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GUIDE Participants have the option, and are not required, to make available break through an adult day center or a 24-hour center. Additional GUIDE Break Solutions requirements and information surrounding the payment for such services are defined in the Involvement Contract. GUIDE Individuals in the new program track that are categorized as safeguard service providers will be qualified to receive a one-time facilities payment of $75,000 (geographically changed by the Geographic Modification Element [GAF] to cover a few of the upfront expenses of developing a new dementia care program.

The infrastructure payment is planned for suppliers who desire to develop brand-new dementia care programs and need resources to begin. GUIDE Individuals qualified as a safeguard service provider based on the proportion 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 safety net service provider, a brand-new program applicant must have had a Medicare FFS recipient population consisted of at least 36% recipients getting the Part D low-income aid or 33.7% recipients who are dually eligible for Medicare and Medicaid. Accepting the infrastructure payment was optional. Neither the Dementia Care Management Payment (DCMP) nor GUIDE respite services will go through beneficiary cost-sharing.

When an aligned recipient is re-assessed and assigned to a new tier, the GUIDE Participant will be qualified to bill the G-code for the established patient payment rate associated with that tier the following month. GUIDE Participants that withdraw or are terminated before the start of the second efficiency year will be required to repay the whole value of their infrastructure payment to CMS.

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After the second performance year, GUIDE Participants that withdraw or are terminated from the GUIDE Design are not needed to repay the infrastructure payment. The primary design 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 Fee Set Up (PFS) services, consisting of persistent care management and primary care management, transitional care management, advance care preparation, and technology-based check-ins.

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The GUIDE Model is not a total-cost-of-care model, so GUIDE Participants will continue to expense under conventional Medicare fee-for-service for all services that are not consisted of under the DCMP. Extra info, including a complete list of duplicative codes, is available in the Request for Applications (Table 8, pg. 35). CMS might add or get rid of codes over time to reflect changes in PFS billing codes.

The care team might include the beneficiary's medical care provider, and if not, the care team is required to recognize and share information with the beneficiary's medical care supplier and professionals and outline the care coordination services required to manage the recipient's dementia and co-occurring conditions. CMS will provide GUIDE Individuals information connected to the performance measures that CMS uses to identify the GUIDE Individual's performance-based adjustment to the DCMP.GUIDE Participants in the recognized program track should be prepared to start providing services under the GUIDE Model on July 1, 2024, and bill for those services throughout the Model Efficiency Duration.

Yes, GUIDE beneficiary and supplier overlap with the Shared Cost savings Program is permitted. The GUIDE Model is created to be compatible with other CMS models and programs that intend to enhance care and minimize costs. CMS thinks targeted support for people with dementia and their caregivers will assist improve population-based care results in general.

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The Dementia Care Management Payment (DCMP), the per beneficiary per month GUIDE payment, will be consisted of in 2024 Shared Savings Program expenses. When 2024 ends up being a benchmark year, DCMPs will be consisted of in Shared Cost savings Program criteria calculations. As an example, if an ACO is getting involved in both the GUIDE Design and the Shared Savings Program during Efficiency Year 2024 and then renews and begins a new agreement period since January 1, 2025, that ACO would have their Shared Cost savings Program criteria based upon 2022, 2023 and 2024, and would have DCMPs counted in Standard Year 3. GUIDE Reprieve Service claims will not be counted toward ACO expenditures, shared cost savings, nor benchmarking start in 2024 for the period of the GUIDE Model.

GUIDE Individuals might take part in numerous CMS Development Center models or Medicare value-based care initiatives to speed up development in care delivery, lower the cost of care, and improve population health. Participants and recipients are eligible to participate in the GUIDE Design and the ACO REACH Model. For the rest of CY 2024, ACO REACH will not consist of the Dementia Care Management Payment (DCMP) or Respite Service claims in the REACH ACOs' overall expense of care expenditures or estimation of shared savings/shared losses.

Overlapping individuals should follow GUIDE billing guidance as set forth listed below. GUIDE Break Service claims will not count towards ACO expenses, shared cost savings, or benchmarking in 2025 and for the duration of the GUIDE Design.

As of January 1, 2025, GUIDE Individuals also getting involved in ACO REACH must discontinue billing the Medicare Physician Cost Schedule Solutions consisted of under the DCMP (See Display 5 in the GUIDE Payment Method Paper (PDF)). Individuals taking part in both models need to follow the GUIDE billing requirements in the GUIDE Participation Agreement and GUIDE Payment Methodology Paper.

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The GUIDE Participant must not bill Medicare separately for the services supplied in the detailed evaluation. The thorough assessment (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 proper Medicare-covered expert service that represents the services rendered.