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) 2024 data collection period, Medicare-certified hospices that served fewer than 50 survey-eligible decedents/caregivers in CY 2023 (January 1, 2023 through December 31, 2023) can apply for an exemption from CY 2024 CAHPS Hospice Survey data collection and reporting requirements.

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, 2024. 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 2023 CAHPS Hospice Survey data collection and reporting requirements is no longer available. The deadline to complete and submit this form was December 31, 2023.

DO NOT use this form to report 2022 decedent counts. Contact the CAHPS Hospice Survey Project Team at hospicecahpssurvey@hsag.com if you need to report your hospice's 2022 decedent counts.

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Items Needed to Complete the Participation Exemption for Size Form

The Participation Exemption for Size Form will need to include for CY 2023 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 or paid caregiver
  • for whom the caregiver has a foreign (non-U.S. or non-U.S. Territory) home address
  • 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:

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

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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 2025 when CMS reviews all hospices' data to see if they met the Fiscal Year (FY) 2026 Annual Payment Update (APU). If your exemption is accepted, you will not face a 4% reduction. However, if CMS data indicates that you have served 50 or more survey-eligible patients in 2023, 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 2023 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.

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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.

For the math equation at the bottom of the form, please insert only the answer to the math equation into the box to the right of the equation.

The Participation Exemption for Size Form has been successfully submitted once you are redirected to a “Thank you for your submission” page.

Do not include a dash/hyphen (-) in the CCN number.

If you wish to bookmark the form for future use, please use this link: https://hospicecahpssurvey.org/en/hospice-tools/forms/

This page was last modified on 01/05/2024

I. General Information

1a. CCN Number * CCN is required. Too few characters. Must be 6 characters Too many characters. Must be 6 characters

Submission Date 04/19/2024

1b. Organization Name * The Name of the Organization is required.

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

2a. Name * Name is required.

2b. Title * Title is required.

2c. Mailing Address 1 * Mailing Address 1 is required.

2d. Mailing Address 2

2e. City * City is required.

2f. State * State is required.

2g. Zip Code * Zip Code is required.

2h. Telephone * Telephone is required.

2i. Fax Number Fax must be 10 digit number

2j. Email Address * Email is required.

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, 2023 and December 31, 2023 (CY 2023) *

TotalPatientsDeceased The Total Patients Deceased is required.

2. Enter the total number of patients during CY 2023 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 *

TotalDischargedAlive The Total Discharged Alive is required.

     b. Enter the number of decedents:

          i. who were under the age of 18 *

TotalUnder18 The Total Under 18 is required.

          ii. who died within 48 hours of admission to hospice care *

TotalDied48hrs The Total Died 48hrs is required.

          iii. for whom there is no caregiver of record *

TotalNoCaregiver The Total No Caregiver is required.

          iv. for whom the caregiver is a non-familial legal guardian or paid caregiver *

TotalNoGuardian The Total No Guardian is required.

          v. for whom the caregiver has a foreign (non-US or non-US Territory) home address *

TotalForeignAddress The Total Foreign Address is required.

          vi. for whom the caregiver requested not to be contacted *

TotalRequestNoContact The Total Request No Contact is required.

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Enter the answer to the equation on the left in the box below.*

Captcha Enter answer to equation on left.

Note: Please print completed Exemption Report form before submitting.

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