Home Health Agency (HHA) - Change of Ownership (CHOW)

Complete the following forms:

• CMS-1572 (a and b) (PDF)
• CMS-1561 Health Insurance Benefit Agreement (PDF)
• Complete the Civil Rights Attestation 

Submit the following:

• Copies of legal documents substantiating the effective date and parties involved in the CHOW (signed and dated by both parties).
• Organizational charts (Pre–CHOW and Post-CHOW) depicting lines of authority

Email above documents to: health.HRD-FedLCR@state.mn.us

Submit CMS 855A application to the designated Medicare Administrative Contractor (MAC).

• CMS 855A Medicare Enrollment Application (PDF) 
• Medicare Fee-for-Service Provider Enrollment Contact List

*Important:  The MAC CMS-855 approval letter is NOT the final approval to participate in the Medicare Program.

The Minnesota Department of Health (MDH) will review all completed documents and will make a recommendation to the MAC to approve or deny the CHOW.  The Centers for Medicare and Medicaid Services has the final authority and will notify the new owner in writing of their decision.

Any questions, please email:  Health.HRD-FedLCR@state.mn.us

Refer to Chapter 2 of the State Operations Manual – Home Health Agency  (See link below)

 https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107c03pdf.pdf

Refer to Chapter 3 (3210) of the State Operations Manual to verify that your situation constitutes a Medicare CHOW (See link below)

https://www.cms.gov/regulations-and guidance/guidance/manuals/downloads/som107c03pdf.pdf