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A beneficiary is eligible to receive services under the GUIDE Model if they fulfill the following requirements: Has dementia, as confirmed by attestation from a clinician on the GUIDE Individual's GUIDE Professional Lineup; Is registered in Medicare Parts A and B (not registered in Medicare Benefit, including Unique Needs Strategies, or PACE programs) and has Medicare as their primary payer; Has not elected the Medicare hospice advantage, and; Is not a long-term assisted living home citizen.

The table below shows a description of the five tiers. GUIDE Individuals will report data on illness stage and caretaker status to CMS when a beneficiary is first lined up to a participant in the model. To make sure consistent recipient assignment to tiers across design participants, GUIDE Individuals should utilize a tool from a set of approved screening and measurement tools to measure dementia phase and caregiver problem.

GUIDE Individuals need to notify recipients about the model and the services that recipients can get through the model, and they must document that a beneficiary or their legal representative, if applicable, approvals to receiving services from them. GUIDE Participants need to then submit the consenting recipient's details to CMS and, within 15 days, CMS will confirm whether the beneficiary meets the design eligibility requirements before aligning the beneficiary to the GUIDE Individual.

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For an individual with Medicare to get services under the design, they need to meet certain eligibility requirements. They will also require to discover a healthcare company that is taking part in the GUIDE Design in their community. CMS will publish a list of GUIDE Individuals on the GUIDE website in Summer season 2024.

For immediate assistance, please find the list below resources: and . You may also get in touch with 1-800-MEDICARE for particular info on questions concerning Medicare benefits. For the functions of the GUIDE Design, a caretaker is specified as a relative, or unpaid nonrelative, who assists the beneficiary with activities of day-to-day living and/or instrumental activities of daily living.

People with Medicare should have dementia to be eligible for voluntary positioning to a GUIDE Participant and may be at any phase of dementiamild, moderate, or serious. When a person with Medicare is very first evaluated for the GUIDE Design, CMS will depend on clinician attestation instead of the existence of ICD-10 dementia diagnosis codes on prior Medicare claims.

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Additionally, they might testify that they have received a written report of a documented dementia diagnosis from another Medicare-enrolled specialist. Once a recipient is voluntarily lined up to a GUIDE Individual, the GUIDE Individual must attach a qualified ICD-10 dementia diagnosis code to each Dementia Care Management Payment (DCMP) month-to-month claim in order for it to be paid by CMS.The approved screening tools consist of 2 tools to report dementia phase the Clinical Dementia Score (CDR) or the Functional Assessment Screening Tool (QUICK) and one tool to report caregiver pressure, the Zarit Burden Interview (ZBI).

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GUIDE Individuals have the alternative to seek CMS approval to use an alternative screening tool by submitting the proposed tool, in addition to published evidence that it stands and reliable and a crosswalk for how it corresponds to the design's tiering thresholds. CMS has complete discretion on whether it will accept the proposed option tool.

The GUIDE Design requires Care Navigators to be trained to deal with caregivers in determining and handling typical behavioral changes due to dementia. GUIDE Participants will also evaluate the beneficiary's behavioral health as part of the thorough evaluation and provide recipients and their caregivers with 24/7 access to a care group member or helpline.

For instance, a lined up recipient would be deemed ineligible if they no longer satisfy one or more of the recipient eligibility requirements. This could happen, for instance, if the recipient becomes a long-lasting nursing home citizen, registers in Medicare Advantage, or stops getting the GUIDE care delivery services from the GUIDE Individual (e.g., because they move out of the program service area, no longer desire to be lined up to the GUIDE Participant, or can not be contacted/are lost to follow-up). The GUIDE Model is not a total cost of care design and does not have requirements around particular drug treatments.

GUIDE Participants will be allowed to modify their service area throughout the period of the Design. Applicants may choose a service area of any size as long as they will have the ability to supply all of the GUIDE Care Delivery Solutions to recipients in the recognized service areas. Recipients who reside in assisted living settings might receive alignment to a GUIDE Individual supplied they fulfill all other eligibility criteria. The GUIDE Participant will determine the recipient's main caretaker and examine the caregiver's understanding, requires, well-being, tension level, and other challenges, including reporting caretaker stress to CMS using the Zarit Burden Interview.

The GUIDE Model is not a shared savings or total expense of care model, it is a condition-specific longitudinal care design. In basic, GUIDE Model participants will be paid a monthly dementia care management payment (DCMP) for each beneficiary. The GUIDE Model is developed to be suitable with other CMS liable care designs and programs (e.g., ACOs and advanced medical care models) that offer health care entities with opportunities to improve care and lower spending.

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DCMP rates will be geographically changed in addition to a Performance Based Change (PBA) to incentivize high-quality care. The GUIDE Model will also pay for a specified amount of reprieve services for a subset of design beneficiaries. Model participants will utilize a set of brand-new G-codes created for the GUIDE Design to send claims for the regular monthly DCMP and the break codes.

Reprieve services will be paid up to an annual cap of $2,500 per beneficiary and will vary in unit costs based on the kind of respite service used. Yes, the regular monthly rates by tier are available listed below.(New Client 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 Company provides to the GUIDE Participant's aligned beneficiaries.

GUIDE Individuals and Partner Organizations will determine a payment arrangement and GUIDE Individuals need to have contracts in place with their Partner Organizations to reflect this payment arrangement. GUIDE Individuals will also be anticipated to keep a list of Partner Organizations ("Partner Organization Roster") and update it as modifications are made throughout the course of the GUIDE Model.