CAHPS® Hospice Survey

Participation Exemption for Size
     

Participation Exemption for Size Process

The Participation Exemption for Size process has been created to provide hospices that have fewer than 50 survey-eligible decedents/caregivers in the "reference period" (see table below) with a means to request an exemption from participation in the CAHPS Hospice Survey. For the calendar year (CY) 2017 data collection period, Medicare-certified hospices that served fewer than 50 survey-eligible decedents/caregivers in CY 2016 (January 1, 2016 through December 31, 2016) can apply for an exemption from CY 2017 CAHPS Hospice Survey data collection and reporting requirements.

“Reference Period” or Decedent Date of Death

Exemption Form Deadline

Exemption Request Review by CMS

Affects APU

Jan 1 to Dec 31, 2014

Aug 15, 2015

2016

FY 2017

Jan 1 to Dec 31, 2015

Dec 31, 2016

2017

FY 2018

Jan 1 to Dec 31, 2016

Dec 31, 2017

2018

FY 2019

Jan 1 to Dec 31, 2017

TBD

2019

FY 2020

APU – Annual payment update; FY – Fiscal year

The Participation Exemption for Size Form will be available to complete on the CAHPS Hospice Survey Web site until December 31, 2017. Please note, exemptions on the basis of size are active for one year only. If a hospice continues to meet the eligibility requirements for this exemption in subsequent years, the organization will need to again request the exemption.

The CAHPS Hospice Survey Participation Exemption for Size Form for the CY 2016 CAHPS Hospice Survey data collection and reporting requirements is no longer available. The deadline to complete and submit this form was December 31, 2016.


Items Needed to Complete the Participation Exemption for Size Form

The Participation Exemption for Size Form will need to include for CY 2016 the number of patients who were discharged alive, the number of patients who died while in hospice care and a count of patients who fell into the following categories. (Do not include a patient in more than one of the following categories.)

  • Patients who were discharged alive
  • Decedents:
    • who were under the age of 18
    • who died within 48 hours of admission to hospice care
    • for whom there is no caregiver of record
    • for whom the caregiver is a non-familial legal guardian
    • for whom the caregiver has a foreign (non-U.S. or U.S. Territory) home address
    • whose caregiver requested that they not be contacted

Note: For multiple hospice programs sharing one CCN, the survey-eligible decedent/caregiver count is the total from all facilities.

Note: The number of patients who were discharged alive should include patients who have the occurrence code "42" – Date of Revocation (only) (FL 31-34) and patients who have the following Patient Status Codes (FL17):

  • “01” – Discharge to Home or Self Care (Routine Discharge)
  • “50” – Discharged/Transferred to a Hospice – “Hospice Home” (Routine or Continuous Home Care [CHC])
  • “51” – Discharged/Transferred to a Hospice – “Hospice Medical Facility” (Inpatient Respite or General Inpatient Care [GIP])

Review your organization’s information prior to submitting the Participation Exemption for Size Form. A suggested review process is provided in the example below.

Example:

Participation Exemption for Size Request (Do not leave any fields blank – enter 0 [zero] if applicable)
1. Enter the total number of patients who died while in hospice care between January 1, 2016 and December 31, 2016 (CY 2016)* 45
2. Enter the total number of patients during CY 2016 who fall into the following categories. Do not include a patient in more than one of the following categories:
   a. Enter the number of patients who were discharged alive* 12
   b. Enter the number of decedents:
      i. who were under the age of 18* 2
      ii. who died within 48 hours of admission to hospice care* 4
      iii. for whom there is no caregiver of record* 0
      iv. for whom the caregiver is a non-familial legal guardian* 1
      v. for whom the caregiver has a foreign (non-U.S. or U.S. Territory) home address* 0
      vi. for whom the caregiver requested not to be contacted* 1

   

Suggested Review Process:

  • Add the counts to be submitted for Questions 2bi. – 2bvi. to obtain the total survey-ineligible decedents/caregivers
    • 2 + 4 + 0 + 1 + 0 + 1 = 8
  • Subtract the total survey-ineligible decedents/caregivers (8) from the total number of patients who died while in hospice care (Question 1)
    • 45 - 8 = 37
  • The total number of survey-eligible decedents/caregivers is 37 which is fewer than 50; and therefore, the hospice in this example would be eligible for the Participation Exemption for Size

Review Process

The CAHPS Hospice Survey Project Team will confirm receipt of the Participation Exemption for Size Form. Confirmation of receipt of the Participation Exemption for Size Form does not constitute approval or denial of this request. CMS will determine the eligibility for size exemption in 2018 when CMS reviews all hospices' data to see if they met the Fiscal Year (FY) 2019 Annual Payment Update (APU). If your exemption is accepted, you will not face a 2% reduction. However, if CMS data indicates that you have served 50 or more survey-eligible patients in 2016, you would not qualify for the exemption and in that instance, you would face the reduction. Therefore, it is the responsibility of the hospice submitting the Participation Exemption for Size Form to accurately portray that the hospice meets the fewer than 50 survey-eligible decedents/caregivers for the CY 2016 and provide the number of patients who died while in hospice care and count of patients who fell into the categories listed on the form.


Participation Exemption for Size Form

The Participation Exemption for Size Form must be completed and submitted online on the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org).

All required fields are indicated with an asterisk (*). Note: For multiple hospice programs sharing one CCN, the survey-eligible decedent/caregiver count is the total from all facilities.

When completing the “Captcha” field, only insert the answer to the math equation. The Participation Exemption for Size Form has been successfully submitted once you are redirected to a “Thank you for your submission” page.

I. General Information

CCN Number: * Date Submitted: 4/24/2017 Name of Hospice: *

II. Contact Person at Hospice for this Exemption for Size Request (Confirmation email will be sent to the Contact Person)

First Name, Last Name: *   Title: *
  Mailing Address: *
  Mailing Address 2:
  City: *      State: *      Zip Code: *
(Area Code) Telephone Number: * Ext:
(Area Code) Fax Number:
Email Address: *

III. Participation Exemption for Size Request (Do not leave any fields blank – enter 0 [zero] if applicable)

1. Enter the total number of patients who died while in hospice care between January 1, 2016 and December 31, 2016 (CY 2016) *
2. Enter the total number of patients during CY 2016 who fall into the following categories. Do not include a patient in more than one of the following categories:
  a. Enter the number of patients who were discharged alive *
  b. Enter the number of decedents:
    i. who were under the age of 18 *
    ii. who died within 48 hours of admission to hospice care *
    iii. for whom there is no caregiver of record *
    iv. for whom the caregiver is a non-familial legal guardian *
    v. for whom the caregiver has a foreign (non-US or US Territory) home address *
    vi. for whom the caregiver requested not to be contacted *


Captcha