C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER G—STANDARDS AND CERTIFICATION › PART 498—APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT PARTICIPATION IN THE MEDICARE PROGRAM AND FOR DETERMINATIONS THAT AFFECT THE PARTICIPATION OF ICFs/IID AND CERTAIN NFs IN THE MEDICAID PROGRAM › Subpart A—General Provisions

42 C.F.R. § 498.4

NFs subject to appeals process in part 498

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A NF is considered a provider for purposes of this part when it has in effect an agreement to participate in Medicaid, including an agreement to participate in both Medicaid and Medicare and it is a—

(a) State-operated NF; or

(b) Non State-operated NF that is subject to compliance action as a result of—

(1) A validation survey by CMS; or

(2) CMS's review of the State's survey findings.

[59 FR 56252, Nov. 10, 1994]
Notes of Decisions
Cited in 6 cases (1 in the last 5 years), 2000–2022 · leading case: Cathedral Rock of North College Hill, Inc., D/B/A Beechknoll Convalescent Center v. Donna E. Shalala, Secretary of Healt
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Cathedral Rock of North College Hill, Inc., D/B/A Beechknoll Convalescent Center v. Donna E. Shalala, Secretary of Healt (2000) ca6 “3 (a)(2)(i); see also 42 C.F.R. § 498.4 (stating that a Medicaid nursing facility is treated as a Medicare provider subject to the Medicare administrative appeals procedures when it has agreed to participate in both Medicaid and Medicare and is the subject of a compliance action…”
Forum Healthcare Group, Inc. v. Centers for Medicare & Medicaid Services (2007) gand · cites it 2× “3 (a)(2)(i); 42 C.F.R. § 498.4 . If a facility challenges a determination that it is not in substantial compliance with the common Medicaid and Medicare regulations and a termination of its participation in both programs, the facility must seek review of the termination through…”
Autumn Health Care of Zanesville, Inc. v. United States Department of Health & Human Services (2013) ohsd “3 (2)(I); see also 42 C.F.R. § 498.4 (stating that a Medicaid nursing facility is treated as a Medicare provider subject to the Medicare administrative appeals procedures when it has agreed to participate in both Medicaid and Medicare and is the subject of a compliance action…”
B. v. Brooks-Lasure (2022) cand · cites it 2× “at 10 ; 13 see 42 C.F.R. § 498.4 (b)(2). Second, the APA and due process claims allege the relocation 14 plan fails to provide for the safe and orderly transfer of residents to adequate facilities.”
Avon Nursing and Rehabilitation v. Azar (2019) nysd “42 C.F.R. § 498.4 . Although § 405(h) has not been incorporated by reference into the Medicaid Act, courts have not interpreted this omission “as abrogating the doctrine of exhaustion of remedies in Medicaid cases” involving dually-participating facilities.”
SOMERSET PLACE, LLC v. Sebelius (2010) ilnd “” 42 C.F.R. § 498.4 (“NFs subject to appeals process in part 498.”
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