Participation in the 2021 ICH CAHPS Surveys
folder_openFacility Participation Requirementscalendar_todayPosted January 5, 2021
In-center hemodialysis (ICH) facilities that served 30 or more survey-eligible patients in calendar year (CY) 2020 must administer the In-center Hemodialysis CAHPS (ICH CAHPS) Survey in the spring and fall of CY2021 to comply with the Centers for Medicare & Medicaid Services’ (CMS) quality reporting requirements for the 2023 payment year.
All ICH facilities should read this announcement in its entirety to determine whether they are required to participate in the ICH CAHPS Survey in CY2021 and if so, review the steps that need to be taken.
Determining Whether Participation in the CY2021 ICH CAHPS Surveys is Required
To determine whether your ICH facility (CCN) is required to participate in the ICH CAHPS Survey in CY2021, count the number of survey-eligible patients your facility served in CY2020. Your count must include hemodialysis patients who:
- were 18 years old or older as of December 31, 2020;
- were alive as of December 31, 2020;
- received hemodialysis on an outpatient basis from your facility for 3 consecutive months or longer at some point in CY2020;
- are not currently receiving hospice care; and
- were not living in a nursing home/skilled nursing facility or other long-term facility such as a prison or jail as of December 31, 2020.
Patients who receive home or peritoneal dialysis are not eligible to participate in the ICH CAHPS Survey; therefore, do not include those patients in your count of survey-eligible patients. In addition, ICH facilities that received Medicare certification after December 31, 2020 are not required to participate in the ICH CAHPS Survey in CY2021.
ICH facilities should note that the ICH CAHPS Coordination Team DOES NOT have information about the number of survey-eligible patients a facility served in CY2020. Therefore, each ICH facility is responsible for determining whether it is required to administer the 2021 ICH CAHPS semiannual surveys.
For Facilities That Are NOT Required To Participate
ICH facilities that served 29 or fewer survey-eligible patients in CY2020 are not required to participate in the ICH CAHPS semiannual surveys in CY2021. However, all such facilities can choose one of the following four options:
- Option 1. Administer the surveys in 2021 following all of the ICH protocols and procedures described in the ICH CAHPS Survey Administration and Specifications Manual;
- Option 2. Administer the survey using a third-party vendor but not following the ICH CAHPS protocols and procedures;
- Option 3. Administer the survey themselves, instead of using a third-party vendor; however, if any changes are made to the survey, it cannot be referred to as a CAHPS Survey; or
- Option 4. Choose not to administer the survey at all.
If a facility that served 29 or fewer survey-eligible patients in CY2020 chooses Option 1, the ICH facility must be registered on the ICH CAHPS website and a vendor must be authorized. CMS will provide a patient sample to the facility’s authorized ICH CAHPS Survey vendor for both the 2021 Spring and Fall Surveys. The surveys must be conducted according to all ICH CAHPS Survey protocols and procedures, which include the following:
- Using a CMS-approved ICH CAHPS Survey vendor to administer the survey on its behalf;
- Administering both the 2021 ICH CAHPS Spring and Fall Surveys;
- Adhering to the ICH CAHPS survey administration procedures and protocols described in the ICH CAHPS Survey Administration and Specifications Manual when administering the survey; and
- Submitting an ICH CAHPS Survey data file for each survey period to the ICH CAHPS Data Center.
If a facility chooses Option 2 or Option 3, CMS will not provide patient samples to the facility, nor will it accept submission of any data files to the Data Center. The ICH facility will be responsible for either working with a survey vendor (if choosing Option 2) or within their own organization (if choosing Option 3) to select the samples for the survey that will be conducted and for conducting all other aspects of the survey.
Please note: Because facilities implementing Option 2 or Option 3 will not submit an ICH CAHPS Survey data file to the Data Center, their collected survey data will not be analyzed for official ICH CAHPS public reporting purposes, nor will the administration of these surveys be used to determine ESRD Quality Incentive Program (QIP) compliance.
Facility Non-Participation Form
If an ICH facility chooses Option 2, Option 3, or Option 4, the facility must complete and submit a 2021 ICH CAHPS Facility Non-Participation Form, which is an online form that is available on the ICH CAHPS website (available under the For Facilities tab once the user logs in to the website). ICH facilities should note the following:
- The Facility Non-Participation Form is an annual form that is valid only for the year in which it was submitted. ICH facilities that submitted the Facility Non-Participation Form in CY2020 must submit the 2021 Facility Non-Participation Form if they do not plan to administer the 2021 ICH CAHPS Spring and Fall Surveys.
- Submission of the Facility Non-Participation Form only alerts the ICH CAHPS Coordination Team that the facility does not wish for a sample file to be provided to their authorized vendor for the current calendar year; it does not affect compliance, which is determined on an annual basis by the ESRD Quality Incentive Program (QIP) team.
- Once the Facility Non-Participation Form is submitted, any existing vendor authorization for the submitted facility is removed from the ICH CAHPS website. This means that if at any point in the future the submitted facility wishes to participate in the ICH CAHPS Surveys, the designated ICH CAHPS Facility Survey Administrator will need to authorize a survey vendor for the facility.
- Facilities certified after December 31, 2020 are not required to complete and submit the online Facility Non-Participation Form, unless they are registered with an authorized vendor on the ICH CAHPS website.
If your organization does not plan to administer the ICH CAHPS Survey in 2021, you must complete and submit the 2021 Facility Non-Participation Form by 5:00 PM Eastern Time on February 28, 2021.
For Facilities That ARE Required To Participate
ICH facilities that served 30 or more survey-eligible patients in calendar year CY2020 must administer the 2021 ICH CAHPS Spring and Fall Surveys to comply with quality reporting requirements for the 2023 payment year.
For Facilities that Administered the ICH CAHPS Survey in CY2020
Unless a 2021 Facility Non-Participation Form is submitted, the Coordination Team will provide a sample file to the survey vendor that is currently authorized on the ICH CAHPS website. If an ICH facility plans to use a different ICH CAHPS Survey vendor than was used in 2020, the facility must update its vendor authorization on the ICH CAHPS website before 5:00 PM Eastern Time on February 28, 2021. Click here for instructions on how to change the online vendor authorization.
For Facilities that have Never Administered the ICH CAHPS Survey
To participate in the survey for the first time, ICH facilities must do the following, if they have not already done so.
- Select and contract with one of the ICH CAHPS Survey vendors that have been approved by CMS. The list of CMS-approved ICH CAHPS Survey vendors is available on the ICH CAHPS website: https://ichcahps.org/GeneralInformation/ApprovedSurveyVendors.aspx.
- Designate a staff member to be the facility’s ICH CAHPS Survey Administrator (SA). For more information about the role of the ICH CAHPS SA, see information provided in Chapter III of the ICH CAHPS Survey Administration and Specifications Manual, which is available on the ICH CAHPS website: https://ichcahps.org/SurveyandProtocols.aspx
- Register on the ICH CAHPS website: https://ichcahps.org/ForFacilities/FacilityUserRegistration.aspx. When registering, your facility’s designated SA will create user credentials (username and password) that will allow him or her to access the private links on the ICH CAHPS website.
- Complete the online “Authorize a Vendor” form on the ICH CAHPS website by February 28, 2021 to authorize your survey vendor to collect and submit ICH CAHPS Survey data on your facility’s behalf.
Please contact the ICH CAHPS Coordination Team at 1-866-245-8083 or via email at firstname.lastname@example.org if you have any questions or need more information about the 2021 ICH CAHPS Surveys.