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Deadline Extended for Hardship Exemption Application

Mar 1, 2016 8 Min Read

featured_questionNew and Updated FAQs Provide Guidance on Public Health Reporting Requirements for the EHR Incentive Programs

The Centers for Medicare & Medicaid Services (CMS) is extending the application deadline for the Medicare EHR Incentive Program hardship exception process that reduces burden on clinicians, hospitals, and critical access hospitals (CAHs). The new deadline for Eligible Professionals, Eligible Hospitals and Critical Access Hospitals is July 1, 2016. CMS is extending the deadline so providers have sufficient time to submit their applications to avoid adjustments to their Medicare payments in 2017.

In January, CMS posted new, streamlined hardship exception application forms that reduce the amount of information that eligible professionals (EPs), eligible hospitals, and CAHs must submit to apply for an exception. The new applications and instructions for providers seeking a hardship exception are available here.

CMS has published frequently asked questions (FAQs) about the public health reporting objective for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. These include three new FAQs about when providers can register their intent to report to a registry, what a provider should do in 2016 if they did not previously intend to report to a public health reporting measure, and the alternate exclusions available for public health reporting in 2016. Review these FAQs below to learn more.

FAQ #14393 (New): Can a provider register their intent after the first 60 days of the reporting period in order to meet the measures if a registry becomes available after that date?

If a registry declares readiness at any point in the calendar year after the initial 60 days, a provider may still register their intent to report with that registry to meet the measure under Active Engagement Option 1. However, a provider who could report to that registry may still exclude for that calendar year if they had already planned to exclude based on the registry not being ready to allow for registrations of intent within the first 60 days of the reporting period.

Created 02/25/2016

FAQ #14397 (New): What should a provider do in 2016 if they did not previously intend to report to a public health reporting measure that was previously a menu measure in Stage 2 and they do not have the necessary software in CEHRT or the interface the registry requires available in their health IT systems?  What if the software is potentially available but there is a significant cost to connect to the interface?

In the 2015 EHR Incentive Programs Final Rule, we stated that we did not intend for providers to be inadvertently penalized for changes to their systems or reporting made necessary by the provisions of that regulation. This included alternate exclusions for providers for certain measures in 2016, which might require the acquisition of additional technologies they did not previously have for measures they did not previously intend to include in their activities for meaningful use (80 FR 62945). Therefore, in order that providers are not held accountable to obtain and implement new or additional systems, we will allow providers to claim an alternate exclusion from certain public health reporting measures in 2016 if they did not previously intend to report to the Stage 2 menu measure.

LIST OF MEASURES FOR EPs WHICH WOULD ALLOW AN ALTERNATE EXCLUSION:

LIST OF MEASURES FOR EHs WHICH WOULD ALLOW AN ALTERNATE EXCLUSION :

Created 02/25/2016

FAQ #14401 (New): For 2016, what alternate exclusions are available for the public health reporting objective?  Is there an alternate exclusion available to accommodate the changes to how the measures are counted?

We do not intend to inadvertently penalize providers for changes to their systems or reporting made necessary by the provisions of the 2015 EHR Incentive Programs Final Rule. This includes alternate exclusions for providers for certain measures in 2016, which might require the acquisition of additional technologies they did not previously have or did not previously intend to include in their activities for meaningful use (80 FR 62945). For 2016, EPs scheduled to be in Stage 1 or Stage 2 must attest to at least 2 measures from the Public Health Reporting Objective Measures 1-3 and eligible hospitals or CAHs scheduled to be in Stage 1 or Stage 2 must attest to at least 3 public health measures from the Public Health Reporting Objective Measures 1-4.

We will allow providers to claim an alternate exclusion for the Public Health Reporting measure(s) which might require the acquisition of additional technologies providers did not previously have or did not previously intend to include in their activities for meaningful use.

We will allow Alternate Exclusions for the Public Health Reporting Objective in 2016 as follows:

FAQ #13657 (Updated): What steps does a provider have to take to determine if there is a specialized registry available for them, or if they should instead claim an exclusion? 

The eligible professional (EP) is not required to make an exhaustive search of all potential registries.  Instead, they must do a few steps to meet due diligence in determining if there is a registry available for them, or if they meet the exclusion criteria.

  1. An EP should check with their State* to determine if there is an available specialized registry maintained by a public health agency.
  2. An EP should check with any specialty society with which they are affiliated to determine if the society maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider’s EHR reporting period. If the EP determines no registries are available, they may exclude from the measure. For EPs:  The provider may meet the specialized registry measure up to 2 times.  This can be done through reporting to:
    • Two registries maintained by a public health agency
    • Two registries maintained by one or more specialty societies
    • One registry maintained by a public health agency and one maintained by a specialty society
    • One registry maintained by a public health agency and one exclusion
    • One registry maintained by a specialty society and one exclusion
    • Two exclusions

PLEASE NOTE: In 2015, providers may also simply claim an alternate exclusion for a measure as defined in FAQ 12985. *If you report to an entity other than a State as your reporting jurisdiction (such as a county) you may elect to check with them.

Created 12/11/2015, Updated 02/25/2016

FAQ #14117 (Updated): What steps do eligible hospitals and Critical Access Hospitals need to take to meet the specialized registry objective? Is it different from EPs?

For an eligible hospital or Critical Access Hospitals (CAHs), the process is the same as for an EP.  The eligible hospital or CAH should check their State* and any such organization or specialty society with which they are affiliated to determine if that entity maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider’s EHR reporting period.

However, we note that eligible hospitals or CAHs do not need to explore every specialty society with which their hospital-based specialists may be affiliated.  The hospital may simply check with their State* and any such organization with which it is affiliated, and if no registries exist, they may simply exclude from the measure.

For further information please see FAQ #:13657.

For eligible hospitals and CAHs:  The provider may meet the specialized registry measure up to 3 times.  This can be done through reporting to:

  • Three registries maintained by a public health agency
  • Three registries maintained by one or more specialized societies
  • One or two registries maintained by a public health agency and two or one maintained by a specialty society
  • Two registries maintained by a public health agency and one exclusion
  • Two registries maintained by a specialty society and one exclusion
  • One registry maintained by a public health agency and one registry maintained by a specialty society and one exclusions*
  • One registry maintained by a public health agency and two exclusions*
  • One registry maintained by a specialty society and two exclusions*
  • Three exclusions

*In these cases, the exclusion which overlaps a category of registries would be based on there being no additional option for reporting beyond those already selected by the eligible hospital or CAH.

PLEASE NOTE: In 2015, providers may also simply claim an alternate exclusion for a measure as defined in FAQ 12985.

*If you report to an entity other than a State as your reporting jurisdiction (such as a county) you may elect to check with them.

Created 01/28/2016, Updated 02/25/2016.

FAQ #13653(Updated): What can count as a specialized registry?

A submission to a specialized registry may count if the receiving entity meets the following requirements:

  • The receiving entity must declare that they are ready to accept data as a specialized registry and be using the data to improve population health outcomes.  Until such time as a centralized repository is available to search for registries, most public health agencies and clinical data registries are declaring readiness via a public online posting. Registries should make this information publicly available for potential registrants.
  • The receiving entity must also be able to receive electronic data generated from CEHRT.  The electronic file can be sent to the receiving entity through any appropriately secure mechanism including, but not limited to, a secure upload function on a web portal, sFTP, or Direct.  Manual data entry into a web portal would not qualify for submission to a specialized registry.
  • The receiving entity should have a registration of intent process, a process to take the provider through test and validation and a process to move into production.  The receiving entity should be able to provide appropriate documentation for the sending provider or their current status in Active Engagement.

For qualified clinical data registries, reporting to a QCDR may count for the public health specialized registry measure as long as the submission to the registry is not only for the purposes of meeting CQM requirements for PQRS or the EHR Incentive Programs.  In other words, the submission may count if the registry is also using the data for a public health purpose.  Many QCDRs use the data for a public health purpose beyond CQM reporting to CMS.  A submission to such a registry would meet the requirement for the measure if the submission data is derived from CEHRT and transmitted electronically.

Created 12/11/2015, Updated 02/25/2016.

For More Information visit
the CMS EHR Incentive Programs website