Hospice Cap
The Fiscal Year (FY) 2015 Hospice Wage Index and Payment Rate Update included a requirement for hospices to file a self–determined hospice aggregate cap. Refer to the following topics for additional information.
- Timeline
- Terminated Providers
- Provider Statistical and Reimbursement (PS&R)
- Forms and Instructions
- Calculation for Newly Medicare-Certified Hospices
- Submitting Cap Determinations
- Cap Overpayments
- Receipt Confirmation
- Sequestration
Timeline
Hospices are required to file a self-determined cap no earlier than 3 months, and no later than 5 months after the end of the hospice cap year, September 30. The earliest a hospice may file its self-determined cap is December 31, and the latest is February 28 of each year.
Terminated Providers
CMS issues 2 years' worth of the Statuary Cap amount at a time. Effective with the 9/30/17 Self-Determined (SD) cap submissions, providers who terminate from the program in the following cap year (i.e., 2023) must submit both the Current Year (i.e., 2022) & their final (terminating) SD cap reviews at the same time. After CGS processes the current year SD cap submissions, we will complete all necessary final cap reviews for your agency. The Statuary Cap Amount for 2023 is $32,486.92. Please note: CGS must receive notice of & process the termination before you can submit your final (terminating) SD cap.
Provider Statistical and Reimbursement (PS&R)
To prepare the cap calculation, hospices should obtain their Provider Statistical and Reimbursement (PS&R) summary and Hospice Cap reports from the CMS website. Instructions are available to assist you.
CGS does not send copies of PS&R reports since hospices are responsible for obtaining these reports directly from the PS&R System. However, if you are unable to obtain this information, you may contact Tom Bisbee at 615.660.5560 for assistance.
Forms and Instructions
To complete your self-determined hospice aggregate cap, you must complete the "Provider Self-Determined Aggregate Cap Limitation" form.
Instructions for completing this form are also available.
Calculation for Newly Medicare-Certified Hospices
The hospice aggregate cap is calculated in a different manner for new hospices that enter the Medicare program and do not participate for an entire cap year. In this situation, the initial cap calculations for newly certified hospices must cover a period of at least 12 but less than 24 months.
For example, the first cap period for a hospice that entered the program on September 1, 2021, is from September 1, 2021 through September 30, 2022. Order your PS&R Summary and Hospice Cap reports from the agency's tie-in date to September 30 of the second cap year. (i.e., September 1, 2021 – September 30, 2022). To obtain the correct beneficiary count from the Hospice Cap report, add the count from the 2021 and 2022 cap years.
You will also need to calculate a prorated Hospice cap amount. Provider entry is required in all gray shaded boxes of this form.
Submitting Cap Determinations
Send your completed "Provider Self-Determined Aggregate Cap Limitation" form, cover letter, and all supporting documents to one of the following:
Mailing Address | Email Address | Fax Number |
---|---|---|
Part A/HHH Audit & Reimbursement |
615.660.5983 |
Or you can email to SDHOSPICECAPS@cgsadmin.com, or fax the above information to (615) 660-5983 Attn: Tom Bisbee.
IMPORTANT NOTE: If CGS does not receive the self-determined cap within 7 days of the end of February/1st few days of March due date, we will issue a Past Due letter and suspend payments.
Cap Overpayments
For any overpayment amount calculated as a result of the self-determined cap, send a check made payable to CGS with a cover letter that explains what the payment is for to the following address:
CGS
P.O. Box 957124
St. Louis, MO 63195-7124
If you do not submit the overpayment at the same time as the self-determined aggregate cap, CGS shall demand the overpayment reported on the self-determined aggregate cap.
Receipt Confirmation
Upon receipt, CGS will perform a cursory review of the filed self-determined cap for obvious errors. Within 45 days of receipt, Hospices will receive a letter from CGS to confirm receipt of the filed self-determined aggregate cap calculation.
CGS will perform a final review of the filed calculation at a later date.
Sequestration
For information about how sequestration amounts are handled pertaining to the hospice cap calculation, refer to the "Sequestration – Impact on Hospice Aggregate Cap Calculations" article.
Updated: 12.19.22