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GUIDE Individuals have the option, and are not needed, to make available break through an adult day center or a 24-hour facility. Additional GUIDE Break Services requirements and details surrounding the payment for such services are defined in the Participation Arrangement. GUIDE Individuals in the brand-new program track that are categorized as safety net service providers will be eligible to get a one-time infrastructure payment of $75,000 (geographically changed by the Geographic Change Element [GAF] to cover a few of the in advance costs of establishing a new dementia care program.

The facilities payment is planned for service providers who desire to establish brand-new dementia care programs and need resources to start. GUIDE Participants certified as a safeguard company based on the proportion of their client population that is dually eligible for Medicare and Medicaid or receive the Part D low-income subsidy.

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To certify as a GUIDE safeguard provider, a new program candidate need to have had a Medicare FFS recipient population made up of at least 36% beneficiaries receiving the Part D low-income aid or 33.7% beneficiaries who are dually eligible for Medicare and Medicaid. Accepting the infrastructure payment was optional. Neither the Dementia Care Management Payment (DCMP) nor GUIDE break services will undergo recipient cost-sharing.

When an aligned beneficiary is re-assessed and appointed to a new tier, the GUIDE Individual will be qualified to bill the G-code for the recognized patient payment rate associated with that tier the following month. GUIDE Participants that withdraw or are ended before the start of the 2nd performance year will be needed to repay the entire value of their infrastructure payment to CMS.

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After the 2nd performance year, GUIDE Individuals that withdraw or are terminated from the GUIDE Design are not needed to pay back the facilities payment. The main 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 change fee-for-service payment for some existing Medicare Physician Fee Schedule (PFS) services, including persistent care management and principal 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 Individuals will continue to expense under standard Medicare fee-for-service for all services that are not included under the DCMP. Additional information, including a complete list of duplicative codes, is available in the Ask for Applications (Table 8, pg. 35). CMS may include or eliminate codes over time to show changes in PFS billing codes.

The care team might consist of the recipient's main care company, and if not, the care team is needed to determine and share information with the recipient's primary care company and specialists and outline the care coordination services needed to handle the recipient's dementia and co-occurring conditions. CMS will supply GUIDE Individuals data associated with the performance determines that CMS uses to identify the GUIDE Participant's performance-based modification to the DCMP.GUIDE Participants in the recognized program track should be prepared to begin furnishing services under the GUIDE Model on July 1, 2024, and bill for those services throughout the Design Efficiency Duration.

Yes, GUIDE beneficiary and supplier overlap with the Shared Cost savings Program is permitted. The GUIDE Design is created to be suitable with other CMS models and programs that intend to improve care and lower spending. CMS thinks targeted assistance for individuals with dementia and their caretakers will help improve population-based care results overall.

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As an example, if an ACO is participating in both the GUIDE Design and the Shared Savings Program during Efficiency Year 2024 and then renews and begins a brand-new arrangement period as of January 1, 2025, that ACO would have their Shared Cost savings Program standard based on 2022, 2023 and 2024, and would have DCMPs counted in Benchmark Year 3. GUIDE Reprieve Service claims will not be counted toward ACO expenditures, shared cost savings, nor benchmarking start in 2024 for the duration of the GUIDE Design.

GUIDE Individuals might take part in several CMS Development Center designs or Medicare value-based care initiatives to accelerate innovation in care shipment, decrease the expense of care, and enhance population health. Participants and recipients are qualified to get involved in the GUIDE Design and the ACO REACH Model. For the rest of CY 2024, ACO REACH will not include the Dementia Care Management Payment (DCMP) or Reprieve Service claims in the REACH ACOs' overall expense of care expenditures or estimation of shared savings/shared losses.

Overlapping participants must follow GUIDE billing guidance as set forth listed below. GUIDE Break Service claims will not count toward ACO expenditures, shared cost savings, or benchmarking in 2025 and for the period of the GUIDE Design.

Since January 1, 2025, GUIDE Participants likewise getting involved in ACO REACH need to stop billing the Medicare Physician Charge Arrange Providers included under the DCMP (See Exhibit 5 in the GUIDE Payment Approach Paper (PDF)). Individuals participating in both models should follow the GUIDE billing requirements in the GUIDE Involvement Agreement and GUIDE Payment Methodology Paper.

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The GUIDE Participant should not bill Medicare individually for the services supplied in the extensive evaluation. The detailed evaluation (and any re-assessments) is covered by the DCMP. If CMS determines the recipient is not qualified for the GUIDE Model, the GUIDE Individual can bill for a suitable Medicare-covered professional service that represents the services rendered.