Hospice Cap Self-Reporting

On 8/6/2015, CMS issued the FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. The Final Rule finalized the proposals to align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the FFY starting in FY 2017 and to align the timeframe for counting the number of beneficiaries with the FFY. This alignment eliminates timeframe complexities associated with counting payments and beneficiaries differently from the FFY and will help hospices avoid mistakes in calculating their aggregate cap determinations. Additionally, shifting the cap accounting year timeframes to coincide with the hospice rate update year (the FFY) better aligns with the intent of the new cap calculation methodology required by the IMPACT Act of 2014 (P.L. 113‒185).

2019 Cap Year (10/1/2018–9/30/2019)

• • HHH MACs are to count both beneficiaries and payments for hospices using the streamlined or the patient-by-patient proportional methods from 10/1/2018 to 9/30/2019.
  • HHH MACs are to calculate the percentage of all hospice days of care that were provided as inpatient days (GIP or respite care) from 10/1/2018 to 9/30/2019.

Any hospice that does not report its self-determined cap by 3/2/2020, will be subject to a 100% payment suspension.

Once hospice providers have self-reported, we will send a confirmation letter within 45 days of receipt. When applicable the confirmation letter will also serve as a demand letter for the provider with an amount due the Medicare Program. We will also perform a cursory review of the submitted self-determination within 60 days of receipt. 

Completing the Pro-Forma

Before completing the CMS issued pro-forma, please review the “Instructions for completing the Pro-Forma for Provider Self-Determination of Aggregate Cap Limitation” tab of the pro-forma. Providers should download and use the CMS issued pro-forma calculation form. The The pro-forma and instructions can be found on the HHH page of our website. If you are having issues with accessing this link above, from our website, select HH+H and your state, click on “Next” and accept the attestation. Then, select Provider Resources > Forms > Other > Hospice Cap. The PS&R data used in filing the self-reported cap cannot be earlier than 01/01 of the applicable cap year. The statutory cap amount to be used for the 2019 self-reported hospice cap calculation is $29,205.44.

Submitting the Pro-Forma

Hospice providers should submit the pro-forma calculation along with supporting documentation and a copy of submitted check (if applicable) to NGS no later than 3/2/2020. Providers are able to submit their determinations via email. Please submit the self-reported hospice cap pro-forma calculation and support via email: selfreportedhospicecap@anthem.com.  

Repaying an Overpayment

If the self-reported cap calculation indicates an amount due to Medicare, please wait to receive a demand letter before making a check payable to National Government Services and submit it in a separate envelope to one of the following locations:

• J6 Wisconsin Providers (AK, AZ, CA, HI, ID, MI, MN, NJ, NY, OR, WA, WI, American Samoa, Guam, North Mariana Islands, Puerto Rico or Virgin Islands)
  National Government Services
  P.O. Box 809199
  Chicago, IL 60680-9199
  

• • JK RHHI Providers (CT, MA, ME, NH, RI, VT)
    National Government Services
    P.O. Box 809366
    Chicago, IL 60680-9366
    
    
  • Physical Address for Courier Deliveries (All)
    U.S. Bank
    Attn: Lockbox (Use P.O. Box Number)
    5635 South Archer Avenue
    Chicago, IL 60638
    

Requesting an Extended Repayment Plan

If a provider is unable to repay the self-determined overpayment within 15 days, they can submit a request for an ERS by emailing them; J6 providers:  J6A.ERS.requests@anthem.com and for JK providers: jkextendedrepaymentsschedules@anthem.com, ATTN: ERS REQUESTS:

• • Written request for extended repayment, including ERS term requested;
  • A signed proposed amortization schedule including interest at the rate indicated on the demand letter;     
  • A check copy of the first payment based on the signed proposed amortization schedule

Depending on the length of the requested repayment term additional documentation may be required. Additional information, including a checklist of documentation requirements for an ERS request, is available on our website. Please note interest starts after 30 days.