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GUIDE Individuals have the option, and are not needed, to make available break through an adult day center or a 24-hour facility. Additional GUIDE Reprieve Providers requirements and information surrounding the payment for such services are defined in the Involvement Agreement.

The infrastructure payment is intended for companies who wish to develop brand-new dementia care programs and need resources to start. GUIDE Individuals qualified as a safety net supplier based upon the proportion of their patient population that is dually qualified for Medicare and Medicaid or receive the Part D low-income aid.

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To qualify as a GUIDE safeguard provider, a brand-new program candidate should have had a Medicare FFS recipient population comprised of at least 36% recipients getting the Part D low-income aid or 33.7% beneficiaries who are dually qualified for Medicare and Medicaid. Accepting the infrastructure payment was optional. Neither the Dementia Care Management Payment (DCMP) nor GUIDE respite services will go through recipient cost-sharing.

When an aligned recipient is re-assessed and assigned to a brand-new tier, the GUIDE Individual will be eligible to bill the G-code for the established 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 2nd performance year, GUIDE Participants that withdraw or are ended from the GUIDE Design are not required to pay back the infrastructure payment. The primary 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 Charge Set Up (PFS) services, consisting of persistent 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 conventional Medicare fee-for-service for all services that are not included under the DCMP. CMS may include or get rid of codes over time to reflect changes in PFS billing codes.

The care team might consist of the beneficiary's medical care company, and if not, the care team is needed to determine and share details with the recipient's primary care provider and specialists and outline the care coordination services needed to manage the beneficiary's dementia and co-occurring conditions. CMS will supply GUIDE Participants information associated with the performance determines that CMS uses to determine the GUIDE Participant's performance-based modification to the DCMP.GUIDE Participants in the established program track need to be prepared to begin providing services under the GUIDE Model on July 1, 2024, and bill for those services during the Model Efficiency Duration.

Yes, GUIDE beneficiary and supplier overlap with the Shared Savings Program is permitted. The GUIDE Model is developed to be suitable with other CMS models and programs that intend to enhance care and reduce costs. CMS believes targeted support for individuals with dementia and their caregivers will assist enhance population-based care results overall.

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As an example, if an ACO is getting involved in both the GUIDE Design and the Shared Cost Savings Program throughout Performance Year 2024 and then renews and starts a new agreement period as of January 1, 2025, that ACO would have their Shared Cost savings Program standard based on 2022, 2023 and 2024, and would have DCMPs counted in Criteria Year 3. GUIDE Respite Service claims will not be counted towards ACO expenses, shared savings, nor benchmarking start in 2024 for the duration of the GUIDE Design.

GUIDE Individuals might take part in multiple CMS Innovation Center designs or Medicare value-based care initiatives to speed up innovation in care shipment, reduce the expense of care, and improve population health. Individuals and beneficiaries are qualified to participate in the GUIDE Model and the ACO REACH Design. For the rest of CY 2024, ACO REACH will not include the Dementia Care Management Payment (DCMP) or Respite Service claims in the REACH ACOs' total expense of care expenditures or estimation of shared savings/shared losses.

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

As of January 1, 2025, GUIDE Individuals likewise taking part in ACO REACH should stop billing the Medicare Doctor Cost Arrange Solutions included under the DCMP (See Exhibit 5 in the GUIDE Payment Method Paper (PDF)). Participants taking part in both designs should follow the GUIDE billing requirements in the GUIDE Participation Arrangement and GUIDE Payment Method Paper.

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The GUIDE Participant should not bill Medicare separately for the services offered in the extensive assessment. The comprehensive evaluation (and any re-assessments) is covered by the DCMP. If CMS figures out the recipient is not eligible for the GUIDE Design, the GUIDE Participant can bill for a proper Medicare-covered expert service that corresponds to the services rendered.