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GUIDE Participants have the option, 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 Involvement Contract. GUIDE Individuals in the new program track that are categorized as safeguard service providers will be eligible to get a one-time infrastructure payment of $75,000 (geographically adjusted by the Geographic Change Element [GAF] to cover some of the upfront costs of developing a brand-new dementia care program.

The infrastructure payment is planned for companies who wish to establish new dementia care programs and need resources to start. GUIDE Participants certified as a safeguard company based on 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 qualify as a GUIDE safeguard provider, a new program applicant must have had a Medicare FFS recipient population made up of at least 36% recipients getting the Part D low-income aid or 33.7% recipients who are dually eligible for Medicare and Medicaid. Accepting the facilities 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 appointed to a new tier, the GUIDE Individual will be eligible to bill the G-code for the recognized client payment rate related to that tier the following month. GUIDE Individuals that withdraw or are terminated before the start of the second efficiency year will be needed to pay back the whole value of their infrastructure payment to CMS.

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After the second efficiency year, GUIDE Individuals that withdraw or are terminated from the GUIDE Model are not required to pay back the facilities 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 Physician Cost Set Up (PFS) services, including chronic care management and principal 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 Participants will continue to costs under traditional Medicare fee-for-service for all services that are not included under the DCMP. CMS might include or remove codes over time to reflect modifications in PFS billing codes.

The care team might consist of the beneficiary's primary care supplier, and if not, the care group is required to determine and share information with the recipient's medical care provider and specialists and lay out the care coordination services required to handle the recipient's dementia and co-occurring conditions. CMS will supply GUIDE Participants information associated with the performance measures that CMS uses to identify the GUIDE Participant's performance-based modification to the DCMP.GUIDE Individuals in the recognized program track must be prepared to begin providing services under the GUIDE Design on July 1, 2024, and costs for those services during the Model Efficiency Period.

Yes, GUIDE recipient and service provider overlap with the Shared Cost savings Program is allowed. The GUIDE Model is designed to be compatible with other CMS models and programs that aim to improve care and lower spending. CMS thinks targeted support for people with dementia and their caregivers will help enhance population-based care outcomes in general.

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As an example, if an ACO is taking part in both the GUIDE Model and the Shared Savings Program during Efficiency 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 criteria based on 2022, 2023 and 2024, and would have DCMPs counted in Benchmark Year 3. GUIDE Reprieve Service claims will not be counted toward ACO expenditures, shared savings, nor benchmarking start in 2024 for the duration of the GUIDE Design.

GUIDE Individuals might take part in multiple CMS Development Center designs or Medicare value-based care efforts to accelerate development in care shipment, minimize the expense of care, and enhance population health. Individuals and beneficiaries are qualified to participate in the GUIDE Design 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 declares in the REACH ACOs' total cost of care expenses or estimation of shared savings/shared losses.

Overlapping individuals need to follow GUIDE billing guidance as set forth 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.

Since January 1, 2025, GUIDE Participants also participating in ACO REACH must stop billing the Medicare Physician Charge Arrange Services consisted of under the DCMP (See Display 5 in the GUIDE Payment Methodology Paper (PDF)). Participants taking part in both designs must follow the GUIDE billing requirements in the GUIDE Involvement Agreement and GUIDE Payment Method Paper.

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The GUIDE Participant should not bill Medicare independently for the services supplied in the extensive assessment. The detailed assessment (and any re-assessments) is covered by the DCMP. If CMS identifies the recipient is not eligible for the GUIDE Model, the GUIDE Participant can bill for an appropriate Medicare-covered expert service that represents the services rendered.