To apply for a change of ownership (CHOW) with the Nursing Home Licensure and Certification Section, the section needs the following original forms and copies:
Note: If it is your intent to assume the previous owner's Medicare provider agreement, complete the "successor provider of services" signature line of the Health Insurance Benefits Agreement (HIB Agreement - form CMS-1561 (PDF, 415 KB)). If you desire issuance of a new provider agreement (necessitates onsite survey to determine compliance), complete the "provider of services" signature line of the HIB Agreement.
A new owner may refuse to accept assignment of the previous owner's provider agreement. This means the provider agreement terminated effective with the CHOW date. The new owner should put the refusal in writing and forward to Survey Consultant II Becky Wertz (contact information below), 45 days prior to the CHOW date to allow for the orderly transfer of any beneficiaries of the provider.
In addition, providers may no longer express a preference for a particular medicare administrative contractor (MAC) or request a change of MAC. If the new owner, following a CHOW, accepts assignment of the existing provider agreement, it will continue with the same MAC as the previous owner. If the new owner does not accept assignment of the existing provider agreement, the Center for Medicare & Medicaid Services (CMS) will consider the new owner as a new enrollee for certification. It must complete the initial application process, have the state agency perform an initial certification survey, and receive certification approval from the CMS regional office. CMS issues the provider a new CMS Certification Number (CCN) and assigns the provider to the local designated MAC. New providers that belong to CMS-recognized chains have the option of being assigned to the local designed MAC or to the MAC that serves the chain home office.
Pursuant to G.S. 131E-102(b), the Division of Health Service Regulation charges an annual nonrefundable license fee to the applicant in the amount of $420.00 plus a nonrefundable per-bed fee of $17.50 per facility. The license fee must accompany the license application prior to the issuance of the nursing home license. Payment should be in the form of check, money order or certified check and must be payable to "The Division of Health Service Regulation." Payment should include the facility's license number. A separate check is required for each licensed entity. The legislation (SB 622, Session Law 2005-276) prohibits DHSR from issuing a license if the provider has not paid the fee.
If applicable, pursuant to G.S. 131E-104, for each requirement applicable to freestanding adult care homes or freestanding nursing homes, the combination nursing home may choose to operate the adult care portion of the home in compliance with either the requirement applicable to freestanding adult care homes or the higher standard applicable to freestanding nursing homes. Indicate the rule choice on the license application and it will remain in effect for the remainder of the licensed year. The facility may choose to use all adult care home (ACH) licensure rules, all nursing home (NH) licensure rules, or a combination of ACH and NH licensure rules to govern those beds. If using both ACH and NH rules for the ACH beds, a checklist will need to be completed indicating the rule choices for each specific requirement. No checklist is required if the combination of ACH and NH rules is not chosen.
Please complete, sign, date these forms, and return them and the license fee with a signed copy of the final lease agreement or bill of sale. The state agency is willing to issue a new license for the CHOW once the current licensee has vacated the premises and surrenders the license, in writing.
Send all the completed forms to:
Becky Wertz, Facility Survey Consultant II
DHHS - DHSR
2711 Mail Service Center
Raleigh, NC 27699-2711
919-855-4580
As part of the application for change of ownership process, applicants requesting enrollment in the Medicare program, must complete a Medicare Provider Enrollment Application, CMS-855A (PDF, 1.04 MB). This process is used to insure that providers/suppliers meet the requirement of Sections 1814(a)(1) and 1833 (e) of Title XVIII of the Social Security Act, which authorizes collection of information to determine Medicare program payments. This office no longer distributes this form. You can obtain this form from the website Medicare Enrollment Application - Institutional Providers, CMS-855A (PDF, 1.04 MB). You can direct any questions regarding the completion of this form to your MAC/C, depending on which contractor is responsible for processing bills or claims.
A facility may change the size of its distinct part twice per cost reporting year. A facility may not request a change in its bed size just because it undergoes a CHOW or because it has changed its cost reporting year. A facility may change the size of its skilling nursing facility (SNF) and/or its NF once on the first day of the beginning of its cost-reporting year and again on the first day of a single cost reporting quarter. This office must receive a written request at least 45 days in advance of the beginning of the next cost reporting year or the cost reporting quarter that falls within the same cost reporting year. The change becomes effective at the beginning of the cost-reporting year or the cost-reporting quarter, whichever applies. This request should identify the current facility configuration and the proposed configuration. Send all requests for certification bed changes to the attention of Ms. Edna Knight, at 919-855-4536.
In addition, a facility may change the designated bed location of the distinct part, as long as there is no change in the number of certified beds, provided a request for this change is received by this office, 30 days in advance of the change.
If you are acquiring the real property (i.e. bricks and mortar) of the facility, you are required to provide the Certificate of Need Section prior written notice of the acquisition. If the ownership of the real property is not changing, you are not required to notify the Certificate of Need Section. The CON Section phone number is 919-855-3873 if you have any questions.
If a facility currently has a NC NOVA license, and should the new owner wish to continue the NC NOVA designation, the new owner must communicate the desire in writing to The Carolinas Center for Medical Excellence within 30 days of the effective date of the change of ownership and proceed with an expedited review in accordance with procedures detailed by the NC NOVA Partner Team and included in the NC NOVA Provider Information Manual.
Questions? Call 919-855-4580, or e-mail Becky.Wertz@dhhs.nc.gov.