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Printed Date: 9/22/2015
Reminder – the "Provider Self-Determined Aggregate Cap Limitation" form is due March 1, 2021
*** File soon so payments will not be suspended ***
The form labeled "SELF DETERMINED HOSPICE CAP REPORT (SDHC)" is attached below. (SDHC_2020_form)
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, 2020.
Also note that 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 2020 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 2020 only applies to hospices certified on or before October 1, 2019. The first cap period for providers certified after October 1, 2019 is the 2021 cap report and will be due February 28, 2022.
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?
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!!)
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 of the following addresses. The payment can also be submitted using 'eCheck'. eCheck is 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 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 (PDF, 210 KB) form and instructions, please access the Forms section of the Palmetto GBA website. You should submit your request for extended repayment at the same time you submit your self report.
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Last Updated: 02/26/2021
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