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A recipient 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 enrolled in Medicare Parts A and B (not registered in Medicare Advantage, including Unique Requirements Strategies, or PACE programs) and has Medicare as their primary payer; Has not elected the Medicare hospice advantage, and; Is not a long-lasting nursing home local.

The table listed below shows a description of the 5 tiers. GUIDE Participants will report data on illness stage and caregiver status to CMS when a beneficiary is first aligned to a participant in the design. To make sure constant beneficiary assignment to tiers throughout model individuals, GUIDE Individuals should utilize a tool from a set of authorized screening and measurement tools to determine dementia stage and caregiver concern.

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

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For an individual with Medicare to receive services under the design, they need to fulfill particular eligibility requirements. They will also need to find a healthcare company that is taking part in the GUIDE Design in their community. CMS will publish a list of GUIDE Participants on the GUIDE website in Summertime 2024.

For instant assistance, please find the following resources: and . You might also contact 1-800-MEDICARE for particular information on questions regarding Medicare benefits. For the purposes of the GUIDE Model, a caretaker is defined as a relative, or unpaid nonrelative, who helps the recipient with activities of everyday living and/or instrumental activities of everyday living.

Individuals with Medicare must have dementia to be qualified for voluntary alignment to a GUIDE Individual and may be at any phase of dementiamild, moderate, or extreme. When a person with Medicare is very first examined for the GUIDE Design, CMS will count on clinician attestation instead of the existence of ICD-10 dementia diagnosis codes on previous Medicare claims.

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Additionally, they might attest that they have gotten a composed report of a recorded dementia diagnosis from another Medicare-enrolled practitioner. When a recipient is voluntarily aligned to a GUIDE Individual, the GUIDE Participant need to 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 include two tools to report dementia phase the Medical Dementia Ranking (CDR) or the Functional Evaluation Screening Tool (QUICKLY) and one tool to report caregiver pressure, the Zarit Burden Interview (ZBI).

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GUIDE Participants have the option to look for CMS approval to use an alternative screening tool by sending the proposed tool, along with released evidence that it stands and dependable and a crosswalk for how it corresponds to the design's tiering thresholds. CMS has full discretion on whether it will accept the proposed option tool.

The GUIDE Model requires Care Navigators to be trained to deal with caretakers in recognizing and handling typical behavioral modifications due to dementia. GUIDE Individuals will also examine the recipient's behavioral health as part of the comprehensive assessment and offer recipients and their caregivers with 24/7 access to a care team member or helpline.

A lined up recipient would be deemed ineligible if they no longer fulfill one or more of the beneficiary eligibility requirements. This might occur, for example, if the beneficiary ends up being a long-lasting nursing home local, enrolls in Medicare Benefit, or stops getting the GUIDE care delivery services from the GUIDE Participant (e.g., due to the fact that they vacate the program service location, no longer dream to be lined up to the GUIDE Individual, or can not be contacted/are lost to follow-up). The GUIDE Design is not an overall expense of care design and does not have requirements around specific drug treatments.

GUIDE Participants will be enabled to modify their service area throughout the period of the Model. Candidates might select a service area of any size as long as they will be able to provide all of the GUIDE Care Delivery Provider to beneficiaries in the determined service areas. Recipients who live in assisted living settings may qualify for alignment to a GUIDE Participant provided they fulfill all other eligibility requirements. The GUIDE Participant will identify the recipient's primary caregiver and examine the caregiver's knowledge, needs, wellness, stress level, and other challenges, consisting of reporting caregiver pressure to CMS utilizing the Zarit Burden Interview.

The GUIDE Design is not a shared cost savings or total expense of care model, it is a condition-specific longitudinal care model. In general, GUIDE Design participants will be paid a month-to-month dementia care management payment (DCMP) for each recipient. The GUIDE Design is created to be suitable with other CMS responsible care designs and programs (e.g., ACOs and advanced main care designs) that offer health care entities with opportunities to improve care and minimize costs.

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DCMP rates will be geographically adjusted along with an Efficiency Based Modification (PBA) to incentivize top quality care. The GUIDE Design will likewise pay for a specified amount of reprieve services for a subset of design recipients. 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 break codes.

Reprieve services will be paid up to an annual cap of $2,500 per recipient and will vary in system costs dependent on the kind of break service used. Yes, the monthly rates by tier are available listed below.(New Client Payment Rate)$150$275$360$230$390(Developed Patient Payment Rate)$65$120$220$120$215GUIDE Participants are accountable for paying Partner Organizations for GUIDE care shipment services that the Partner Company supplies to the GUIDE Individual's lined up recipients.

GUIDE Individuals and Partner Organizations will identify a payment arrangement and GUIDE Individuals need to have contracts in place with their Partner Organizations to show this payment plan. GUIDE Participants will also be anticipated to maintain a list of Partner Organizations ("Partner Organization Lineup") and update it as changes are made throughout the course of the GUIDE Design.