance and helps maintain operational transparency with the Nebraska Department of Health and Human Services.
The MLTC-62 Nebraska form is designed to fulfill the requirements set by the Centers for Medicare and Medicaid Services (CMS), under the Department of Health and Human Services, concerning the disclosure of ownership/control interest and convictions. This form aids in ensuring transparency and compliance with applicable regulations, which are outlined in 42 CFR 455.100 through 42 CFR 455.106. Entities seeking to enroll or contract with the Nebraska Department of Health and Human Services must disclose any ownership interests, control interests, or convictions of their managing employees, owners, or agents. This process helps maintain the integrity and trustworthiness of healthcare providers within Nebraska's Medicaid program.
Submission of the MLTC-62 form is mandated:
It's the provider's responsibility to ensure that all submitted information is up-to-date, accurate, and complete. Moreover, any changes to the disclosed information must be reported promptly by completing a new Ownership and Disclosure form.
The MLTC-62 form requires several pieces of crucial information to be filled out, including but not limited to:
Yes, if the entity completing the MLTC-62 form is a government entity or a non-profit organization, they are instructed to check a specific box near the beginning of the form. After marking this box, they are directed to skip directly to fields C, D, and E, bypassing certain sections that may not be applicable to their type of organization. This adaptation in the process acknowledges the distinct nature of governmental and non-profit entities compared to for-profit, private sector providers, streamlining their reporting requirements while ensuring relevant disclosures are made.
Filling out the MLTC-62 Nebraska form requires careful attention to detail and an understanding of the requested information. Common mistakes often emerge from a lack of thorough reading or misunderstanding the instructions. These errors can delay processing, impact compliance, and affect your organization's standing with the Department of Health and Human Services.
Firstly, incomplete personal information for individuals with ownership or controlling interests is a frequent oversight. Details such as correct Social Security Numbers (SSNs) or Federal Employer Identification Numbers (FEINs), and accurate dates of birth are crucial for ensuring timely processing. Leaving these fields blank or entering incorrect data can result in unnecessary complications.
Another common error involves the ownership interest percentage. Some individuals mistakenly report their ownership levels inaccurately. It's vital to calculate and report these percentages properly, as they directly influence the determination of control and the necessity for disclosure on the form.
Each of these errors can lead to delays in processing and may have legal implications for the disclosing entity. To avoid such mistakes, it's recommended to review all entered information for accuracy and completeness before submission. Additionally, consulting with a professional familiar with the form's requirements can ensure that all necessary disclosures are made correctly.
By avoiding these common pitfalls, entities can streamline their submission process, maintain compliance with regulatory requirements, and uphold their responsibility to the Nebraska Department of Health and Human Services.
When working with the MLTC-62 Nebraska form, which is essential for disclosing ownership, control interest, and criminal convictions related to Medicare, Medicaid, and other services, several other forms and documents often accompany it in the submission process. Understanding these supplementary documents can help ensure a comprehensive and compliant submission to the Nebraska Department of Health and Human Services. Below is a brief overview of five such documents:
Together with the MLTC-62 form, these documents form a robust packet of information that supports a provider's initial enrollment and ongoing compliance with Nebraska Medicaid and CMS regulations. It's crucial for providers to accurately complete and regularly update this information as required to maintain their good standing in the Medicaid program.
The MLTC-62 Nebraska form is similar to other regulatory disclosure forms used by health and human services departments across the United States, each designed to ensure transparency and compliance among providers who participate in Medicaid, Medicare, and other federally-funded health programs. These forms collectively aim to prevent fraud and abuse by requiring detailed disclosures about ownership, control interests, and any criminal convictions related to the involvement in federal health care programs. The forms share a common goal of safeguarding public funds and ensuring that providers meet strict ethical and legal standards.
Form CMS-855A is a Medicare enrollment application for institutional providers that closely resembles the MLTC-62 Nebraska form in several aspects. Like the MLTC-62, the CMS-855A requires information on ownership and control interests, as well as disclosures about managing employees and any individuals or entities with a 5% or greater interest in the provider. Both forms also require disclosures of criminal convictions related to participation in federal health programs, emphasizing the government's efforts to vet providers thoroughly to protect the integrity of its health programs.
The Ownership Disclosure Form used by many states for Medicaid provider enrollment is another document with notable similarities to the MLTC-62 form. Though specific requirements may vary slightly from state to state, these forms generally seek detailed information about the individuals and entities with ownership or control interests in Medicaid-participating providers. Like the MLTC-62, state-specific ownership disclosure forms often include questions about familial relationships among those with significant ownership interests, ensuring transparency and allowing for comprehensive background checks to mitigate conflicts of interest and other potential integrity issues.
When filling out the MLTC 62 Nebraska form, which is essential for reporting ownership, controlling interest, and conviction history for those associated with Medicaid services, it's critical to adhere to certain dos and don'ts for a smooth and efficient process.
Do:
Don't:
Understanding the complexities of legal forms, especially those required by governmental entities, can easily give rise to misconceptions. The MLTC-62 Nebraska form, mandated for disclosure of ownership, controlling interest, and convictions for Medicaid service providers, is no exception. Below are nine common misconceptions about this form and their clarifications to deepen understanding and compliance.
Clarifying these misconceptions encourages accurate and complete disclosures, aiding compliance with the Centers for Medicare and Medicaid Services and the Nebraska Department of Health and Human Services. It’s essential for entities required to file an MLTC-62 to review the form meticulously and ensure all information is current and accurately reflects their operation and ownership structure.
When dealing with the MLTC-62 Nebraska form, several key takeaways are essential for ensuring compliance with the Department of Health & Human Services and the Centers for Medicare and Medicaid Services requirements:
Moreover, if the provider is a government entity or non-profit organization, certain sections of the form are bypassed, streamlining the process for these entities. However, due diligence in completing and updating the MLTC-62 form is crucial for all providers to maintain compliance with regulatory requirements.
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