Self-Determined Hospice Cap Calculation - Reminder: The Provider Self-Determined Aggregate Cap Limitation Form is due February 28, 2019

Reminder — the "Provider Self-Determined Aggregate Cap Limitation" form is due February 28, 2019
  • The following article includes the link to the form and reporting instructions
  • The form is required of hospital-based and freestanding hospices for whom Palmetto GBA processes claims
  • If the form is not received on time, a past due letter will be issued and payments will be suspended
*** File soon so payments will not be suspended ***

The form labeled "Provider Self-Determined Aggregate Cap Limitation" is attached.

The form is only one page. The top section 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, 2018.

  • The due date for submitting the form is February 28, 2019
  • Only send the signed form (supporting information is not needed)
  • The email and postal addresses for submitting form are below
  • The addresses for sending payment (if applicable) are listed below
  • Information on requesting an Extended Repayment Schedule is also noted below

Also note that when 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. A final hospice cap review for the 2018 cap year will be performed and issued by Palmetto GBA, and will incorporate any self-determined hospice cap overpayment and sequestration amounts.

New this year: Providers will be required to obtain their own PS&R data in order to complete the Self-Determined Hospice Cap report. We will not be furnishing this data to all providers as in previous years. 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 2018 only applies to hospices certified on or before October 1, 2017. The first cap period for providers certified after October 1, 2017, is the 2019 cap report and will be due February 29, 2020.

If you have any questions, please send them to us via email at

Submitting the Self-Determined Cap Calculation
What to send?

  • Send only the completed and signed form (no other documentation)

When to send?

  • The 2018 Provider Self-Determined Aggregate Cap Limitation is due on February 28, 2019
  • If the completed form is not filed on time, a past due letter will be sent within seven (7) days and payments will be suspended
  • If unable to file the form on time, 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 email or mail. Email is the preferred method and offers the quickest acknowledgment receipt. (Only send by one method!)

Email to: Reference only your Provider Number in the subject line.

Mail to:

U.S. Postal Service
Palmetto GBA
Attn: Hospice Cap Reporting
Mail Code: AG-330
PO Box 100144
Columbia, SC 29202-3144 
Courier Service
Palmetto GBA
Attn: Hospice Cap Reporting
Mail Code: AG-330
2300 Springdale Drive, Building One
Camden, SC 29020-1728

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 and ERS) and mail the check to either of the following addresses. The payment can also be submitted using eCheck. eCheck is a feature of the eServices portal, where one can submit payments electronically. To register for and utilize this feature, access our website and select the eServices link.

U.S. Postal Service
Palmetto GBA
JM HHH Overpayments
Mail Code: AG-260
PO Box 100277
Columbia, SC 29202-3277
Courier Service
Palmetto GBA
JM HHH Overpayments
Mail Code: AG-260
2300 Springdale Drive, Building One
Camden, SC 29020-1728

Requesting an Extended Repayment Schedule
If you are unable to repay the cap overpayment, 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 of your payments. 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.

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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