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A beneficiary is eligible to receive services under the GUIDE Model if they meet the following criteria: Has dementia, as confirmed by attestation from a clinician on the GUIDE Individual's GUIDE Practitioner Roster; Is enrolled in Medicare Components A and B (not registered in Medicare Advantage, including Unique Requirements Plans, or speed programs) and has Medicare as their primary payer; Has actually not chosen the Medicare hospice advantage, and; Is not a long-term nursing home local.

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 first lined up to a participant in the design. To make sure constant recipient assignment to tiers across design participants, GUIDE Individuals should use a tool from a set of authorized screening and measurement tools to measure dementia stage and caretaker concern.

GUIDE Participants should inform beneficiaries about the design and the services that recipients can receive through the design, and they must record that a beneficiary or their legal representative, if applicable, approvals to receiving services from them. GUIDE Individuals must then submit the consenting recipient's information to CMS and, within 15 days, CMS will validate whether the recipient satisfies the model eligibility requirements before lining up the recipient to the GUIDE Individual.

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For a person with Medicare to receive services under the model, they must fulfill specific eligibility requirements. They will also need to discover a health care provider that is taking part in the GUIDE Model in their community. CMS will publish a list of GUIDE Participants on the GUIDE site in Summer season 2024.

For instant assistance, please find the list below resources: and . You might likewise contact 1-800-MEDICARE for particular info on concerns concerning Medicare advantages. For the purposes of the GUIDE Design, a caretaker is specified as a relative, or unpaid nonrelative, who helps the recipient with activities of everyday living and/or instrumental activities of everyday living.

People with Medicare should have dementia to be qualified for voluntary alignment to a GUIDE Participant and might be at any phase of dementiamild, moderate, or extreme. When an individual with Medicare is first evaluated for the GUIDE Model, CMS will rely on clinician attestation instead of the presence of ICD-10 dementia medical diagnosis codes on previous Medicare claims.

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They may confirm that they have gotten a composed report of a documented dementia medical diagnosis from another Medicare-enrolled specialist. As soon as a beneficiary is voluntarily lined up to a GUIDE Individual, the GUIDE Individual must connect an eligible ICD-10 dementia diagnosis code to each Dementia Care Management Payment (DCMP) regular monthly claim in order for it to be paid by CMS.The approved screening tools include 2 tools to report dementia stage the Medical Dementia Score (CDR) or the Functional Evaluation Screening Tool (QUICK) and one tool to report caregiver stress, the Zarit Problem Interview (ZBI).

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GUIDE Participants have the choice to seek CMS approval to utilize an alternative screening tool by submitting the proposed tool, along with published proof that it is valid and trusted and a crosswalk for how it corresponds to the model's tiering thresholds. CMS has complete discretion on whether it will accept the proposed alternative tool.

The GUIDE Model requires Care Navigators to be trained to work with caretakers in determining and managing common behavioral modifications due to dementia. GUIDE Participants will likewise assess the beneficiary's behavioral health as part of the thorough assessment and provide beneficiaries and their caretakers with 24/7 access to a care staff member or helpline.

For instance, an aligned beneficiary would be considered disqualified if they no longer meet several of the beneficiary eligibility requirements. This could happen, for example, if the recipient becomes a long-lasting nursing home homeowner, registers in Medicare Advantage, or stops receiving the GUIDE care delivery services from the GUIDE Individual (e.g., because they vacate the program service area, no longer dream to be aligned to the GUIDE Individual, or can not be contacted/are lost to follow-up). The GUIDE Model is not a total cost of care model and does not have requirements around specific drug treatments.

GUIDE Participants will be permitted to modify their service area throughout the duration of the Model. The GUIDE Individual will determine the beneficiary's main caretaker and evaluate the caretaker's understanding, needs, well-being, tension level, and other obstacles, including reporting caretaker pressure to CMS utilizing the Zarit Burden Interview.

The GUIDE Model is not a shared cost savings or total cost of care design, 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 Design is developed to be compatible with other CMS accountable care designs and programs (e.g., ACOs and advanced main care models) that offer health care entities with opportunities to enhance care and decrease spending.

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DCMP rates will be geographically adjusted along with a Performance Based Change (PBA) to incentivize top quality care. The GUIDE Design will likewise spend for a specified amount of respite services for a subset of model beneficiaries. Model individuals will utilize a set of new G-codes developed for the GUIDE Design to submit claims for the regular monthly DCMP and the respite codes.

Break services will be paid up to an annual cap of $2,500 per recipient and will vary in system costs reliant on the kind of respite service used. Yes, the monthly rates by tier are 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 delivery services that the Partner Company provides to the GUIDE Individual's lined up beneficiaries.

GUIDE Individuals and Partner Organizations will figure out a payment arrangement and GUIDE Individuals should have agreements in place with their Partner Organizations to reflect this payment arrangement. GUIDE Participants will also be expected to keep a list of Partner Organizations ("Partner Company Roster") and upgrade it as changes are made throughout the course of the GUIDE Model.