Wisconsin Nursing Home Change of Ownership Application
Whenever ownership of a facility is transferred from the person or
persons named in the license to any other person or persons, the applicant
must obtain a new license. The following information explains the
process for a potential change of ownership of a nursing home. The
Department shall issue a license for a nursing home if it finds the
applicant to be "fit and qualified". The Department has up
to 60 days to give the approval for the transfer of license once they have
received a completed application.
Information detailed below includes:
INTRODUCTION - General information
explaining the change of ownership process
FORMS - Forms to be completed and
ADDITIONAL ITEMS TO BE SUBMITTED
- BQA Memo
50, Wisconsin Statutes
DHS 132, Wisconsin Administrative Code
To assist in the completion of the Change of Ownership application,
providers may use the Change of Ownership
Checklist to ensure all of the required documents are completed.
Under Wisconsin Statutes, Section 50.03(3)(b) and (13)(a), a new
owner/operator must notify the Department of Health Services of the
potential transfer of ownership, and file an application under subsection
(3)(b) for a new license at least 30 days prior to final transfer of
ownership. Please note, however, that Wisconsin Administrative Code, Section
DHS 132.14(5), allows the Department 60 days after receiving a complete
application for a license, to conduct its review and either issue a license
or deny the application. It is essential that the licensure packet you
submit to this office include all required documentation in order for the
application to be considered complete. To avoid any unnecessary delays, it
would be helpful to submit your application at least 60 days, and as many as
90 days prior to the anticipated license transfer date.
Upon receipt of the completed application for licensure and additional
required forms, the Licensing and
Regulatory Support Services Section will review the information in
accordance with all requirements under Section DHS 132.14, Wisconsin
Administrative Code. The Department also reviews the facility's previous
survey history (including outstanding violations, plans of correction and
forfeitures - see Section 50.03(13)(c) and (d).), and documentation provided
to substantiate the applicant's financial stability. Inaccurate or
incomplete information may result in a delay in processing the transfer.
A completed application must include all required documentation.
Once this documentation is received the 60 day time period for review by the
Licensing and Regulatory Support Services Section will begin.
If the Department approves the transferee's application for license, the
Department will issue the license following receipt of written confirmation
from both the applicant and the current licensee that the closing has been
finalized as specified in Chapter 50, Wisconsin Statutes. This document must
be signed by both parties and include the actual date of transfer. The new
licensee may be issued a probationary, conditional, or regular license.
EXISTING AND/OR OUTSTANDING FORFEITURES
If the facility has existing Class A or B violations or federal
deficiencies which indicate that the facility is not in substantial
compliance with federal requirements, the Department will not issue a new
license until the violations/deficiencies are corrected. We urge you to
review the last survey conducted at the facility. Survey reports and results
of complaint investigations are on file and can be viewed by contacting
either the appropriate district office or Diana Cleven, Division of Quality
Assurance, P.O. Box 2969, Madison, Wisconsin 53701, (608) 266-6383. If
copies are requested, a fee of $.25 per page will be required.
If the facility has any outstanding forfeitures, these forfeitures should
be paid prior to the transfer of the license. The transferor is liable for
all forfeitures assessed for violations occurring prior to the transfer of
EFFECTIVE DATE OF TRANSFER
It is preferable to make transfers effective on the first day of the
month. If the facility's license is effective the first of the month, the
Title XIX (Medical Assistance) provider agreement will also be effective the
first of the month. For Title XIX, a monthly patient liability amount is
established for each Medical Assistance patient who has excess income. If
the effective date of the new provider agreement falls during the month, you
will need to contact the local certifying agency which grants Medical
Assistance eligibility (e.g., County Social Service Dept., or Social
Security Office) in order to have the patient liability prorated for the
dates of residence under the two provider numbers. However, if the provider
agreement begins on the first of the month, you do not need to take this
action. Contact EDS if you have any questions. The telephone number for EDS
is (608) 221-4746. Please be advised that once the license transfer is
official and the new license has been issued, the effective date will not be
Please also be reminded that if the ownership of a facility changes, the
medical records and indexes shall remain with the facility.
- Application for Nursing Home License- F-62019
(PDF, 106 KB)
- Resident's Rights Report - F-62151.
(PDF, 59 KB) This form is being sent to make
you aware that all facilities are required to establish a system of
reviewing complaints and allegation of violations of residents' rights.
This form will be sent to the facility annually for completion. Please
sign and return the original of Form F62151. By doing so, you will have indicated
to us that you understand the requirements for establishing such a
- Authorization to Accept Personal Services and to Receive Registered
and Certified Mail - F-62308.
(PDF, 54 KB) The person named should be
someone who is located on-site, at the facility.
- Projected Cash Flow Statement and Projected Balance Sheet - F-01022A,
F-01022B, F-01022C, F-01022D, F-01022E (Excel-each
sheet is a different form). Projected Cash Flow Statement and Projected Balance
Sheet - DHS 132.14(3)(c) Wisconsin Administrative Code, requires that a
new licensee submit evidence to establish that it has sufficient
resources to permit operation of the facility for a period of 6 months.
The Department will make a determination of financial stability for this
6 month period based on the figures provided on the enclosed Projected
Cash Flow Statement and Projected Balance Sheet. Other types of
financial documentation demonstrating sufficient resources to cover
operating losses will also be considered (e.g., letters of credit,
personal financial statements together with a signed affidavit
committing personal resources)
- Background Information Disclosure -
F-82064 (PDF, 56 KB) and Background
Information Disclosure Appendix - F-82069
(PDF, 43 KB)
- A cover letter should accompany the completed application forms and
should include: (1) a detailed description of the proposed transfer, (2)
the name, address and telephone number of a contact person, and (3) the
date on which the license transfer is expected to occur.
- The fee for the processing of the change of ownership should equal the
number of nursing home beds of the facility times $6.00. For example if
the nursing home has 100 beds the amount of the processing fee would be
100 beds X $6.00 = $600.00. The check should be made payable to the
Department of Health Services. This fee will be applied only towards the
processing of the change of owner/operator and will not be used to cover
any required annual fee, which is due on or before October 1. This fee
- Copy of Articles of Incorporation and bylaws or copy of Articles of
Organization and the Operating Agreement (for LLCs) or partnership
agreement (if applicable).
- Submit a copy of the final signed legal document
(e.g. closing statement, purchase agreement, lease agreement, etc.) at
the time of the actual transfer. A copy of the draft should be submitted
prior to the actual transfer.
- Written notification of transfer from the transferor pursuant to
Section 50.03(13)(b), Wis. Statutes.
- If the applicant is a foreign corporation this office will require a
copy of a Certificate of Authority for the corporation to transact
business in the State of Wisconsin. (Foreign non-profit corporations
must only provide a copy of their Articles of Incorporation and bylaws).
General partnerships are not required to file Certificates of Authority.
If the applicant is a domestic corporation or a foreign or domestic
limited liability company, this office will require a copy of a
Certificate of Status. These certificates must be obtained through the
Department of Financial Institutions, Division of Corporations, 345 W.
Washington Ave., 3rd Floor, P.O. Box 7846, Madison 53707-7846, (608)
- A copy of the current organizational chart identifying the parent
company and its subsidiaries (if applicable). If not applicable, please
so indicate in your cover letter.
- Provide a copy of the management agreement/contract if the applicant
will be contracting services with a management company after the change
of ownership occurs. Also indicate what other facilities the management
company has owned, operated or managed within the previous 5-year
If the facility is currently Medicare certified, the existing provider
agreement will remain in effect. A new provider number will not be issued
for changes of owner/operator. However, the new owner may refuse to accept
assignment of the previous owner's provider agreement. If this is the case,
then the provider agreement will be terminated effective with the change of
ownership date. The refusal to accept assignment should be put in writing by
the new owner and forwarded to the Centers for Medicare and Medicaid
Services (CMS), 233 N. Michigan Ave., Suite 600, Chicago, Illinois
60601-5519. This request must be made 45 days prior to the change of
ownership date to allow for the orderly transfer of any beneficiaries that
may be patients of the provider. If the new owner would then wish to
participate in the Medicare program, the new owner would need to re-apply
for certification and this request would be treated as any initial applicant
to the Medicare program including the completion of an initial survey for
If the facility is a skilled care facility currently participating in the
Medicare program, but the applicant wishes to voluntarily terminate
participation in the Medicare program, written notice must be provided to
the Division of Quality Assurance.
According to 42 CFR 489.52:
(2) The notice may state the intended date of termination, which must
be the first day of a month.
(b) Termination date. (1) If the notice does not specify a date, or the
date is not acceptable to CMS, CMS may set a date that will not be more
than 6 months from the date on the provider's notice of intent.
(2) CMS may accept a termination date that is less than 6 months after
the date on the provider's notice if it determines that to do so would not
unduly disrupt services to the community or otherwise interfere with the
effective and efficient administration of the Medicare program.
(3) A cessation of business is deemed to be a termination by the
provider, effective with the date of which it stopped providing services
to the community.
(c) Public notice. (1) The provider must give notice to the public at
least 15 days before the effective date of termination.
(2) The notice must be published in one or more local newspapers and
must- (i) Specify the termination date; and (ii) Explain to what extent
services may continue after that date, in accordance with the exceptions
set forth in s489.55.
If the facility is a skilled care facility and is not currently
certified in the Title XVIII (Medicare) program but wishes to participate,
please send a written request for Medicare certification to:
Department of Health Services
DQA - BNHRC
Attn: Gail Hansen
1 W. Wilson, P.O. Box 2969
Madison, WI 54701-2969
PLEASE NOTE: Forms CMS-671, CMS-672, CMS-1561 (two copies) and HHS-690
must be returned with original signatures.
The Bureau of Nursing Home Services, Division of Long Term Care,
certifies facilities for participation in the Title XIX program. New Medical
Assistance provider agreements and an application will be sent to the new
licensee for completion and signature before a new Medical Assistance
provider number can be assigned. The Bureau of Nursing Home Services
reserves the right to make a final interpretation as to whether a change of
ownership has actually occurred for the purpose of calculating Title XIX
daily accommodation rates. Once the transfer of ownership has been finalized
and a new license issued by the Bureau of Nursing Home Resident Care, the new licensee will not be allowed to bill the Wisconsin
Medical Assistance Program for reimbursement using the previous operator's
If the facility has T19 Medicaid certification, go to the following
website to obtain the Medicaid application: http://www.dhs.wisconsin.gov/ForwardHealth/.
If you need assistance with the Medicaid application, contact EDS Customer
Service at 1-800-947-9627.
If the facility is Medicaid certified only the following form will also
need to be completed and submitted to the Division of Quality Assurance,
Bureau of Technology, Licensing and Education:
- Skilled Nursing Facility and Intermediate Care Facility Application
Wisconsin Medical Assistance Program (WMAP) certified providers who sell
or otherwise transfer their business or business assets are liable for
repayment to Department of Health Services (DHS) of any erroneous payments
or overpayments made to them by the WMAP. Pursuant to s. 49.45(21), Wis.
Stats., the person or persons to whom a "transfer of ownership" is
made shall also be held liable by the DHS for repayment. Therefore, prior to
final transfer of ownership, transferees are responsible for contacting the
DHS to ascertain if the owner is liable under this provision. Inquiries
regarding the determination of any pending liability on the part of the
owner should be in writing and made at least twenty days prior to the
transfer. Written notices should include the following information:
- Name and address of: Transferee and Transferor
- Facility name and provider number
Inquiries should be made by calling (608) 266-9746 or writing:
Bureau of Nursing Home Services
P. O. Box 309
Madison, WI 53701
The WMAP has the authority to enforce these provisions within four years
following transfer of a business or business assets.
Please return all completed forms to:
Department of Health Services
DQA - BNHRC
Attn: Gail Hansen
1 W. Wilson, P.O. Box 2969
Madison, WI 53701-2969
Questions can be directed to Gail
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April 03, 2013