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A beneficiary is eligible to get services under the GUIDE Design if they satisfy the following criteria: Has dementia, as validated by attestation from a clinician on the GUIDE Participant's GUIDE Practitioner Roster; Is registered in Medicare Parts A and B (not registered in Medicare Benefit, including Unique Needs Plans, or speed programs) and has Medicare as their main payer; Has not elected the Medicare hospice benefit, and; Is not a long-lasting assisted living home resident.

The table listed below programs a description of the 5 tiers. GUIDE Individuals will report data on disease phase and caregiver status to CMS when a beneficiary is first lined up to a participant in the design. To make sure constant beneficiary assignment to tiers throughout model participants, GUIDE Individuals must utilize a tool from a set of approved screening and measurement tools to measure dementia stage and caretaker problem.

GUIDE Individuals must inform beneficiaries about the model and the services that beneficiaries can receive through the model, and they must record that a beneficiary or their legal agent, if appropriate, permissions to getting services from them. GUIDE Participants need to then submit the consenting recipient's information to CMS and, within 15 days, CMS will confirm whether the beneficiary meets the model eligibility requirements before aligning the recipient to the GUIDE Participant.

Key Modern Stacks to Watch During 2026

For an individual with Medicare to receive services under the model, they must satisfy particular eligibility requirements. They will likewise need to find a healthcare supplier that is participating in the GUIDE Design in their neighborhood. CMS will release a list of GUIDE Participants on the GUIDE site in Summer 2024.

For immediate assistance, please find the following resources: and . You might likewise contact 1-800-MEDICARE for specific details on concerns relating to Medicare advantages. For the functions of the GUIDE Design, a caretaker is specified as a relative, or unsettled nonrelative, who assists the recipient with activities of day-to-day living and/or crucial activities of day-to-day living.

Individuals with Medicare should have dementia to be eligible for voluntary alignment to a GUIDE Individual and might be at any phase of dementiamild, moderate, or severe. When an individual with Medicare is very first assessed for the GUIDE Design, CMS will count on clinician attestation instead of the existence of ICD-10 dementia medical diagnosis codes on previous Medicare claims.

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They might attest that they have received a written report of a documented dementia diagnosis from another Medicare-enrolled specialist. When a beneficiary is voluntarily aligned to a GUIDE Individual, the GUIDE Individual should attach a qualified ICD-10 dementia diagnosis code to each Dementia Care Management Payment (DCMP) monthly claim in order for it to be paid by CMS.The approved screening tools consist of two tools to report dementia phase the Clinical Dementia Score (CDR) or the Functional Evaluation Screening Tool (QUICKLY) and one tool to report caretaker strain, the Zarit Burden Interview (ZBI).

Future-Proofing Modern System Frameworks for 2026

GUIDE Individuals have the option to seek CMS approval to use an alternative screening tool by sending the proposed tool, in addition to released proof that it stands and reputable and a crosswalk for how it represents the model's tiering thresholds. CMS has full discretion on whether it will accept the proposed option tool.

The GUIDE Design requires Care Navigators to be trained to work with caregivers in determining and handling typical behavioral modifications due to dementia. GUIDE Participants will also assess the recipient's behavioral health as part of the detailed assessment and provide recipients and their caregivers with 24/7 access to a care team member or helpline.

An aligned recipient would be deemed ineligible if they no longer meet one or more of the beneficiary eligibility requirements. This could happen, for instance, if the recipient ends up being a long-term retirement home homeowner, registers in Medicare Advantage, or stops receiving the GUIDE care delivery services from the GUIDE Participant (e.g., due to the fact that they move out of the program service location, no longer dream to be aligned to the GUIDE Participant, or can not be contacted/are lost to follow-up). The GUIDE Model is not a total expense of care model and does not have requirements around particular drug treatments.

GUIDE Individuals will be permitted to revise their service location throughout the period of the Design. Applicants might select a service location of any size as long as they will have the ability to supply all of the GUIDE Care Shipment Services to recipients in the recognized service areas. Recipients who live in assisted living settings may get approved for positioning to a GUIDE Individual supplied they satisfy all other eligibility criteria. The GUIDE Participant will determine the beneficiary's primary caretaker and assess the caregiver's understanding, needs, wellness, stress level, and other challenges, consisting of reporting caregiver pressure to CMS using the Zarit Concern Interview.

The GUIDE Design is not a shared cost savings or overall expense of care design, it is a condition-specific longitudinal care design. In general, GUIDE Model participants will be paid a regular monthly dementia care management payment (DCMP) for each recipient. The GUIDE Model is developed to be compatible with other CMS responsible care models and programs (e.g., ACOs and advanced medical care models) that provide health care entities with opportunities to improve care and minimize costs.

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DCMP rates will be geographically changed as well as an Efficiency Based Change (PBA) to incentivize high-quality care. The GUIDE Model will also pay for a defined amount of respite services for a subset of model beneficiaries. Design participants will utilize a set of brand-new G-codes produced for the GUIDE Model to send claims for the month-to-month DCMP and the reprieve codes.

Reprieve services will be paid up to a yearly cap of $2,500 per beneficiary and will differ in unit costs depending on the type of break service utilized. Yes, the monthly rates by tier are available listed below.(New Patient Payment Rate)$150$275$360$230$390(Established Patient Payment Rate)$65$120$220$120$215GUIDE Participants are accountable for paying Partner Organizations for GUIDE care shipment services that the Partner Company provides to the GUIDE Individual's aligned recipients.

GUIDE Individuals and Partner Organizations will determine a payment arrangement and GUIDE Individuals must have agreements in place with their Partner Organizations to show this payment plan. GUIDE Participants will likewise be anticipated to preserve a list of Partner Organizations ("Partner Company Lineup") and update it as changes are made throughout the course of the GUIDE Model.