Form CMS-10275 Participation Exemption Request (PER) Form

Home Health Care CAHPS Survey
Participation Exemption Request (PER) Form
for the Annual Payment Update for Calendar Year 2021
Use this form to request an exemption from participating in the HHCAHPS survey for the
calendar year (CY) 2021 Annual Payment Update (APU) period on the basis of your size.
When is the exemption in force? The exemption is in force only for the CY 2021 APU period,
which is between April 1, 2019, and March 31, 2020. 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, 2018, and March
31, 2019. 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 2021 APU HHCAHPS Survey data collection
period, which runs from April 1, 2019, through March 31, 2020.
What do I need to do? You need to provide a count of your agency’s HHCAHPS-eligible
patients served between April 1, 2018, and March 31, 2019. 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 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 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, 2018, and March 31, 2019, who were 18 years old and older whose care

1

was covered by Medicare or Medicaid. Count patients who were discharged and later
readmitted 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 or Medicaid.
To determine the number of unduplicated or unique patients served, count each patient
only once regardless of the number of readmissions 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, 2018, and March 31, 2019,
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.
Question

Response

1. Enter your agency’s 6-digit CMS Certification Number (CCN,
formerly known as the Medicare Provider Number) .......................
Enter the name of your agency ............................................................
2. Count and enter the number of patients served between April 1,
2018, and March 31, 2019, 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, 2018, and March 31, 2019, who were 18
years old or older on the date of your count whose home care was
paid for by Medicare 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, 2018, and March 31, 2019, for routine maternity care
only ............................................................................................

2

Question

Response

d. Number of patients who did not receive at least two (2) skilled
care home visits between April 1, 2018, and March 31, 2019...
e.1 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 .........................................................................
e.2 In the text box below, provide a brief explanation that includes
the number of patients and the relevant state laws/regulations
that apply to all patients you have entered in step e.1 above.
Text box here:
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.

After you have completed your count, please go to the HHCAHPS website and complete the
online Participation Exemption Request Form for CY 2021.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1066. The expiration date for OMB control number 0938-1066 is January 31, 2021. The time
required to complete this information collection is estimated to average 12 minutes per response, including the
time to review instructions, search existing data sources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500 Security
Boulevard, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.

3