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Monday,
June 17, 2013

Home Health Care CAHPS
Survey
The official website for
news and information about the HHCAHPS
Survey

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HHAs   »   Participation
Exemption Request Form

Home Health Care CAHPS
Survey

Participation Exemption
Request (PER) Form

For the Annual Payment Update
for Calendar Year
2015

Medicare-certified home health agencies
(HHAs) that served 59 or fewer unduplicated patients
from April 1, 2012 through March 31, 2013 who met
HHCAHPS survey-eligibility criteria are eligible for an
exemption from participating in the HHCAHPS Survey for
the calendar year (CY) 2015 annual payment update (APU).

HHAs seeking an exemption from
participating in the HHCAHPS Survey for the CY 2015 APU
must provide a count of the number of patients served
between April 1, 2012 and March 31, 2013 who met
survey-eligibility criteria.

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.

Instructions for Completing
the Participation Exemption Request 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, 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).

Next count and enter in Step 3 the number of
unduplicated (unique) patients served between April 1,
2012 and March 31, 2013 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. Do not include a
patient in more than one category. For example, if a
patient who was served between April 1, 2012 and March
31, 2013 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.

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.

CCN
Number:

AGENCY
NAME:

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, 2012 and March
31, 2013 who were 17 years old or younger on the
day of your count

3.

Count and enter the TOTAL number of
UNDUPLICATED patients served between April 1, 2012
and March 31, 2013 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.)

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.

Number
of patients who were known to be deceased as of
the day of your count

b.

Number
of patients who were discharged to hospice

c.

Number
of patients who received skilled home care between
April 1, 2012 and March 31, 2013 for routine
maternity care only

d.

Number
of patients who did not receive at least two (2)
skilled care home visits between April 1, 2012 and
March 31, 2013

e.

Number
of patients who have a condition or illness for
which the state in which the patient resides has
regulations or laws restricting the release of
patient information for patients with those
conditions

f.

Number
of patients who at their initial contact with the
agency, on their own initiative, said that the HHA
may not release their name and any contact
information to anyone other than the HHA
personnel

If you enter a number in this field,
you may be requested to provide documentation to
CMS.

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