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A recipient is qualified to get services under the GUIDE Model if they meet the following requirements: Has dementia, as confirmed by attestation from a clinician on the GUIDE Individual's GUIDE Professional Lineup; Is enrolled in Medicare Components A and B (not enrolled in Medicare Advantage, consisting of Unique Needs Plans, or rate programs) and has Medicare as their primary payer; Has not elected the Medicare hospice benefit, and; Is not a long-term assisted living home homeowner.

The table listed below programs a description of the five tiers. GUIDE Participants will report information on disease stage and caretaker status to CMS when a beneficiary is first aligned to an individual in the design. To guarantee constant beneficiary assignment to tiers across design individuals, GUIDE Participants must use a tool from a set of approved screening and measurement tools to determine dementia phase and caregiver concern.

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

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For an individual with Medicare to receive services under the design, they should fulfill particular eligibility requirements. They will also require to find a healthcare service provider that is taking part in the GUIDE Model in their neighborhood. CMS will publish a list of GUIDE Individuals on the GUIDE website in Summer 2024.

For instant aid, please find the following resources: and . You may also contact 1-800-MEDICARE for particular details on questions relating to Medicare benefits. For the functions of the GUIDE Model, a caretaker is defined as a relative, or unpaid nonrelative, who helps the recipient with activities of day-to-day living and/or crucial activities of daily living.

People with Medicare should have dementia to be eligible for voluntary positioning to a GUIDE Individual and might be at any stage of dementiamild, moderate, or extreme. When an individual with Medicare is first assessed for the GUIDE Model, CMS will depend on clinician attestation rather than the existence of ICD-10 dementia diagnosis codes on previous Medicare claims.

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Additionally, they might confirm that they have received a written report of a recorded dementia diagnosis from another Medicare-enrolled practitioner. When a beneficiary is willingly lined up to a GUIDE Individual, the GUIDE Individual need to attach 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 two tools to report dementia phase the Clinical Dementia Rating (CDR) or the Functional Evaluation Screening Tool (FAST) and one tool to report caretaker stress, the Zarit Concern Interview (ZBI).

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GUIDE Individuals have the option to seek CMS approval to use an alternative screening tool by submitting the proposed tool, along with released evidence that it stands and reputable and a crosswalk for how it corresponds to the model'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 caretakers in identifying and handling common behavioral changes due to dementia. GUIDE Individuals will also evaluate the recipient's behavioral health as part of the thorough assessment and provide beneficiaries and their caretakers with 24/7 access to a care team member or helpline.

A lined up recipient would be considered disqualified if they no longer fulfill one or more of the beneficiary eligibility requirements. This could happen, for example, if the beneficiary becomes a long-lasting retirement home homeowner, enlists in Medicare Benefit, or stops getting the GUIDE care shipment services from the GUIDE Individual (e.g., since they vacate the program service location, no longer wish to be aligned to the GUIDE Individual, or can not be contacted/are lost to follow-up). The GUIDE Model is not a total expense of care design and does not have requirements around particular drug treatments.

GUIDE Individuals will be allowed to revise their service location throughout the period of the Design. Applicants might pick a service area of any size as long as they will be able to offer all of the GUIDE Care Delivery Solutions to recipients in the determined service areas. Recipients who reside in assisted living settings might certify for alignment to a GUIDE Individual supplied they meet all other eligibility requirements. The GUIDE Individual will determine the recipient's primary caregiver and evaluate the caregiver's understanding, needs, well-being, stress level, and other obstacles, including reporting caregiver stress to CMS using the Zarit Problem Interview.

The GUIDE Model is not a shared savings or overall expense of care model, it is a condition-specific longitudinal care model. In general, GUIDE Design individuals will be paid a month-to-month dementia care management payment (DCMP) for each recipient. The GUIDE Design is designed to be compatible with other CMS responsible care models and programs (e.g., ACOs and advanced primary care models) that provide healthcare entities with chances to improve care and reduce costs.

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DCMP rates will be geographically adjusted in addition to an Efficiency Based Change (PBA) to incentivize premium care. The GUIDE Design will likewise spend for a defined quantity of break services for a subset of design recipients. Model individuals will use a set of new G-codes created for the GUIDE Design to submit claims for the month-to-month DCMP and the break codes.

Break services will be paid up to an annual cap of $2,500 per recipient and will differ in system costs depending on the type of respite service utilized. Yes, the regular monthly rates by tier are readily available listed below.(New Patient Payment Rate)$150$275$360$230$390(Established Client Payment Rate)$65$120$220$120$215GUIDE Individuals are accountable for paying Partner Organizations for GUIDE care shipment services that the Partner Organization provides to the GUIDE Individual's lined up recipients.

GUIDE Individuals and Partner Organizations will identify a payment arrangement and GUIDE Participants need to have contracts in place with their Partner Organizations to reflect this payment arrangement. GUIDE Individuals will likewise be expected to keep a list of Partner Organizations ("Partner Organization Lineup") and upgrade it as changes are made throughout the course of the GUIDE Model.