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A recipient is qualified to receive services under the GUIDE Design if they meet the following criteria: Has dementia, as validated by attestation from a clinician on the GUIDE Participant's GUIDE Specialist Roster; Is enrolled in Medicare Components A and B (not registered in Medicare Benefit, including Special Needs Plans, or speed programs) and has Medicare as their primary payer; Has not chosen the Medicare hospice advantage, and; Is not a long-term assisted living home local.

The table listed below programs a description of the five tiers. GUIDE Individuals will report information on illness stage and caregiver status to CMS when a beneficiary is very first aligned to an individual in the design. To guarantee consistent beneficiary assignment to tiers across design participants, GUIDE Participants should utilize a tool from a set of approved screening and measurement tools to measure dementia stage and caretaker concern.

GUIDE Participants should notify recipients about the model and the services that recipients can get through the design, and they should record that a beneficiary or their legal agent, if relevant, consents to getting services from them. GUIDE Individuals should then send the consenting beneficiary's info to CMS and, within 15 days, CMS will validate whether the beneficiary fulfills the design eligibility requirements before lining up the recipient to the GUIDE Participant.

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For an individual with Medicare to get services under the model, they must satisfy specific eligibility requirements. They will also need to discover a healthcare provider that is participating in the GUIDE Model in their community. CMS will publish a list of GUIDE Participants on the GUIDE website in Summer 2024.

For immediate assistance, please discover the following resources: and . You may also contact 1-800-MEDICARE for specific info on concerns relating to Medicare advantages. For the purposes of the GUIDE Design, a caretaker is specified as a relative, or unpaid nonrelative, who helps the recipient with activities of everyday living and/or critical activities of everyday living.

Individuals with Medicare need to have dementia to be qualified for voluntary positioning to a GUIDE Individual and might be at any stage of dementiamild, moderate, or severe. When an individual with Medicare is first assessed for the GUIDE Design, CMS will depend on clinician attestation instead of the presence of ICD-10 dementia diagnosis codes on prior Medicare claims.

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They might confirm that they have actually received a composed report of a recorded dementia diagnosis from another Medicare-enrolled specialist. As soon as a beneficiary is willingly lined up to a GUIDE Participant, the GUIDE Individual should connect an eligible ICD-10 dementia diagnosis code to each Dementia Care Management Payment (DCMP) monthly claim in order for it to be paid by CMS.The authorized screening tools consist of 2 tools to report dementia stage the Clinical Dementia Score (CDR) or the Functional Evaluation Screening Tool (FAST) and one tool to report caretaker stress, the Zarit Problem Interview (ZBI).

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GUIDE Individuals have the choice to seek CMS approval to utilize an alternative screening tool by sending the proposed tool, together with released proof that it stands and reliable and a crosswalk for how it corresponds to the design's tiering limits. CMS has complete discretion on whether it will accept the proposed alternative tool.

The GUIDE Model needs Care Navigators to be trained to work with caretakers in recognizing and handling common behavioral modifications due to dementia. GUIDE Participants will also examine the beneficiary's behavioral health as part of the detailed assessment and provide recipients and their caregivers with 24/7 access to a care staff member or helpline.

For instance, a lined up beneficiary would be considered ineligible if they no longer meet several of the recipient eligibility requirements. This might happen, for instance, if the recipient becomes a long-term nursing home local, registers in Medicare Advantage, or stops getting the GUIDE care shipment services from the GUIDE Participant (e.g., since they move out of the program service location, no longer desire to be aligned to the GUIDE Individual, or can not be contacted/are lost to follow-up). The GUIDE Model is not a total cost of care model and does not have requirements around specific drug treatments.

GUIDE Participants will be permitted to modify their service area throughout the period of the Design. Applicants might pick a service area of any size as long as they will have the ability to provide all of the GUIDE Care Delivery Solutions to beneficiaries in the determined service locations. Beneficiaries who reside in assisted living settings might certify for positioning to a GUIDE Participant supplied they fulfill all other eligibility requirements. The GUIDE Participant will identify the beneficiary's primary caregiver and examine the caregiver's understanding, needs, well-being, tension level, and other obstacles, including reporting caretaker strain to CMS using the Zarit Problem Interview.

The GUIDE Model is not a shared savings or total expense of care model, it is a condition-specific longitudinal care model. In basic, GUIDE Model individuals will be paid a monthly dementia care management payment (DCMP) for each beneficiary. The GUIDE Design is created to be suitable with other CMS responsible care models and programs (e.g., ACOs and advanced primary care models) that offer health care entities with chances to improve care and reduce spending.

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DCMP rates will be geographically changed along with an Efficiency Based Change (PBA) to incentivize premium care. The GUIDE Model will also pay for a specified amount of break services for a subset of model recipients. Model participants will utilize a set of new G-codes created for the GUIDE Model to send claims for the monthly DCMP and the break codes.

Break services will be paid up to a yearly cap of $2,500 per beneficiary and will vary in system costs reliant on the kind of reprieve service utilized. Yes, the month-to-month rates by tier are available listed below.(New Patient Payment Rate)$150$275$360$230$390(Developed Client Payment Rate)$65$120$220$120$215GUIDE Participants are accountable for paying Partner Organizations for GUIDE care delivery services that the Partner Organization provides to the GUIDE Participant's lined up recipients.

GUIDE Individuals and Partner Organizations will identify a payment arrangement and GUIDE Individuals need to have agreements in location with their Partner Organizations to show this payment plan. GUIDE Individuals will likewise be expected to keep a list of Partner Organizations ("Partner Company Roster") and upgrade it as changes are made throughout the course of the GUIDE Model.