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Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

STATE FEES FOR NURSE AIDE 


REGISTRATION


Daniel R. Levinson


Inspector General 


December 2005


OEI-07-05-00070

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Office of Inspector General 
 http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 

as amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors 

in carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts management and program 

evaluations (called inspections) that focus on issues of concern to HHS, Congress, and 

the public. The findings and recommendations contained in the inspections reports 

generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 

effectiveness of departmental programs. OEI also oversees State Medicaid fraud control 

units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 

and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 

convictions, administrative sanctions, or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support in OIG's internal operations. The OCIG imposes program exclusions and 

civil monetary penalties on health care providers and litigates those actions within 

HHS. The OCIG also represents OIG in the global settlement of cases arising under the 

Civil False Claims Act, develops and monitors corporate integrity agreements, develops 

compliance program guidances, renders advisory opinions on OIG sanctions to the 

health care community, and issues fraud alerts and other industry guidance. 
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Δ EXECUTIVE SUMMAR Y 

OBJECTIVE 

To determine whether, and to what extent, States impose fees related to 

registration on individuals listed in their nurse aide registries. 

BACKGROUND 

The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) included 

numerous provisions intended to lead to improvements in the quality of 

care in long term care facilities. For instance, OBRA 1987 requires that 

each State establish and maintain a nurse aide registry. This registry 

consists of individuals who have successfully completed nurse aide 

training and competency evaluation programs or have otherwise been 

deemed competent to function as nurse aides, as well as individuals who 

have been barred from serving as nurse aides due to substantiated 

adverse findings of abuse, neglect, and misappropriation. 

Sections 1819(e)(2) and 1919(e)(2) of the Social Security Act prohibit 

States from imposing any charges related to registration on individuals 

listed in the registry. 

This study was based on two methods of data collection: (1) Web site 

searches and telephone inquiries to determine whether each State 

imposed fees related to registration of individuals on nurse aide 

registries; and (2) surveys mailed to those States that, based on Office of 

Inspector General (OIG) Web site searches and telephone inquiries, 

indicated they might be charging fees that statute, regulation, and 

manual provisions prohibit. 

FINDINGS 

Twenty-four States imposed fees that nurse aides may be required to pay 

for placement on nurse aide registries. Some States charged nurse aides 

more than one type of fee (e.g., a fee for initial placement and a fee for 

continued placement), while other States charged nurse aides only one 

fee. Twenty States listed nurse aides as a source of payment for initial 

placement fees, and 14 States listed nurse aides as a source of payment 

for continued placement fees on their registries. Seven States charged 

fees for criminal background checks and/or fingerprinting required for 

initial placement on their registries that nurse aides may be required to 

pay. 

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EXE CUTIVE S U MMAR Y

Four States imposed fees on nurse aides as a requirement to work in long 

term care facilities. These four States did not explicitly charge for initial or 

continued placement on the registry, but required fees for a nurse aide to 

work in a long term care facility. Failure to pay these fees could lead to 

nurse aides being removed from the registry. 

Guidance was provided only to States that requested it and oversight 

conducted of all States regarding registry fees was limited. Based on 

survey responses from the subset of States that charged fees, five States 

reported that they sought additional guidance from the Centers for 

Medicare & Medicaid Services (CMS). The nature of the guidance these 

States received varied, such as advice provided over the telephone, or a 

mailed copy of the governing regulation. It does not appear that CMS 

shared the guidance with other States or regions. Ten States reported 

that they sought guidance from their own State legal entities, rather than 

CMS. 

RECOMMENDATIONS 

OIG recommends that CMS: 

Ensure States cease imposing fees on nurse aides that violate 

Federal requirements. The statute, regulation, and State Medicaid 

Manual offer broad prohibitions against charging fees on nurse aides for 

placement on nurse aide registries. However, OIG found that a number 

of States are charging such fees. CMS should take action to ensure that 

this practice is discontinued. 

Clarify prohibitions on the charging of fees related to nurse aide 

registries. The actions of States identified in this study suggest that the 

statute, regulation, and/or State Medicaid Manual may not provide 

sufficient guidance and that additional guidance is necessary. For 

example, CMS could issue program guidance to all States to help clarify 

the prohibitions on fees. 

Conduct appropriate oversight to prevent States from charging 

inappropriate fees. This study provides specific information on which 

States require immediate oversight. Additionally, CMS may want to 

develop a process for ongoing oversight to prevent States from charging 

prohibited fees in the future. 

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EXE CUTIVE S CUTIVE S U MMAR Y

AGENCY COMMENTS 

CMS concurred with all three OIG recommendations. CMS indicated 

that it will work through the regional offices to notify States found to be 

imposing fees in violation of Federal requirements that such practices 

must cease and will ensure proper revenue offsets were made to any 

claims for Federal financial participation. CMS indicated that it will 

also ensure that all State Medicaid agencies receive written reminders 

of statutory and regulatory provisions that prohibit charges on nurse 

aides related to the nurse aide registry, that regional offices will receive 

a copy of the report, and that regional offices conduct periodic reviews of 

States’ compliance with nurse aide registry requirements. 

OFFICE OF INSPECTOR GENERAL RESPONSE 

OIG appreciates CMS’s comments to this report and is encouraged with 

the active participation CMS plans to take in ensuring that nurse aides 

are not charged fees related to their placement on their respective 

State’s nurse aide registry. 

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Δ T ABLE OF CONTENTS 

EXECUTI VE SUMMARY ........................................ i 

INTRODUCTI ON ................................................ 1 

FINDI NGS ....................................................... 4 

States imposed fees for placement on registries ............... 4

States imposed fees for employment ........................ 5

Guidance in response to States and limited oversight........... 6

RECOM M E NDATI O NS .......................................... 8

APPENDI XES .................................................. 10 

A: State Fees for Initial Placement on Registries ............. 10

B: State Fees for Continued Placement on Registries ......... 11

C: State Fees for Criminal Background Check and/or

Fingerprinting for Placement on Registries ............... 12

AGENCY COMME NTS ......................................... 13

ACKN O W LEDGMENTS ......................................... 15
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Δ INTRODU C TION 

OBJECTIVE 

To determine whether, and to what extent, States impose fees related to 

registration on individuals listed in their nurse aide registries. 

BACKGROUND 

The Omnibus Budget Reconciliation Act of 1987 included numerous 

provisions intended to lead to improvements in the quality of care in 

long term care facilities, such as the requirement that each State 

establish and maintain a nurse aide registry. This registry lists 

individuals who have successfully completed nurse aide training and 

competency evaluation programs or have otherwise been deemed 

competent to function as nurse aides, as well as individuals who are 

barred from serving as nurse aides due to substantiated adverse 

findings of abuse, neglect, and misappropriation. 

Prohibition Against Nurse Aide Registry Fees 

Sections 1819(e)(2) and 1919(e)(2) of the Social Security Act (the Act) 

and Federal regulation 42 CFR § 483.156(b)(4) prohibit States from 

imposing any charges related to registration on individuals listed in the 

registry. State Medicaid Manual section 2514(H) directs that the States 

“ . . . may not impose any charges on a nurse aide relating to the 

registry,” and section 4460 directs that the State must “ . . . ensure that 

the nurse aide registry . . . does not impose any charges related to 

registration on individuals listed in the registry.” 

Other Nurse Aide Registry Studies 

This report is one of several Office of Inspector General (OIG) studies 

regarding nurse aide registries. The first report, “Nurse Aide 

Registries: State Compliance and Practices” (OEI-07-03-00380) found, 

in part, that States failed to update registries with substantiated 

adverse findings and remove records of inactive nurse aides, as 

required. The second report, “Nurse Aide Registries: Long Term Care 

Facility Compliance and Practices” (OEI-07-04-00140) found that 

17 percent of long term care facilities employed individuals as nurse 

aides without required registrations. While conducting these studies, 

OIG was informed that States might be charging fees for placing 

individuals on their respective registries. 

After initiating this study, OIG learned that the Centers for 

Medicare & Medicaid Services (CMS) requested all States to complete a 

self-assessment related to nurse aide registry requirements. This 

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INTROD UCT ION 

activity occurred in response to prior OIG reports. Part of the 

self-assessment asked States to report compliance regarding fees 

charged for placement of individuals on nurse aide registries. At the 

time of this review, the results of this self-assessment were not 

available. 

METHODOLOGY 

OIG utilized two methods of data collection in this study: (1) Web site 

searches and telephone inquiries to determine whether each State 

imposed fees related to registration of individuals on nurse aide 

registries; and (2) surveys mailed to those States that, based on OIG 

Web site searches and telephone inquiries, indicated the State might be 

charging fees that statute, regulation, and manual provisions prohibit. 

Web Site Searches and Telephone Inquiries 

For each of the 50 States and the District of Columbia (hereinafter 

referred to as a State), OIG accessed the nurse aide registry Web site, if 

available, to determine whether or not the State imposed fees associated 

with placement of individuals on the nurse aide registry (excluding 

training and competency evaluation fees). OIG then contacted all 

States via telephone. For those States that had information on their 

Web sites about whether fees were charged, OIG confirmed this 

information. For all other States, OIG obtained information about 

whether or not fees were charged. 

Survey Responses 

Based on information collected through Web site searches and 

telephone inquiries, OIG identified States that imposed fees for such 

things as initial placement on the registry, renewal of registrations, and 

criminal background checks and/or fingerprinting. OIG mailed a brief 

survey to these States asking about the fees charged, sources of 

payment, and the guidance the States had sought, if any, when deciding 

to charge these fees. OIG received a 100 percent response rate to the 

survey. 

OIG followed up with CMS central office regarding guidance provided to 

individual States and oversight conducted. OIG requested, and 

subsequently received from CMS, all guidance it reported providing to 

States on fees related to nurse aide registration. 

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INTROD UCT ION

Standards 

This study was conducted in accordance with the “Quality Standards for 

Inspections” issued by the President’s Council on Integrity and 

Efficiency and the Executive Council on Integrity and Efficiency. 

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Δ FINDINGS 

Twenty-four States imposed fees that nurse 

aides may be required to pay for placement on 

nurse aide registries 

Based on information obtained 

from State nurse aide registry Web 

sites and telephone inquiries, and 

confirmed through State responses 

to a mail survey, OIG determined that 24 States imposed fees that 

nurse aides may be required to pay for initial and/or continued 

placement on nurse aide registries.1 This number might be higher as 

other States may have bundled the registry fees into competency 

evaluation or other fees; therefore, for some States OIG was unable to 

identify the fees specific to registration. Some States charged nurse 

aides more than one type of fee (e.g., a fee for initial placement and a fee 

for continued placement), while other States charged nurse aides only 

one fee. Registry fees included application, registration, initial 

certification, reciprocity,2 renewal of registrations, criminal background 

checks, and/or fingerprinting. In all 24 States, either the nurse aide is 

solely responsible for payment of the fees, or the nurse aide pays in 

specified circumstances, such as if the nurse aide was unemployed at 

the time of renewal. 

Twenty States charged a fee that nurse aides may be required to pay for 

initial placement on the registry 

OIG identified the following types and ranges of fees for initial 

placement on the registry: application ($15-$50), registration ($15), 

initial certification ($12-$120), and reciprocity ($10-$58). A listing of 

State fees for initial placement can be found in Appendix A. The States’ 

various uses of “application,” “registration,” and “initial certification” 

are synonymous and are not related to completion of a training 

program, for which fees may sometimes be charged pursuant to sections 

1819(f)(2)(A)(iv) and 1919(f)(2)(A)(iv) of the Act. Rather, these charges 

are merely for inclusion in the registry. Alaska charged the highest 

total fees ($170) for initial placement on the registry. In response to the 

mail survey, 10 of the 20 States that charged fees for initial placement 

on the registry reported that nurse aides are the sole source of payment. 

1 All 24 States charged at least 1 fee that nurse aides may be required to pay even if other 

fees were paid only by the long term care facility. 

2 Reciprocity is a process by which a registered nurse aide from another State may qualify 

for registration in a new State by virtue of his or her status in the previous State. An 

individual is only eligible for reciprocity if he or she has been entered on a nurse aide 

registry in another State in accordance with the training and competency evaluation 

requirements of section 1919(f)(2) of the Act, and if the individual is currently listed on 

that State’s nurse aide registry as active and without substantiated adverse findings. 

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F I NDING S 

The remaining 10 States reported that fees were received from either 

nurse aides or long term care facilities. 

Fourteen States charged a fee that nurse aides may be required to pay for 

continued placement on the registry 

Fees ranged from $5 to $120 for (typically biennial) renewals, or more if 

the renewal was processed after the expiration date. A listing of State 

fees for continued placement can be found in Appendix B. Eight States 

reported that fees were received from either nurse aides or long term 

care facilities, and six States reported that fees were received from 

nurse aides only. In addition to the 14 States, 4 States reported that 

fees were received from long term care facilities only, which does not 

violate the prohibition on charging nurse aides, so long as the costs are 

not passed on to nurse aides. One additional State did not charge if the 

renewal was accomplished timely, but charged $10 for each year past 

the expiration date, not to exceed $100. 

Seven States charged fees that nurse aides may be required to pay for 

criminal background checks and/or fingerprinting for placement on the 

registry 

The criminal background checks and/or fingerprinting were required as 

a condition for initial placement on the registry, and fees ranged from 

$5 to $600. A listing of State fees for criminal background checks and/or 

fingerprinting can be found in Appendix C. Of the seven States, 

four reported that fees were received from nurse aides only, and 

three States reported that fees were received from either nurse aides, 

long term care facilities, or State entities. Other States may have 

conducted criminal background checks and/or fingerprinting of their 

nurse aides, but did not charge a fee. 

In the mail survey, four States Four States imposed fees on nurse aides as a 

reported not charging for initial requirement to work in long term care facilities or continued placement on the 

registry, but charged fees for nurse aides to work in long term care 

facilities. Two of these States required an initial certification, 

application, or renewal fee in order for a nurse aide to work in a long 

term care facility. For example, in its response to the mail survey, 

Nevada staff stated, “Nevada does not charge any amount for a person 

to be placed on the registry . . . however, [Nevada] charge[s] a fee for an 

application for a certificate to practice as a nursing assistant.” 

Similarly, New Hampshire responded, “No fees are applied to the 

registry placement process.” However, OIG learned during the 

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F I NDING S 

telephone inquiry that New Hampshire nurse aides working in long 

term care facilities must become “licensed nursing assistants” and pay a 

$20 license application fee. Both Nevada and New Hampshire charged 

renewal fees for this certificate or license, respectively. Arkansas and 

Delaware charged fees for criminal background checks and/or 

fingerprinting required for employment in a long term care facility. 

These States reported that fees were received from long term care 

facilities, State entities, or nurse aides. 

Payment or nonpayment of fees in these States does not affect 

a nurse aide’s initial placement on the registry. However, 

42 CFR § 483.156(c)(2) requires that individuals who have performed no 

nursing or nursing-related services for a period of 24 consecutive 

months be removed from the registry, unless the individual’s registry 

record includes documented substantiated findings of abuse, neglect, or 

misappropriation of property. OIG alerted CMS that these fees may 

relate to the registry given that failure to pay the fees will ultimately 

result in the nurse aide’s removal from the registry. In these States, it 

is therefore difficult to conclude whether the fees charged to nurse aides 

are, in effect, fees for placement on the States’ registries. 

Guidance was provided only to States that 

requested it and oversight conducted of

 all States regarding registry fees

 was limited 

OIG asked States that charged 

fees what guidance they sought 

from CMS concerning charges to 

nurse aides. Based on survey 

responses from this subset of 

States, five reported that they 

sought additional guidance from CMS. The nature of the guidance 

these States received from CMS varied, such as advice provided over the 

telephone or a mailed copy of the governing regulation. It does not 

appear that CMS shared the guidance with other States or regions. 

Ten States reported that they sought guidance from their own State 

legal entities on charging registry fees, rather than from CMS. This 

may demonstrate that these States were unclear about the legality of 

fees for nurse aide registration. 

OIG requested from CMS examples of guidance it provided to States 

(see examples in the text box on the next page), which came from both 

central and regional offices. This guidance does not appear to have 

clarified the uncertainty regarding the breadth of the prohibition on 

charging fees to nurse aides, as illustrated by the results of this study. 

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Exampl s of CMS guidance to States:

Oregon-In 1992, CMS region X conducted a program

review of the nurse aide registry and stated in the report

that employed nurse aides cannot be charged training,

testing, certification, or renewal fees and that these fees

must be paid by the employer. However, unemployed nurse

aides may be charged fees.

Virginia-In 1995, CMS region III issued a letter stating

that if Virginia s statutory due process requirements go

beyond Federal requirements, then the State is permitted to

charge fees for these activities.

Arizona-In 1999, CMS region IX responded to an inquiry

saying that the State may not impose a charge for

fingerprinting of individuals listed in the registry.

Kentucky-In 1999, CMS central offce provided a response

to an inquiry via electronic mail stating that Kentucky

cannot impose charges on nurse aides to remain on the

registry (i. , charge renewal fees).

OIG found little evidence of CMS oversight as it relates to fees States

charge for nurse aide registration. Only one State reported in the mail

survey that the CMS regional offce had conducted a program review

which was in 1992, and recommended that the State cease charging

employed nurse aides for certification fees. While the State has ceased

charging fees to employed nurse aides, as per CMS guidance, the State

continues to charge fees to unemployed nurse aides.

OIG followed up with CMS central offce staff about the extent of

program reviews conducted. OIG was told that the CMS component

that previously performed the program reviews was disbanded in the

mid- 1990s. OIG was also told that the CMS regional offce Medicaid

Financial Management work plan for fiscal year 2005 includes one

planned review of compliance with nurse aide training and competency

evaluation program requirements in one region. This review would

include an examination of nurse aide registry fees. Finally, in late

2004, CMS did ask all States to complete a self-assessment related to

nurse aide registry requirements in response to prior OIG reports.

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ΔEXE CUTIVE S U MMAR Y RECOMME NDA TIONS 

Twenty-four States imposed fees on nurse aides for initial or continued 

placement on nurse aide registries, a violation of Federal requirements. 

In addition, four States imposed fees on nurse aides for the ability to 

work in long term care facilities, which could have a direct effect on 

nurse aides’ placement on the registry. Finally, CMS provided guidance 

only in response to specific State requests and conducted limited 

oversight of all States regarding registry fees. Therefore, OIG 

recommends that CMS: 

Ensure States cease imposing fees on nurse aides that violate Federal 

requirements 

The statute, regulation, and State Medicaid Manual offer broad 

prohibitions against charging fees on nurse aides for placement on 

nurse aide registries. However, OIG found that a number of States are 

charging such fees. CMS should take action to ensure that this practice 

is discontinued. 

Clarify prohibitions on the charging of fees related to nurse aide registries 

The actions of States identified in this study suggest that the statute, 

regulation, and/or State Medicaid Manual may not provide sufficient 

guidance and that additional guidance is necessary. For example, CMS 

could issue program guidance to all States to help clarify the 

prohibitions on fees. 

Conduct appropriate oversight to prevent States from charging 

inappropriate fees 

This study provides specific information on which States require 

immediate oversight. Additionally, CMS may want to develop a process 

for ongoing oversight to prevent States from charging prohibited fees in 

the future. 

AGENCY COMMENTS 

CMS concurred with all three OIG recommendations. CMS indicated 

that it will work through the regional offices to notify States found to be 

imposing fees in violation of Federal requirements that such practices 

must cease and will ensure proper revenue offsets were made to any 

claims for Federal financial participation. CMS indicated that it will 

also ensure that all State Medicaid agencies receive written reminders 

of statutory and regulatory provisions that prohibit charges on nurse 

aides related to the nurse aide registry, that regional offices will receive 

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R E C O MMENDA T I O N S 

a copy of the report, and that regional offices conduct periodic reviews of 

States’ compliance with nurse aide registry requirements. 

OFFICE OF INSPECTOR GENERAL RESPONSE 

OIG appreciates CMS’s comments to this report and is encouraged with 

the active participation CMS plans to take in ensuring that nurse aides 

are not charged fees related to their placement on their respective 

State’s nurse aide registry. 

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Δ APPENDIX ~ A 

State Fees for Initial Placement on Registries 

State Application Registration Initial 

Certification Reciprocity* 

Alaska 

Arizona 

California 

Colorado 

Connecticut 

District of Columbia 

Kansas 

Maryland 

Massachusetts 

Michigan 

Mississippi 

New Jersey 

New Mexico 

New York 

Oklahoma 

Oregon 

Rhode Island 

Vermont 

Washington 

Wyoming 

$50 

$0 

$15 

$20 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$25 

$20 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$0 

$15 

$0 

$120 

$0 

$0 

$0 

$0 

$12** 

$20 

$20 

$0 

$12 

$0 

$0 

$0 

$0 

$0 

$40 

$0 

$0 

$15 

$60 

$0 

$45 

$0 

$10 

$58 

$15 

$0 

$0 

$20 

$0 

$25 

$30 

$35 

$50 

$15 

$0 

$0 

$0 

$0 

$0

Source: Office of Inspector General survey of State fees, 2005. 

* - The reciprocity fee is in addition to application, registration, and initial certification 

 fees. For a discussion of reciprocity, see footnote 2 on page 4. 

** - Fee paid by long term care facilities only. 

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Δ APPENDIX ~ B 

State Fees for Continued Placement on 

Registries 

State Fee 

Alaska 

Arizona 

California 

Colorado 

Maryland 

Michigan 

Mississippi 

Oklahoma 

Oregon 

Rhode Island 

South Carolina 

Vermont 

Virginia 

Washington 

Wyoming 

$120 

fee for late renewal only 

$20* 

$20* 

$30 

$20 

$25 

$5 

$40* 

$24 

$25 

$25* 

$45 

$25* 

$50

Source: Office of Inspector General survey of State fees, 2005. 

* - Renewal fee if renewal completed timely; 

 additional late fees apply. 

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Δ APPENDIX ~ C 

State Fees for Criminal Background Check 

and/or Fingerprinting for Placement on 

Registries 

State Fee 

Alaska 

California 

Colorado 

Florida 

Pennsylvania 

Rhode Island 

Wyoming 

$59-$89 

$42-$62 

$30-$600 

$33-$57 

$24 

$5 

$60 

Source: Office of Inspector General survey of State fees, 2005. 

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Δ AGENCY COMMENTS 

Centers for Medicare & Medicaid Services’ Comments 

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A G E N C Y CO MMENT S

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Δ ACKNOWLEDGMENTS 

This report was prepared under the direction of Brian T. Pattison, 

Regional Inspector General for Evaluation and Inspections in the 

Kansas City regional office, and Gina C. Maree, Assistant Regional 

Inspector General. Other principal Office of Evaluation and Inspections 

staff who contributed include: 

Tricia Fields, Team Leader 

Brian T. Whitley, Program Analyst 

Dennis Tharp, Program Analyst 

Sandy Khoury, Program Specialist 

Tricia Davis, Director, Medicare & Medicaid Branch 

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