CAHPS Insider: August 2025

CMS News

Exceptions for Texas

Due to the ongoing effects of the public health emergency caused by the effects of severe storms, straight-line winds, and flooding in the state of Texas, CMS is granting exceptions under some Medicare quality reporting and value-based purchasing programs.

Exceptions include missing Q1 2025 HCAHPS and OAS CAHPS data, which were submitted on July 9, 2025.

CMS is also applying the MIPS automatic Extreme and Uncontrollable Circumstances (EUC) policy to eligible clinicians in affected counties for the 2025 performance period. These clinicians will have all four MIPS performance categories automatically reweighted to 0% and receive a neutral payment adjustment in the 2027 payment year, unless they choose to submit data for at least two categories, in which case they’ll receive a final score and payment adjustment.

For additional information, please visit the CMS Current Emergencies page and the CMS News Alert.

HCAHPS

Preview Reports

Inpatient Preview Reports are available now through September 3, 2025 by logging in to the HQR Portal. Preview Reports display results that will be publicly reported on Care Compare and in the Provider Data Catalog in October 2025.

Public Reporting Refresh

Publicly reported HCAHPS results on Care Compare have been updated to reflect results from Q4 2023 – Q3 2024 (October 1, 2023 – September 30, 2024).

Final Rule

The Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) Final Rule has been published on the Federal Register. It includes no changes to HCAHPS Survey administration and submission requirements. The includes a reminder that scoring is modified to only score hospitals on the six unchanged Hospital VBP dimensions of the HCAHPS Survey until the updates for the HCAHPS Survey have been publicly reported for one year. For additional information, please see the CMS Fact Sheet.

OAS CAHPS

Preview Reports

Preview Reports with results from the OAS CAHPS Survey for Q4 2023 – Q3 2024 (October 2023 – September 2024) are available by logging in to the OAS CAHPS website.

Public Reporting Refresh

Publicly reported OAS CAHPS results have been refreshed on the Provider Data Catalog to display results for procedures between Q4 2023 – Q3 2024 (October 2023 – September 2024). Results are available at the facility, state, and national levels.

Proposed Rule

CMS published the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs CY 2026 Proposed Rule on July 17, 2025. The rule proposes no changes to the OAS CAHPS Survey or required participation. The rule will be finalized in November 2025. The Proposed Rule is published on the Federal Register and is available for public comment through September 15, 2025.

Additional Ineligible CPT Codes

CMS has added two CPT codes to the list of procedures that are excluded from OAS CAHPS eligibility:

→ 20560, Needle insertion without injection into 1 or 2 muscles

→ 20561, Needle insertion without injection into 3 or more muscles

Appendix P of the Protocols & Guidelines will be updated this fall to reflect the change. The complete Protocols & Guidelines Manual is available on the OAS CAHPS website under Survey Materials.

Data Suppression

During voluntary participation in the OAS CAHPS Survey, CMS allowed HOPDs and ASCs to choose to not publicly report data. Since the October 2025 refresh contains data for four full quarters of mandated reporting (Q1 2024 – Q4 2024) for HOPDs, they will no longer have the option to suppress data. All data will be publicly reported for HOPDs beginning with the October 2025 data refresh.

ASCs will continue to have the ability to choose to not report data publicly while the reporting period includes voluntary data, which will extend through the July 2026 refresh. Beginning in October 2026, all OAS CAHPS data will be publicly reported.

If your ASC would like to keep data private for the October 2025 refresh, please contact NRC Health CAHPS Compliance by August 13, 2025.

HHCAHPS

Preview Reports

Preview Reports with results from the HHCAHPS Survey from Q2 2024 – Q1 2025 (April 2024 – March 2025), including Star Ratings, are available under the For HHAs tab on the HHCAHPS website. You must be logged on to view your report. Providers have until August 8, 2025 to review their data. These data will be displayed on Care Compare and in the Provider Data Catalog in October 2025.

Public Reporting Refresh

In July 2025, HHCAHPS data were refreshed on Care Compare and in the Provider Data Catalog to include results from Q1 2024 – Q4 2024 (January 1, 2024 – December 31, 2024). These data are also available in Archived Publicly Reported Data on the HHCAHPS website. This includes HHA-level data, state and national averages, Star Ratings cut points, and patient mix adjustment coefficients.

CAHPS Hospice

Final Rule

The FY 2026 Hospice Wage Index and Quality Reporting Final Rule has been published in the Federal Register. It contains no updates for the CAHPS Hospice Survey or survey administration.

ICH CAHPS

Vendor Authorization Deadline

Facilities participating in the 2025 ICH CAHPS Fall Survey must have an active contract with an approved survey vendor and have authorized that vendor by the August 31, 2025 deadline. A new vendor authorization can be completed when logged in to the ICH CAHPS website and is only required if:

→ Your organization is participating in ICH CAHPS for the first time,

→ Your organization is changing to a new survey vendor, or

→ Spring 2025 is listed as the ending survey period in your existing vendor authorization.

ICH CAHPS Coordination Team Semi-Annual Review

The ICH CAHPS Survey Coordination Team publishes a semi-annual newsletter. The July 2025 edition is now available on the ICH CAHPS website and contains important updates and reminders, including an update on the revised survey on the horizon, which is currently working through the approval process. It also contains information on patient engagement materials, upcoming deadlines, and the public reporting schedule.

Strategies to Improve Response Rates

CMS recognizes the challenges with declining ICH CAHPS response rates and has provided suggestions and patient engagement materials to increase participation.

→       Ensure patient contact information is current in EQRS

→       Let patients know what to expect

− Cover the basics such as the purpose, timeline, and plans to improve patient care based on survey results

−       Show them this survey envelope example so they recognize it in the mail

−       Familiarize them with NRC Health’s support line number – 1-800-733-6714

→       Use a poster or flyer in your facility to promote awareness and participation

− Add your logo and print the pre-approved templates in English and Spanish

→       Provide FAQs in your waiting room

− Print the FAQ documents in English and Spanish and make them available to your patients

→       Refer patients to the ICH CAHPS Dialysis Patient website

− Patients can find FAQs and additional information on ichcahps.org/Dialysis–Patients

ACO REACH

Preparing for the PY 2025 Fielding

ACO REACH CAHPS 2025 begins soon! Here are some things you can do to prepare and important upcoming dates:

→ Print and display the ACO REACH CAHPS FAQs prominently in your waiting room. Click for FAQs in English and Spanish.

→ CMS has analyzed the challenges reaching patients in residential care and assisted living facilities and has worked to mitigate the risk of missing feedback from this important patient population. Please create a list of the residential care and assisted living facilities where you have patients residing. Residents will be sent an alternate envelope and will not receive telephone follow-up. Please return this file to NRC Health CAHPS Compliance by August 13, 2025.

CAHPS for MIPS

Reporting Delay

Due to a delay with receiving some of the final Medicare claims data needed to calculate cost measures, MIPS final scores for the 2024 performance year will be published this fall, with the Targeted Review period to follow. Payment adjustments for the 2026 MIPS payment year will be released approximately one month after the final scores are released. The Targeted Review period will close 30 days MIPS payment adjustments are released. An updated timeline of important dates is available here.

PCF PECS

Final PCF PEC Survey Semiannual Newsletter

As the Primary Care First Model draws to a close, the PCF PEC Survey Team has published the final edition of their Semiannual Newsletter. It is available on the PCF PECS website here. It includes statistics on the overall PCF PEC Survey, a reminder that Supplemental Reports were released to practices on June 6, 2025, and model closeout reminders.

If you have questions, please reach out to PCF Support at PCF@Telligen.com or 888-517-7753.

PIX

Final Rule

The 2025 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) has been published in the Federal Register. In previous rulemaking, Psychiatric Inpatient Experience (PIX) Survey was finalized as a measure of patient experience for inpatient psychiatric facilities. The PIX Survey will become mandatory with for data collection beginning in CY 2026. There are no changes to this requirement. CMS received comments, including questions about how PIX results will be factored into Star Ratings. CMS will consider these comments for future rulemaking.

External Submission Deadlines