Home Health Care CAHPS Survey
Participation Exemption Request (PER) Form
for the Annual Payment Update for Calendar Year 2019

Use this form to request an exemption from participating in the HHCAHPS survey for the CY 2019 APU period on the basis of your size.

Before completing the online Participation Exemption Request (PER) form, HHAs are encouraged to print this form and conduct the count first using the hardcopy form before entering the counts on the online form. Click here to review and print a hardcopy of the PER form.

When is the exemption in force? The exemption is in force only for the CY 2019 APU period which is between April 1, 2017 and March 31, 2018. The exemption is good for one year only. You must reapply if you want to request an exemption in subsequent years.

Who can apply for the exemption? Your home health agency (HHA) can request an exemption if you served 59 or fewer HHCAHPS-survey eligible patients between April 1, 2016 and March 31, 2017. Every fall, CMS reviews all participation exemption requests to evaluate, with other data, whether your agency will receive an exemption.

What does the exemption mean? If you believe that you are exempt, you do not need to participate in the HHCAHPS Survey for the CY 2019 APU HHCAHPS Survey data collection period, which runs from April 1, 2017 through March 31, 2018.

What do I need to do? You need to provide a count of your agency's HHCAHPS-eligible patients served between April 1, 2016 and March 31, 2017. The PER form below will help you do this. Please see the instructions below.

This form will assist you in determining if you have 59 or fewer HHCAHPS-eligible patients.

Instructions for Completing the Participation Exemption Request (PER) Form:

  • In Step 1, enter your 6-digit CCN (CMS Certification Number), which was formerly known as the Medicare Provider ID number. If your agency was recently certified by CMS and you have not yet received a CCN, you will need to wait until a CCN is assigned before you can complete the online Participation Exemption Request (PER) Form.
  • The system will automatically display the name of your agency (based on the CCN you enter in Step 1). If your agency name is different from the agency name that is displayed and the CCN you entered into the form is correct, please contact CMS.
  • The PER form is designed so that you will first count and enter the number of patients served who were 17 years old or younger on the day of your count (in Step 2). These patients are not eligible to be included in the HHCAHPS Survey.
  • Next count and enter in Step 3 the number of unduplicated (unique) patients served between April 1, 2016 and March 31, 2017 who were 18 years old and older whose care was covered by Medicare and/or Medicaid. Count patients who were discharged and later re-admitted for home care only once. Also, include patients enrolled in a Medicare Advantage plan or Medicaid managed care plan in this count, as their care is paid for by Medicare and/or Medicaid.

    To determine the number of unduplicated or unique patients served, count each patient only once regardless of the number of re-admissions during the specified 12-month period. Include in your count both current and discharged patients.
  • Of the patients included in the count in Step 3, enter the number of patients who fall into each of the categories in Steps 4a through 4f. These patients are not eligible to be included in the HHCAHPS Survey. Do not include a patient in more than one category. For example, if a patient who was served between April 1, 2016 and March 31, 2017 was released to hospice, but you know that that patient is deceased, you would include that patient in the count of patients known to be deceased but not in the count of those discharged to hospice. For Step 4e.2, you must provide a brief description of the relevant state laws/regulations and the number of affected patients until all patients entered in Step 4e.1 have been accounted for.
1. Enter your agency's 6-digit CMS Certification Number (CCN, formerly known as the Medicare Provider Number), then click the button beside the number that you entered.
 
  Agency name shown reflects information in the most current list of CMS agencies. Please contact CMS if this does not match your agency's name.
2. Count and enter the number of patients served between April 1, 2016 and March 31, 2017 who were 17 years old or younger on the day of your count Right arrow
3. Count and enter the TOTAL number of UNDUPLICATED patients served between April 1, 2016 and March 31, 2017 who were 18 years old or older on the date of your count whose home care was paid for by Medicare and/or Medicaid (See instructions above for additional details on who to include.) Right arrow
4. Of the patients included in the count in Step 3, enter the number of patients who fall into the following categories. Do not include a patient in more than one of the following categories.
  a. Right arrow
  b. Right arrow
  c. Right arrow
  d. Right arrow
  e1. Right arrow
e2.
  f.
If you enter a number in this field, you may be requested to provide documentation to CMS.
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OMB Control No 0938-1066