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GUIDE Individuals have the choice, and are not needed, to make available respite 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 Involvement Agreement. GUIDE Individuals in the new program track that are classified as safety net suppliers will be eligible to get a one-time facilities payment of $75,000 (geographically changed by the Geographic Change Element [GAF] to cover a few of the in advance expenses of establishing a brand-new dementia care program.

The infrastructure payment is intended for suppliers who wish to establish brand-new dementia care programs and need resources to start. GUIDE Individuals certified as a safeguard company based on the percentage of their patient population that is dually eligible for Medicare and Medicaid or get the Part D low-income aid.

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To certify as a GUIDE safeguard supplier, a brand-new program applicant should have had a Medicare FFS recipient population made up of a minimum of 36% recipients receiving the Part D low-income subsidy or 33.7% beneficiaries who are dually eligible for Medicare and Medicaid. Accepting the infrastructure payment was optional. Neither the Dementia Care Management Payment (DCMP) nor GUIDE break services will be subject to beneficiary cost-sharing.

When a lined up recipient is re-assessed and assigned to a brand-new tier, the GUIDE Individual will be qualified to bill the G-code for the established patient payment rate connected with that tier the following month. GUIDE Individuals that withdraw or are terminated before the start of the second efficiency year will be needed to repay the entire 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 Design are not needed to repay the infrastructure payment. The main model 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 Doctor Charge Arrange (PFS) services, including persistent 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 design, so GUIDE Participants will continue to expense under conventional Medicare fee-for-service for all services that are not included under the DCMP. Extra info, including a total list of duplicative codes, is readily available in the Ask for Applications (Table 8, pg. 35). CMS may include or remove codes in time to show modifications in PFS billing codes.

The care team might include the recipient's medical care company, and if not, the care group is required to determine and share information with the recipient's main care provider and specialists and describe the care coordination services required to handle the recipient's dementia and co-occurring conditions. CMS will supply GUIDE Individuals information related to the efficiency measures that CMS utilizes to identify the GUIDE Participant's performance-based adjustment to the DCMP.GUIDE Participants in the established program track need to be prepared to begin furnishing services under the GUIDE Model on July 1, 2024, and bill for those services throughout the Design Efficiency Duration.

Yes, GUIDE beneficiary and service provider overlap with the Shared Savings Program is enabled. The GUIDE Design is developed to be suitable with other CMS designs and programs that intend to improve care and lower costs. CMS believes targeted assistance for individuals with dementia and their caretakers will assist improve population-based care outcomes overall.

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The Dementia Care Management Payment (DCMP), the per recipient monthly GUIDE payment, will be consisted of in 2024 Shared Cost savings Program expenses. When 2024 becomes a benchmark year, DCMPs will be consisted of in Shared Savings Program standard calculations. As an example, if an ACO is taking part in both the GUIDE Design and the Shared Cost Savings Program throughout Performance Year 2024 and after that renews and begins a brand-new arrangement period since January 1, 2025, that ACO would have their Shared Savings Program benchmark based upon 2022, 2023 and 2024, and would have DCMPs counted in Standard Year 3. However, GUIDE Break Service claims will not be counted toward ACO expenses, shared savings, nor benchmarking start in 2024 for the period of the GUIDE Model.

GUIDE Participants might take part in several CMS Development Center designs or Medicare value-based care efforts to accelerate development in care delivery, decrease the expense of care, and enhance population health. Participants 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 include the Dementia Care Management Payment (DCMP) or Reprieve Service claims in the REACH ACOs' total expense of care expenses or computation of shared savings/shared losses.

Overlapping participants must follow GUIDE billing guidance as set forth below. ACO REACH claim decreases will not apply to DCMP. ACO REACH will consist of DCMP expenses for functions of positioning computations. However, GUIDE Break Service claims will not count toward ACO expenses, shared savings, or benchmarking in 2025 and throughout of the GUIDE Model.

As of January 1, 2025, GUIDE Participants likewise getting involved in ACO REACH must stop billing the Medicare Doctor Fee Schedule Solutions included under the DCMP (See Exhibition 5 in the GUIDE Payment Approach Paper (PDF)). Participants getting involved in both designs need to follow the GUIDE billing requirements in the GUIDE Participation Agreement and GUIDE Payment Approach Paper.

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The GUIDE Individual should not bill Medicare independently for the services provided in the detailed evaluation. The thorough evaluation (and any re-assessments) is covered by the DCMP. If CMS determines the recipient is not qualified for the GUIDE Design, the GUIDE Participant can bill for a suitable Medicare-covered professional service that represents the services rendered.