Hospice Self-Calculation of Aggregate Cap -- Meet March 31 Deadline or Payments will be Suspended
March 21, 2015 09:42 AM
The National Association for Home Care & Hospice (NAHC) has made a concerted effort to keep hospice providers apprised of issues related to a new Centers for Medicare & Medicaid Services (CMS) requirement for hospices to self-calculate and report their aggregate cap status to their assigned Medicare Administrative Contractor (MAC) within five months following the close of the cap year, beginning with the 2014 cap year. Hospices are also required to pay back or make payment arrangements for any liability within this same time frame. Timely implementation of the cap reporting requirement has faced several challenges; as a result there is some confusion among hospice providers about the applicability of the requirement and how to meet it on a timely basis. Due to a variety of questions and concerns fielded in recent weeks by members of NAHC’s hospice team, this article provides answers to frequently-asked questions related to the hospice cap reporting requirement and supplies information (some of which has been reported previously) on how providers can meet the requirement.
HOSPICE SELF-CALCULATION OF AGGREGATE CAP
WHO MUST COMPLY? ALL Medicare-participating hospice providers must self-calculate their 2014 hospice aggregate cap and report it to their assigned MAC BY MARCH 31, 2015. Failure to submit the cap calculation by the deadline will result in payment suspension. Hospices will be required to submit aggregate cap calculations on an annual basis from here on out.
WHAT INFORMATION DO I NEED TO CALCULATE MY AGGREGATE CAP? A hospice will need the following:
The PROVIDER SELF-DETERMINED AGGREGATE CAP LIMITATION spreadsheet that was issued by CMS in early March, as well as the instructions that accompany the spreadsheet. (All of the MACs have posted the spreadsheet and instructions on their websites; it is strongly advised that you use the spreadsheet and instructions issued by your assigned MAC and CLOSELY REVIEW the materials on your MAC website as each MAC may have different requirements relative to submission of documents related to the cap calculation and its submission )
From the PS&R:
The Provider-Summary Report with PAID DATES THRU January 31, 2015 or later, and
The Hospice Beneficiary Count Summary (either Streamlined of Fully Pro-Rated depending on which is applicable to your hospice)
HOW DO I KNOW IF MY HOSPICE IS STREAMLINED OR FULLY PRO-RATED? From 1983 until 2011, all hospices were on the streamlined beneficiary counting method. In 2011, CMS created the pro-rated (or proportional) method for counting beneficiaries in response to a number of cap liability appeals that challenged use of the streamlined method. Hospices were permitted to “elect” the proportional method for the 2011 cap year if they chose to do so. In 2012, unless a hospice requested that it be kept on the streamlined method, it was transitioned to the pro-rated beneficiary count method. All new hospices automatically were placed on the pro-rated method. As a result, the majority of hospice providers are likely on the pro-rated method. However, you cannot assume that your hospice is on the pro-rated method. Your cap determination letter from your MAC that was issued for the 2012 cap year may state what beneficiary counting method you are under. If you are uncertain what method you are under and can find no documentation of it, you will need to seek that information from your MAC.
WHAT IF I CANNOT ACCESS THE PS&R REPORT? In order to access the PS&R, providers need to go through a CMS software system, IACS. At the beginning of 2015, CMS began phasing out IACS and moving to a new software system, EIDM. Some providers were not in “active status” in the IACS system when CMS began to transition the PS&R to a different system, EIDM (starting Jan. 31, 2015) and have not been able to register as the transition has been postponed and no new registrations may be submitted. A hospice in this situation must obtain the PS&R information from their MAC. NOTE: Palmetto sent copies of the PS&R reports to all hospices under its jurisdictions; both CGS and NGS will provide reports to hospices that are unable to secure them if the hospice requests it.
WILL THE MAC-SUPPLIED PS&R REPORTS PROVIDE INFORMATION ABOUT WHAT BENEFICIARY COUNTING METHOD MY HOSPICE IS UNDER? The PS&R report supplied by the MAC (Hospice Beneficiary Count Summary) may specify either “Streamlined” or “Fully Pro-Rated”. If not, all Beneficiary Count Summary reports contain a “Beneficiary Identification Period” line - on the top right side of the page. If your Beneficiary Identification Period begins with 9/28/13, you are on the Streamlined method. If your Beneficiary Identification Period begins with 11/01/13, you are on the Proportional or Fully Pro-Rated method.
MY HOSPICE IS UNDER CAP, BUT WHEN I PUT THE REQUIRED INFORMATION IN THE SPREADSHEET, I COME UP WITH A POSITIVE VALUE IN LINE 5 -- DO I REALLY OWE MONEY TO MEDICARE? CMS made every effort to keep the self-calculation spreadsheet as simple as possible. However, it is important that providers first read the accompanying instructions as they provide important information about the cap calculation. CMS has indicated if the value that you arrive at in line 5 is positive, you should put a ZERO in line 5, which then indicates that your hospice has no cap-related liability.
NOW THAT I HAVE COMPLETED MY CAP CALCULATION FOR 2014, DOES THAT “CLOSE” THE 2014 CAP YEAR? The self-calculation of the aggregate cap represents an interim assessment of a hospice’s cap liability. A hospice that calculates a liability owed to CMS must pay that liability by March 31, 2015, or make arrangements for payment at that time. Information regarding making arrangements for payment can be obtained from your MAC. At some time in the future (likely some months in the future) your assigned MAC will conduct an assessment based on more recent data related to your beneficiary count for the 2014 cap year and will issue a final cap determination notice. The MAC’s final cap determination calculation will also take the 2% sequester into account. A hospice’s cap liability may change between its self-calculation and the MAC’s final cap determination for the cap year, in which case the hospice is obligated to pay any additional liability owed.
Following are links to information that is available on the MAC websites related to self-calculation of the hospice cap:
CGS: Hospice Cap, Instructions for completing the Pro-Forma for Provider Self-Determination of Aggregate Cap Limitation
NGS: Hospice Cap: Self-Reporting Instructions
Palmetto: Self-Determined Hospice Cap Calculation, Sequestration: Impact on Hospice Aggregate Cap Calculation
Previous NAHC Report hospice cap coverage:
March 10, 2015: Hospice Cap Roundup: Self Calculation and Reporting (2015), the Sequester, and 2013 Cap Determinations
February 4, 2015: An Update on Self-Reporting of Aggregate Cap for Hospices