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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.


Hospices are required to file a self-determined cap no earlier than 3 months after, 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 now issues 2 years worth of the Statuary Cap amount at a time, effect with the 9/30/17 Self-Determined (SD) cap submissions, CGS is making the following change in process for providers that have terminated from the program. Providers who have terminated from the program in the following cap year (i.e. 2018) to submit both Current Year (i.e. 2017) & their final (terminating) SD cap reviews at the same time. After CGS has completed processing the current year SD cap submissions we will complete all necessary final cap reviews for your agency. Statuary Cap Amount for 2018 is $28,689.04.

Provider Statistical and Reimbursement (PS&R)

To assist hospices in preparing their cap calculation, hospices should obtain their Provider Statistical and Reimbursement (PS&R) summary and Hospice Cap reports from the CMS websiteExternal Website. Instructions are available to assist you in obtaining your PS&R reports.

CGS does not send copies of PS&R reports to hospices. Hospices are responsible for obtaining these reports direct from the PS&R System. However, hospices who are unable to obtain this information 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"Microsoft Excel File 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 entering the Medicare program, if the hospice has not participated in the program for an entire cap year. In this situation, the initial cap calculations for newly certified hospices must cover a period of at least 12 months but less than 24 months.

For example, the first cap period for a hospice entering the program on September 1, 2017, is from September 1, 2017 through September 30, 2018. When ordering your PS&R Summary and Hospice Cap reports you would use periods from agency's tie-in date to September 30 of second cap year. (i.e. using dates from above example September 1, 2017, thru September 30, 2018). To obtain the correct beneficiary count from the Hospice Cap report you would add together the count from the 2017 and 2018 cap years.

You will also need to calculate a prorated Hospice cap amountMicrosoft Excel File. Provider entry is required in all gray shaded boxes of this form.

Submitting Cap Determinations

Hospices should send their completed "Provider Self-Determined Aggregate Cap Limitation"Microsoft Excel File form along with a cover letter and all supporting documents to the following address:

Part A/HHH Audit & Reimbursement
CGS Administrators, LLC
PO Box 20015
Nashville, TN 37202

Or fax the above information to (615) 660-5983 Attn: Tom Bisbee.

IMPORTANT NOTE: If the self-determined cap is not received within 7 days of the February 28th due date, a Past Due letter will be issued and payments will be suspended.

Cap Overpayments

Any overpayment amount calculated as a result of the self-determined cap should be sent, along with a cover letter that explains what the payment is for, to the following address:

P.O. Box 957124
St. Louis, MO 63195-7124

Checks must be made payable to CGS.

If the overpayment is not submitted at the same time as the self-determined aggregate cap, CGS shall demand the overpayment reported on the self-determined aggregate cap.

Receipt Confirmation

CGS will perform a cursory review of the filed self-determined cap for obvious errors upon receipt. Hospices will receive a letter from CGS to confirm receipt of the filed self-determined aggregate cap calculation within 45 days of receipt.

CGS will perform a final review of the filed calculation at a later date.


The sequestration order, first issued on March 1, 2013, has been extended for services with dates of service or dates of discharge April 1, 2013 until further notice. 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. Please note that this article references dates based on the 2013 cap year; however the information applies to other cap years.

Updated: 02.01.18

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