How can a facility be certified for participation in the Medicare and/ or Medicaid program? How do I obtain an application?

A facility must be licensed as a Skilled Nursing Facility to be certified to participate in the Medicare program. A facility licensed as a Skilled Nursing Facility or an Intermediate Care Facility can be certified to participate in the Medicaid program.

Refer to 19 CSR 30-81.010 (2) available online, http://health.mo.gov/seniors/nursinghomes/lawsregs.php.

Medicare Application:
Submit the CMS-855A Medicare Enrollment Application directly to the designated Medicare fee-for-service contractor (also referred to as the fiscal intermediary or the Medicare Administrative Contractor (MAC)).

Submit the following to the Department of Health & Senior Services (DHSS), Division of Regulation and Licensure (DRL), Section for Long-Term Care (SLCR), Certification Unit. (Referred to as the State Agency (SA)):

  • Long Term Care Facility Application for Medicare and Medicaid (CMS 671);
  • Bed Listing for Licensure & Certification (DA 113);
  • Floor Diagram with room numbers indicated;
  • Health Insurance Benefit Agreement (CMS 1561);
  • Patient Transfer Agreement as required under 42 CFR § 483.75(n).
  • Assurance of Compliance (HHS 690): New applicants for Medicare funding and current providers undergoing a Change of Ownership (CHOW) will be responsible for submitting this attestation electronically to the OCR via OCR’s online Assurance of Compliance portal at https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf. The provider will receive electronic verification from OCR of successful submission of the attestation. You must submit a copy of this confirmation to the SA.

Medicaid ONLY Application:
Submit the following to the Department of Health & Senior Services (DHSS), Division of Regulation and Licensure (DRL), Section for Long-Term Care (SLCR), Certification Unit. (Referred to as the State Agency (SA)):

  • Long Term Care Facility Application for Medicare and Medicaid (CMS 671);
  • Bed Listing for Licensure & Certification (DA 113).

Application forms are available on the Centers for Medicare & Medicaid Services (CMS) website at
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/index.html, or contact the Certification Unit at 573-526-8507.

The Bed Listing for Licensure & Certification (DA 113) is available on the DHSS website at http://health.mo.gov/seniors/nursinghomes/pdf/580-2783.pdfPDF Document.

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