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GUIDE Individuals have the alternative, and are not needed, to make offered reprieve through an adult day center or a 24-hour center. Additional GUIDE Break Services requirements and details surrounding the payment for such services are defined in the Participation Arrangement.

The infrastructure payment is intended for service providers who desire to develop new dementia care programs and need resources to begin. GUIDE Individuals qualified as a safety net provider based upon the percentage of their client population that is dually eligible for Medicare and Medicaid or get the Part D low-income aid.

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To qualify as a GUIDE safeguard provider, a new program candidate should have had a Medicare FFS beneficiary population comprised of at least 36% beneficiaries receiving 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 respite services will undergo beneficiary cost-sharing.

When a lined up beneficiary is re-assessed and assigned to a brand-new tier, the GUIDE Participant will be eligible to bill the G-code for the recognized patient payment rate associated with that tier the following month. GUIDE Participants that withdraw or are ended before the start of the second efficiency year will be required to pay back the entire value of their infrastructure payment to CMS.

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After the second performance year, GUIDE Participants that withdraw or are ended from the GUIDE Model are not needed to repay 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 Physician Fee Arrange (PFS) services, including chronic care management and principal care management, transitional care management, advance care planning, and technology-based check-ins.

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The GUIDE Design is not a total-cost-of-care model, so GUIDE Participants will continue to bill under standard Medicare fee-for-service for all services that are not consisted of under the DCMP. Additional info, including a complete list of duplicative codes, is offered in the Request for Applications (Table 8, pg. 35). CMS might include or remove codes over time to reflect modifications in PFS billing codes.

The care team may consist of the recipient's medical care service provider, and if not, the care team is needed to identify and share details with the beneficiary's main care provider and specialists and detail the care coordination services needed to handle the recipient's dementia and co-occurring conditions. CMS will offer GUIDE Participants data connected to the performance measures that CMS uses to determine the GUIDE Individual's performance-based modification to the DCMP.GUIDE Participants in the established program track must be prepared to begin providing services under the GUIDE Design on July 1, 2024, and expense for those services throughout the Design Efficiency Duration.

Yes, GUIDE beneficiary and provider overlap with the Shared Cost savings Program is enabled. The GUIDE Model is created to be compatible with other CMS designs and programs that intend to improve care and decrease spending. CMS believes targeted support for individuals with dementia and their caretakers will help improve population-based care results overall.

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As an example, if an ACO is taking part in both the GUIDE Design and the Shared Cost Savings Program during Performance Year 2024 and then restores and begins a brand-new contract period 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 Reprieve 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 get involved in several CMS Development Center models or Medicare value-based care initiatives to accelerate development in care delivery, lower the cost of care, and enhance population health. Participants and recipients are eligible to get involved in the GUIDE Design and the ACO REACH Model. For the rest of CY 2024, ACO REACH will not include the Dementia Care Management Payment (DCMP) or Reprieve Service declares in the REACH ACOs' total expense of care expenses or calculation of shared savings/shared losses.

Overlapping individuals ought to follow GUIDE billing guidance as set forth below. GUIDE Respite Service claims will not count toward ACO expenses, shared savings, or benchmarking in 2025 and for the duration of the GUIDE Model.

As of January 1, 2025, GUIDE Individuals also getting involved in ACO REACH must cease billing the Medicare Physician Charge Schedule Solutions included under the DCMP (See Exhibit 5 in the GUIDE Payment Methodology Paper (PDF)). Participants participating in both designs must follow the GUIDE billing requirements in the GUIDE Involvement Agreement and GUIDE Payment Methodology Paper.

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The GUIDE Individual should not bill Medicare separately for the services provided in the extensive evaluation. The thorough evaluation (and any re-assessments) is covered by the DCMP. If CMS identifies the recipient is not qualified for the GUIDE Design, the GUIDE Individual can bill for an appropriate Medicare-covered expert service that corresponds to the services rendered.