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CMS

Post-Acute Care Quality Programs





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Reporting Exception Granted Due to California Wildfires and Straight-line Winds

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions1 [ #bookmark0 ] under certain Medicare quality reporting and value-based purchasing programs to providers and facilities located in areas affected by the "California Wildfires and Straight-line Winds "as identified by both Department of Health and Human Services (HHS) Public Health Emergency (PHE) declarations HHS.GOV.PHE.CA [ https://aspr.hhs.gov/legal/PHE/Pages/CA-Wildfires-Jan2025.aspx ] Wildfires_January 2025, [ https://aspr.hhs.gov/legal/PHE/Pages/CA-Wildfires-Jan2025.aspx ] and the Federal Emergency Management Agency (FEMA) disaster declarations DR-4856-CA [ https://www.fema.gov/disaster/4856 ] to assist these providers and facilities while they direct their resources toward caring for their patients and addressing potential infrastructure challenges affecting their healthcare operations.

Affected areas covered by these exceptions are detailed on the Designated Areas: Disaster 4856 [ https://www.fema.gov/disaster/4856/designated-areas ]_ _ pages, under the section Public Assistance, designations PA-A and PA-B, of the FEMA website. If FEMA expands the emergency disaster declaration to include additional affected areas at a later date, CMS will likewise extend reporting requirement exceptions to accommodate these areas but will not necessarily publish updated communications.

At the time of this communication, the exceptions being granted are for the reporting requirements and deadlines as detailed in the table below.

1 The terminology “exception” is used as a general term intended for ease of reference, to collectively refer to policies established under separate programs, and may not be consistent with the specific terminology established under each individual program.

Table 1Table 2table 3Table 4

*"_CONSIDERATIONS FOR AFFECTED PROVIDERS AND FACILITIES THAT CHOOSE TO_ _REPORT DATA UNDER AN EXTRAORDINARY CIRCUMSTANCE EXCEPTION (ECE)_"*

Providers and facilities should be aware of the potential impact to reporting requirements and payment programs when deciding whether or not to report data included in the exceptions. If data are voluntarily submitted, they will be publicly reported or used in scoring.

In particular, hospitals located within the designated affected areas listed under this disaster declaration should be aware of the potential subsequent impact to the Hospital Value-Based Purchasing (VBP) Program and HAC Reduction Program minimum case threshold counts for inclusion in these programs and which measures have enough data for scoring. For example, hospitals might be scored solely on the HAC Reduction Program’s claims-based "CMS Patient Safety "and "Adverse Events Composite "(CMS PSI- 90) measure due to non-submissions resulting in not meeting the minimum number of Centers for

Disease Control and Prevention’s HAI measures with sufficient cases. For the HAC Reduction Program, if data for the excepted period are submitted, they will be used for scoring in the program.

*"_OTHER CMS QUALITY PROGRAM EXCEPTION POLICIES_"*

*Additional Reporting Requirement Exceptions*

Providers and facilities located within a designated area listed in the FEMA disaster declaration who seek an exception for a reporting requirement not covered by this table may request an individual exception using the applicable Extraordinary Circumstance Exception [ https://www.qualityreportingcenter.com/globalassets/2023/03/iqr/dviqr-ece-quick-reference_march-2023_vfinal508.pdf ] (ECE) request process for the respective program(s). CMS will assess and decide upon each ECE request on a case-by-case basis.

*Merit-based Incentive Payment System (MIPS)*

In addition to the above table, the MIPS automatic Extreme and Uncontrollable Circumstances (EUC) policy will be applied at the individual level to MIPS eligible clinicians identified as located in the aforementioned affected areas. Additional information on this policy can be found in the 2024 MIPS [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2840/2024-MIPS-Automatic-EUC-Policy.pdf ] Automatic EUC Factsheet [ https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2840/2024-MIPS-Automatic-EUC-Policy.pdf ].

table 5

*"_CASES OF NON-EXCEPTION_"*

*Program Participants in Non-Designated Areas*

Providers and facilities located _outside_ the FEMA-designated areas are not covered by these exceptions, but they may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs they participate in using the applicable ECE request

process for the respective program(s). CMS will assess and decide upon each ECE request on a case-by- case basis.

*End-Stage Renal Disease Quality Incentive Program (ESRD QIP)*

The ESRD QIP does not participate in these exceptions. Impacted dialysis facilities should submit ECE requests according to the process and form found on the ESRD QIP QualityNet ECE Policy Page [ https://qualitynet.cms.gov/esrd/esrdqip/participation#tab5 ] within 90 days of the event.

*Medicare Promoting Interoperability Program*

Under the Medicare Promoting Interoperability Program, a Hardship Exception Application [ https://cmsqualitysupport.servicenowservices.com/cms_hh ] may be available for eligible hospitals and critical access hospitals affected by the aforementioned disaster, as long as the requesting eligible hospital or critical access hospital has not met the 5 hardship maximum (as set forth in Social Security Act section 1886(b)(3)(B)(ix)(II)). Please note that the Medicare Promoting Interoperability Program has a separate hardship exception process from the Hospital IQR Program. An exception or hardship under one program will not ensure an exception or hardship under the other program.

*"_ADDITIONAL INFORMATION_"*

*Program*



*ECE Email Contact for Inquiries*



*Additional ECE Information*



ESRD QIP



QRFormsSubmission@hsag.com



ESRD QIP Information [ https://qualitynet.cms.gov/esrd/esrdqip/participation#tab5 ]



HH QRP



HHAPUreconsiderations@ <HHAPUreconsiderations@CMS.hhs.gov> CMS.hhs.gov <HHAPUreconsiderations@CMS.hhs.gov>



Home Health Quality Reporting [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Reconsideration-and-Exception-and-Extension ] (HHQR) Program ECE Information [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Reconsideration-and-Exception-and-Extension ]



Home Health Value-Based Purchasing (HHVBP) Model



HHVBPquestions@lewin.com



HHVBP Information [ https://innovation.cms.gov/innovation-models/expanded-home-health-value-based-purchasing-model ]



Hospice QRP



HospiceQRPReconsiderations <HospiceQRPReconsiderations@cms.hhs.gov> @cms.hhs.gov <HospiceQRPReconsiderations@cms.hhs.gov>



Hospice QRP ECE Information [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Extensions-and-Exemption-Requests ]



Hospital IQR, IPFQR, PCHQR,

Hospital VBP, ASCQR, OQR, REHQR, HAC Reduction, and Hospital Readmissions Reduction Programs, Hospital Validation



*" "*

*" "*

QRFormsSubmission@hsag.com



*" "*

Hospital and ASC QRPs ECE [ https://qualitynet.cms.gov/inpatient/iqr/participation#tab3 ] Information [ https://qualitynet.cms.gov/inpatient/iqr/participation#tab3 ]



IRF QRP



IRFQRPReconsiderations@ <IRFQRPReconsiderations@cms.hhs.gov>

cms.hhs.gov <IRFQRPReconsiderations@cms.hhs.gov>



IRF QRP ECE Information [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-Quality-Reporting-Reconsideration-and-Exception-and-Extension ]



LTCH QRP



LTCHQRPReconsiderations@ <LTCHQRPReconsiderations@cms.hhs.gov> cms.hhs.gov <LTCHQRPReconsiderations@cms.hhs.gov>



LTCH QRP ECE Information [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/LTCH-Quality-Reporting-Reconsideration-and-Exception-and-Extension ]



Medicare Promoting Interoperability Program



https://cmsqualitysupport.serviceno [ https://cmsqualitysupport.servicenowservices.com/qnet_qa ] wservices.com/qnet_qa [ https://cmsqualitysupport.servicenowservices.com/qnet_qa ]



Medicare Promoting Interoperability [ https://www.cms.gov/regulations-guidance/promoting-interoperability/resource-library ] Program Hardship Exception [ https://www.cms.gov/regulations-guidance/promoting-interoperability/resource-library ]

Information [ https://www.cms.gov/regulations-guidance/promoting-interoperability/resource-library ]



MIPS/QPP



qpp@cms.hhs.gov <QPP@cms.hhs.gov>



QPP; [ https://qpp.cms.gov/ ]

QPP Resource Center [ https://qpp.cms.gov/resources/help-and-support ]



SNF QRP



SNFQRPReconsiderations@ <SNFQRPReconsiderations@cms.hhs.gov> cms.hhs.gov <SNFQRPReconsiderations@cms.hhs.gov>



SNF QRP ECE Information [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-QR-Reconsideration-and-Exception-and-Extension ]



SNF VBP Program



SNFVBP@rti.org



SNF VBP Program ECE [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/SNF-VBP/Extraordinary-Circumstance-Exception- ]_ _Information [ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/SNF-VBP/Extraordinary-Circumstance-Exception- ]



*Please do not respond directly to this email. *For assistance regarding the information contained in this message, please contact the "Inpatient and Outpatient Healthcare Quality Systems Development and Program Support Team "at https://cmsqualitysupport.servicenowservices.com/qnet_qa, or *844.472.4477 *weekdays from 8 a.m. to 8 p.m. ET. For questions regarding technical issues, contact the "CCSQ Support Center "at QNetSupport@cms.hhs.gov, or by calling, toll-free *866.288.8912 *(TTY: 877.715.6222), weekdays from 8 a.m. to 8 p.m. ET.






Center for Clinical Standards and Quality








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