Provider Self-Determined Aggregate Cap Limitation Form Due February 28, 2023

A link to the self-determined hospice cap report (SDHC report) can be found below. You may use either the excel version or the pdf version. The file is named (SDHC_2022_form).

The top section of the one-page form contains the cap computation. The lower section contains the certification statement. Be sure to complete both sections. Please note the following related to submitting the self-determined hospice aggregate cap for the period ended September 30, 2022:

• The due date for submitting the form is February 28, 2023 
• Only send the signed form (supporting information is not needed) 
• The email and mail addresses for submitting form are listed below
• The addresses for sending payment (if applicable) are listed below
• Information on requesting an extended repayment schedule is also noted below 

As a patient continues on hospice care, the proportional beneficiary count will tend to decrease with the increase in the total days of hospice care. As a result, the overpayment may increase from the amount self-determined. An initial hospice cap review for the 2022 cap year will be performed and issued by Palmetto GBA and will incorporate any self-determined hospice cap overpayment and sequestration amounts.

Providers are required to obtain their own PS&R data in order to complete the self-determined hospice cap report. If you do not have access to the EIDM system, you should register now. Information about registering can be found on the CMS website.

The cap for 2022 only applies to hospices certified on or before October 1, 2021. The first cap period for providers certified after October 1, 2021, is the 2023 cap report and will be due February 28, 2024.

If you have any questions, please send them to us via email at HospiceCap@Palmettogba.com. 

Submitting the Self-Determined Cap Calculation

What to Send
Send only the completed and signed form (no other documentation) .

When to Send

• The 2022 provider self-determined aggregate cap limitation report is due on February 28, 2023 
• If the completed form is not filed timely, a past due letter will be sent within seven days and payments will be suspended 
• If unable to file the form timely, a written request can be submitted prior to the due date to request a 50 percent payment suspension 
• If an overpayment is computed and the amount due is not submitted, payments will be withheld 

How to Send
The form can be sent by mail or email. Email is the preferred method and offers the quickest acknowledgment receipt. (Only send by one method.)

• Email to: HospiceCap@palmettogba.com. Reference only your provider number in the subject line. 
• If unable to use email, mail to:

Repaying an Overpayment (if applicable)
If the cap computation indicates an amount due the Medicare program, please submit a check made payable to Palmetto GBA for the full amount (or the first month payment if requesting an ERS) and mail the check to either one of the addresses below. The payment can also be submitted using eCheck, a feature of the eServices portal, where registered providers can submit payments electronically. To register and utilize this feature, access our website and select the eServices link.

Requesting an Extended Repayment Schedule 
If you are unable to repay the cap overpayment in full, you may submit documentation supporting a request for extended repayment. This documentation must be sent at the time of the submission of your cap computation to avoid withholding. The required documentation includes, but is not limited to, balance sheets, income statements, cash flow statements, and statements of source and application funds. 

A copy of the check sent in as the first payment of the proposed repayment schedule must be included with the documentation. To obtain the Request for Extended Repayment Plan form and instructions, please access the Forms section of the Palmetto GBA website.

• SDHC_2022_Form (XLSX)
• SDHC_2022_Form (PDF)
• Instructions_for_completing_SDHC_2022  (PDF)
• Instructions_for_Ordering_PSR_and_Beneficiary_Report_2022 (PDF)