Using Modern Digital Strategy to Maximum Impact

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A recipient is eligible to get services under the GUIDE Model if they meet the following requirements: Has dementia, as validated by attestation from a clinician on the GUIDE Participant's GUIDE Professional Lineup; Is enrolled in Medicare Components A and B (not enrolled in Medicare Advantage, including Special Requirements Strategies, or PACE programs) and has Medicare as their primary payer; Has not chosen the Medicare hospice advantage, and; Is not a long-lasting retirement home citizen.

The table below programs a description of the 5 tiers. GUIDE Individuals will report information on illness phase and caretaker status to CMS when a beneficiary is very first aligned to a participant in the design. To make sure consistent beneficiary task to tiers throughout design individuals, GUIDE Individuals should utilize a tool from a set of approved screening and measurement tools to measure dementia phase and caretaker problem.

GUIDE Participants must inform recipients about the model and the services that beneficiaries can receive through the model, and they must document that a recipient or their legal agent, if applicable, consents to receiving services from them. GUIDE Participants should then send the consenting recipient's information to CMS and, within 15 days, CMS will validate whether the beneficiary meets 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 design, they should meet specific eligibility requirements. They will likewise need to find a healthcare supplier that is getting involved in the GUIDE Model in their neighborhood. CMS will release a list of GUIDE Participants on the GUIDE site in Summertime 2024.

For immediate assistance, please find the list below resources: and . You may likewise call 1-800-MEDICARE for specific info on questions relating to Medicare advantages. For the functions of the GUIDE Design, a caretaker is defined as a relative, or unpaid nonrelative, who helps the beneficiary with activities of everyday living and/or critical activities of daily living.

Individuals with Medicare need to have dementia to be eligible for voluntary positioning to a GUIDE Individual and might be at any stage of dementiamild, moderate, or severe. When a person with Medicare is first examined for the GUIDE Design, CMS will rely on clinician attestation rather than the existence of ICD-10 dementia diagnosis codes on previous Medicare claims.

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They might attest that they have actually gotten a composed report of a documented dementia diagnosis from another Medicare-enrolled practitioner. As soon as a recipient is willingly lined up to a GUIDE Individual, the GUIDE Participant should 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 authorized screening tools include 2 tools to report dementia stage the Clinical Dementia Score (CDR) or the Functional Evaluation Screening Tool (FAST) and one tool to report caretaker strain, the Zarit Concern Interview (ZBI).

Key Development Tools to Adopt in 2026

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

The GUIDE Model requires Care Navigators to be trained to deal with caregivers in identifying and handling common behavioral changes due to dementia. GUIDE Participants will likewise assess the recipient's behavioral health as part of the extensive assessment and offer recipients and their caretakers with 24/7 access to a care staff member or helpline.

For instance, an aligned recipient would be considered ineligible if they no longer satisfy one or more of the beneficiary eligibility requirements. This could take place, for instance, if the beneficiary becomes a long-lasting retirement home citizen, registers in Medicare Advantage, or stops receiving the GUIDE care delivery services from the GUIDE Individual (e.g., because they vacate the program service location, no longer desire to be aligned to the GUIDE Participant, or can not be contacted/are lost to follow-up). The GUIDE Design is not a total cost of care design and does not have requirements around particular drug treatments.

GUIDE Individuals will be allowed to revise their service area throughout the period of the Design. Applicants may pick a service location of any size as long as they will have the ability to supply all of the GUIDE Care Delivery Services to beneficiaries in the determined service locations. Recipients who reside in assisted living settings might receive positioning to a GUIDE Participant offered they meet all other eligibility requirements. The GUIDE Participant will determine the beneficiary's main caretaker and examine the caregiver's knowledge, requires, well-being, stress level, and other challenges, including reporting caregiver stress to CMS utilizing the Zarit Concern Interview.

The GUIDE Design is not a shared cost savings or overall 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 beneficiary. The GUIDE Model is designed to be suitable with other CMS responsible care models and programs (e.g., ACOs and advanced medical care designs) that offer health care entities with chances to improve care and decrease spending.

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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 spend for a specified amount of break services for a subset of design recipients. Model participants will use a set of new G-codes produced for the GUIDE Model to submit claims for the monthly DCMP and the reprieve 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 type of reprieve service used. Yes, the month-to-month rates by tier are offered 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 shipment services that the Partner Organization offers to the GUIDE Participant's lined up recipients.

GUIDE Individuals and Partner Organizations will identify a payment arrangement and GUIDE Participants should have contracts in location with their Partner Organizations to reflect this payment plan. GUIDE Individuals will also be anticipated to maintain a list of Partner Organizations ("Partner Organization Lineup") and upgrade it as modifications are made throughout the course of the GUIDE Design.