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

The infrastructure payment is meant for providers who wish to develop brand-new dementia care programs and need resources to get going. GUIDE Participants certified as a security net company based upon the percentage of their client population that is dually eligible for Medicare and Medicaid or get the Part D low-income subsidy.

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To certify as a GUIDE security web company, a new program applicant must have had a Medicare FFS recipient population comprised of at least 36% beneficiaries getting the Part D low-income aid or 33.7% recipients who are dually qualified for Medicare and Medicaid. Accepting the facilities payment was optional. Neither the Dementia Care Management Payment (DCMP) nor GUIDE reprieve services will go through recipient cost-sharing.

When a lined up beneficiary is re-assessed and designated to a new tier, the GUIDE Individual will be qualified to bill the G-code for the established patient payment rate associated with that tier the following month. GUIDE Individuals that withdraw or are terminated before the start of the 2nd performance year will be needed to pay back the whole value of their infrastructure payment to CMS.

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After the 2nd performance year, GUIDE Individuals that withdraw or are terminated from the GUIDE Design are not needed to pay back the infrastructure payment. The main model payment under the GUIDE Design 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 Charge Arrange (PFS) services, including chronic care management and primary care management, transitional care management, advance care preparation, and technology-based check-ins.

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The GUIDE Design is not a total-cost-of-care model, so GUIDE Individuals will continue to costs under conventional Medicare fee-for-service for all services that are not consisted of under the DCMP. CMS may add or remove codes over time to show modifications in PFS billing codes.

The care group might include the beneficiary's medical care service provider, and if not, the care group is required to determine and share details with the beneficiary's medical care service provider and professionals and describe the care coordination services required to handle the recipient's dementia and co-occurring conditions. CMS will supply GUIDE Individuals data related to the efficiency measures that CMS uses to figure out the GUIDE Individual's performance-based adjustment to the DCMP.GUIDE Participants in the recognized program track must be prepared to begin providing services under the GUIDE Model on July 1, 2024, and bill for those services during the Model Performance Duration.

Yes, GUIDE beneficiary and company overlap with the Shared Cost savings Program is permitted. The GUIDE Design is created to be compatible with other CMS designs and programs that intend to improve care and lower spending. CMS thinks targeted support for individuals with dementia and their caregivers will assist improve population-based care outcomes in general.

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As an example, if an ACO is getting involved in both the GUIDE Model and the Shared Cost Savings Program during Performance Year 2024 and then renews and starts a brand-new arrangement 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 Benchmark Year 3. GUIDE Respite Service claims will not be counted towards ACO expenses, shared cost savings, nor benchmarking start in 2024 for the period of the GUIDE Model.

GUIDE Participants might participate in multiple CMS Innovation Center models or Medicare value-based care efforts to speed up innovation in care delivery, lower the expense of care, and improve population health. Individuals and beneficiaries are eligible to get involved 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 Break Service claims in the REACH ACOs' overall cost of care expenses or computation of shared savings/shared losses.

Overlapping participants must follow GUIDE billing guidance as set forth listed below. GUIDE Break Service claims will not count towards ACO expenditures, shared cost savings, or benchmarking in 2025 and for the duration of the GUIDE Model.

As of January 1, 2025, GUIDE Individuals likewise taking part in ACO REACH must discontinue billing the Medicare Physician Fee Arrange Providers included under the DCMP (See Display 5 in the GUIDE Payment Approach Paper (PDF)). Participants taking part in both models should follow the GUIDE billing requirements in the GUIDE Participation Contract and GUIDE Payment Method Paper.

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The GUIDE Participant must not bill Medicare individually for the services provided in the extensive assessment. The extensive evaluation (and any re-assessments) is covered by the DCMP. If CMS figures out the recipient is not qualified for the GUIDE Design, the GUIDE Individual can bill for a proper Medicare-covered professional service that corresponds to the services rendered.