CMS Updates SNF Attachment Guidance Ahead of May 1 Enrollment Deadline

REGULATORY BACKGROUND

On November 17, 2023, the Centers for Medicare & Medicaid Services (CMS) published the final rule, Medicare and Medicaid Programs; Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities and Nursing Facilities; Medicare Providers’ and Suppliers’ Disclosure of Private Equity Companies and Real Estate Investment Trusts (See 88 FR 80141) (the Final Rule). The Final Rule implements portions of the Affordable Care Act that require SNFs to disclose ownership, managerial, control, and other information as part of their Medicare enrollment, including information on ADPs.

To implement the Final Rule, CMS issued an updated CMS-855A SNF Attachment on October 1, 2024. In November 2024, CMS issued a subregulatory guidance document that further clarifies the new disclosure requirements. This document has been updated over time, as recently as April 9, 2025. The updated CMS-855A SNF Attachment must be completed by all SNFs by May 1, 2025.

WHAT IS AN ADP?

CMS defines an ADP as any person or entity who:

• Exercises operational, financial, or managerial control over the SNF or a part thereof, or provides policies or procedures for any of the SNF’s operations or provides financial or cash management services to the SNF
• Leases or subleases real property to the SNF or owns a whole or part interest equal to or exceeding 5% of the total value of such real property
• Provides management or administrative services, management or clinical consulting services, or accounting or financial services to the facility.

This definition is intentionally broad and encompasses a wide variety of service providers. Further, an entity or person is considered an ADP based on the services they provide, rather than their title or professional status. CMS has provided a non-exhaustive list of examples, detailed below.

Financial Control and Cash Management Services

• Accounting: Includes any accounting services, including tax preparation and preparation of cost reports.
• Financial Control: Includes monitoring or managing the SNF’s finances, holding authority to approve the expenditure of SNF funds, an owning organization of the SNF that funds part of the SNF’s operations, and banks that have given the SNF a line of credit.
• Financial Services: Includes investment banking, investment management, asset management, financial advice, accounting, financial audits, and other services for the SNF.
• Cash Management Services: Includes advising on cash flow and other financial matters and handling the SNF’s financial transactions, such as automated clearing house payments and mobile banking.

Clinical and Compliance Services

• Clinical Consulting: Assessing or advising on how to improve or modify any aspect of the SNF’s provision of healthcare.
• Policies and Procedures: Developing or furnishing guidelines regarding the execution of any aspect of the SNF’s operations (e.g., a consultant hired to prepare emergency/evacuation plans, patient treatment procedures, and patient transfer procedures).
  • CMS clarified that this does not include the mere use of templates. Thus, an SNF that merely purchases template policies from a company would not need to disclose the company as an ADP unless the company is also offering advising, implementation, customization, or any other aspect of the policy development and execution.

Operational and Management Services

• Administrative Services: Includes compliance/oversight; nurse staffing companies; human resources; public relations, outreach, and advertising; and technical assistance to the SNF’s main information system.
• Operational Control and Management Services: Overseeing or having responsibility for any aspect of the SNF’s daily activities or transactions, such as (1) medical records, (2) patient activities, (3) dietary/food operations, (4) maintenance, (5) marketing, (6) social services, and (7) therapy, whether provided under contract or other arrangement with the SNF.
• Managerial Control: Supervisors and non-supervisors who oversee and are responsible for any aspect of the SNF’s operations, including management and oversight of matters such as maintenance. This does not mean every SNF employee who is responsible for any action in the SNF’s organization (e.g., nurses and administrative assistants) need to be reported. There must be some degree of broader oversight and decision-making authority involved.

Real Estate

• Landlords: Leasing or subleasing real property to the SNF.
• Ownership: Owning a whole or part interest equal to or exceeding 5% of the total value of the SNF’s real property.

In its guidance, CMS provided a limited list of individuals and entities that are not considered ADPs:

• Pharmacies, laboratories, and x-ray suppliers.
• Dietary, custodial, housekeeping, laundry, and building security providers.
• Government entities, such as state survey agencies, or accrediting organizations.
• Electronic health record vendors and payroll vendors.
• Lawyers furnishing legal services so long as their services are within the scope of their lawyer-client relationship and their scope of practice. A lawyer who otherwise exercises managerial control or provides nonlegal services that fall into a category above must be disclosed.

CMS has instructed SNFs to err on the side of disclosure:

If the SNF is uncertain as to whether a certain party must be reported, it should disclose said party. As we stated in the November 17, 2023, final rule: “In general, this rule should be construed towards disclosure and, if in doubt about whether additional information should be released, SNFs should disclose it.”

WHAT INFORMATION MUST SNFs DISCLOSE ON ADPs?

SNFs must disclose fairly detailed information about ADPs, the services they provide, their organizational structures, and any shared ownership between the ADP and SNF. All required information is detailed in the SNF Attachment. SNFs must obtain the following information from their ADPs:

• For ADPs that are corporations: All directors and officers and any person or entity with 5% or greater direct or indirect ownership in the corporation.
• For ADPs that are LLCs: Any person or entity that manages the LLC and any person or entity with a direct or indirect ownership interest in the LLC regardless of ownership percentage.
• For ADPs that are general partnerships: All persons or entities with a partnership/ownership interest regardless of the percentage.
• For ADPs that are limited partnerships: All persons or entities with a general partnership/ownership interest (regardless of the percentage) and all persons or entities with a limited partnership interest of at least 10% interest.
• For ADPs that are trusts: All trustees.

The SNF must also submit a diagram of the organizational structure of each ADP, which must include a written description of the relationship of each ADP to both the SNF and to all the SNF’s other ADPs. For instance, if the SNF’s management company has an ownership interest in the SNF’s landlord, such relationship must be disclosed.

WHAT IF SNFs CANNOT OBTAIN ADP INFORMATION?

CMS acknowledges that SNFs may have difficulty obtaining information from ADPs but nonetheless requires SNFs to use the “maximum feasible efforts to secure the required data.” However, SNFs are not required to make multiple attempts to obtain information regarding an ADP or its ownership structure if the ADP refuses to provide the data and the information is not available publicly or within the SNF’s records. If a SNF must submit the SNF Attachment to its Medicare administrative contractor (MAC) with missing ADP data, the SNF should include a brief email or letter to the MAC that identifies the missing data. However, CMS stresses that this notification “does not mean or imply that the SNF will automatically be exempt from disclosing this data.” CMS further recommends (though does not require) that the SNF thoroughly document all efforts to obtain data, including the following:

• Identifying the unattainable data in question
• Outlining contact attempts (via phone, email, or other means)
• Identifying the ADP(s) and their reason(s) for refusing to provide data
• The number of attempts made to obtain the data
• Whether (and to what extent) the SNF attempted to secure the data via other means if the SNF could not obtain it from the ADP
• Why all efforts to secure the data have been exhausted, including, but not limited to, why the SNF does not plan to make any additional efforts.

APRIL 9 UPDATE

The guidance document was recently updated to provide that companies that furnish physical therapy, occupational therapy, speech-language therapy, or other rehabilitation services to the SNF’s patients are considered ADPs under the “administrative services” category.

TAKEAWAYS

All SNFs must complete and submit the SNF Attachment by May 1, 2025. The SNF Attachment requires significant information from contractors and service providers who may not be familiar with Medicare disclosure requirements. SNFs should anticipate working closely with ADPs to secure the required information in accordance with CMS guidance. CMS recommends that SNFs work with legal counsel or their professional advisors to determine what information should be disclosed. Certain disclosed data will be publicly available on data.gov in accordance with Privacy Act protections and exceptions for personally identifiable information.

SNFs must certify that the information they provide CMS is true and accurate, and CMS can take administrative action against SNFs that provide misleading or false information. SNFs that fail to provide ADP disclosures may be subject to administrative penalties from CMS, which can include the denial or revocation of their Medicare enrollment. It remains to be seen how CMS and the MACs will enforce the ADP requirements, particularly in cases where SNFs cannot obtain required information or in cases where ADPs provide SNFs with incorrect information.