List name, date of birth, SSN/FEIN, and address of each person or entity that owns 5% or more direct or indirect ownership or controlling interest in the applicant provider  (N/A not acceptable) If you are applying as an individual, list your information.

Disclosing Entity: The entity that is requesting Medicaid enrollment.

Ownership Interest: Indicates an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.  

Indirect Ownership Interest: Indicates the possession of equity in the capital, the stock, or the profits of the disclosing entity.

Person with an ownership or control interest – Indicates a person or corporation that:

• Has an ownership interest totaling 5% or more in a disclosing entity;

• Has an indirect ownership interest equal to 5% or more in a disclosing entity; has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity.

• Has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity;

• Owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5% of the value of the property or assets of the disclosing entity.

• Is an officer or director of a disclosing entity that is organized as a corporation; or,

• Is a partner in a disclosing entity that is organized as a partnership

Individual

• Individual enrollments will not have additional owners

• If the Applicant uses FEIN, it must be owned 100% by the Applicant

• The individual ownership information has been prepopulated from previous screens.

• Additional records are not allowed

• If changes in the information are required, the applicant must return to Basic, Tax and Address information screens to update respective fields

Expiration Date:

In KY MPPA, some records cannot be deleted. To add a new record, the previous record must have an Expiration Date added in order to keep the history on file. To add an Expiration Date to a record, click the "Edit" button and add an Expiration Date. If a new record is added to the grid, the active dates of the new record cannot overlap existing record dates.

Error Codes:

• "No one owns 5% or more" and "Owner" cannot have overlapping dates; end date one of the segments."- This message will be displayed if one of the actual individual or entity owners dates overlap with "No one owns 5% or more" segment. End date one of the segment.

• "Cannot add same Tax ID {0} with overlapping date segments"- This error message will be shown if there are more than 1 record for the same Tax ID with overlapping date segments. End date one of the segments.

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page