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GUIDE Participants have the option, and are not needed, to make offered break through an adult day center or a 24-hour center. Extra GUIDE Reprieve Providers requirements and details surrounding the payment for such services are defined in the Participation Contract.

The facilities payment is planned for suppliers who wish to establish new dementia care programs and need resources to start. GUIDE Individuals qualified as a safeguard company based on the proportion of their client population that is dually eligible for Medicare and Medicaid or receive the Part D low-income aid.

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To qualify as a GUIDE safeguard provider, a new program applicant must have had a Medicare FFS recipient population comprised of a minimum of 36% beneficiaries getting the Part D low-income subsidy or 33.7% beneficiaries who are dually qualified for Medicare and Medicaid. Accepting the facilities payment was optional. Neither the Dementia Care Management Payment (DCMP) nor GUIDE break services will go through beneficiary cost-sharing.

When an aligned recipient is re-assessed and assigned to a new tier, the GUIDE Participant will be eligible to bill the G-code for the established patient payment rate related to that tier the following month. GUIDE Participants that withdraw or are ended before the start of the second performance year will be needed to pay back the entire value of their facilities payment to CMS.

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After the second efficiency year, GUIDE Participants that withdraw or are terminated from the GUIDE Design are not needed to pay back the infrastructure payment. The main design payment under the GUIDE Model is a per-beneficiary, per-month care management payment called the Dementia Care Management Payment (DCMP). The DCMP will replace fee-for-service payment for some existing Medicare Doctor Cost Arrange (PFS) services, consisting of chronic care management and primary care management, transitional care management, advance care planning, and technology-based check-ins.

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The GUIDE Model is not a total-cost-of-care design, so GUIDE Individuals will continue to costs under standard Medicare fee-for-service for all services that are not included under the DCMP. CMS might include or remove codes over time to reflect changes in PFS billing codes.

The care group might include the recipient's medical care supplier, and if not, the care group is required to recognize and share details with the beneficiary's primary care supplier and specialists and outline the care coordination services required to manage the recipient's dementia and co-occurring conditions. CMS will supply GUIDE Participants information connected to the efficiency determines that CMS utilizes to identify the GUIDE Participant's performance-based modification to the DCMP.GUIDE Individuals in the recognized program track should be prepared to begin furnishing services under the GUIDE Model on July 1, 2024, and expense for those services throughout the Model Performance Period.

Yes, GUIDE beneficiary and provider overlap with the Shared Savings Program is allowed. The GUIDE Design is designed to be suitable with other CMS models and programs that intend to enhance care and minimize costs. CMS believes targeted assistance for people with dementia and their caregivers will assist improve population-based care outcomes overall.

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As an example, if an ACO is taking part in both the GUIDE Model and the Shared Cost Savings Program throughout Performance Year 2024 and then renews and begins a new contract duration as of January 1, 2025, that ACO would have their Shared Cost savings Program criteria based on 2022, 2023 and 2024, and would have DCMPs counted in Standard Year 3. GUIDE Respite Service claims will not be counted towards ACO expenses, shared cost savings, nor benchmarking beginning in 2024 for the period of the GUIDE Design.

GUIDE Individuals might take part in several CMS Innovation Center designs or Medicare value-based care efforts to speed up development in care delivery, reduce the expense of care, and improve population health. Participants and recipients are qualified to take part in the GUIDE Design and the ACO REACH Design. For the rest of CY 2024, ACO REACH will not consist of the Dementia Care Management Payment (DCMP) or Respite Service claims in the REACH ACOs' overall expense of care expenses or computation of shared savings/shared losses.

Overlapping participants must follow GUIDE billing guidance as set forth below. ACO REACH claim reductions will not apply to DCMP. ACO REACH will include DCMP expenses for purposes of alignment calculations. Nevertheless, GUIDE Break Service claims will not count towards ACO expenditures, shared savings, or benchmarking in 2025 and throughout of the GUIDE Design.

As of January 1, 2025, GUIDE Participants likewise taking part in ACO REACH need to discontinue billing the Medicare Doctor Cost Schedule Services included under the DCMP (See Display 5 in the GUIDE Payment Method Paper (PDF)). Participants getting involved in both designs must follow the GUIDE billing requirements in the GUIDE Involvement Contract and GUIDE Payment Method Paper.

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The GUIDE Individual must not bill Medicare separately for the services offered in the extensive evaluation. The extensive assessment (and any re-assessments) is covered by the DCMP. If CMS figures out the beneficiary is not qualified for the GUIDE Model, the GUIDE Participant can bill for an appropriate Medicare-covered professional service that represents the services rendered.