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A recipient is qualified to receive services under the GUIDE Design if they fulfill the following criteria: Has dementia, as validated by attestation from a clinician on the GUIDE Participant's GUIDE Specialist Roster; Is enrolled in Medicare Components A and B (not registered in Medicare Benefit, consisting of Unique Requirements Strategies, or speed programs) and has Medicare as their main payer; Has not elected the Medicare hospice benefit, and; Is not a long-lasting assisted living home local.

The table below shows a description of the 5 tiers. GUIDE Participants will report information on illness phase and caretaker status to CMS when a beneficiary is very first aligned to an individual in the design. To ensure consistent beneficiary project to tiers across model individuals, GUIDE Participants must utilize a tool from a set of authorized screening and measurement tools to determine dementia stage and caretaker problem.

GUIDE Participants need to inform beneficiaries about the model and the services that beneficiaries can receive through the design, and they need to document that a recipient or their legal representative, if suitable, consents to getting services from them. GUIDE Individuals need to then submit the consenting recipient's info to CMS and, within 15 days, CMS will validate whether the recipient satisfies the model eligibility requirements before lining up the beneficiary to the GUIDE Participant.

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For a person with Medicare to receive services under the design, they must fulfill particular eligibility requirements. They will also need to discover a health care service provider that is taking part in the GUIDE Model in their neighborhood. CMS will publish a list of GUIDE Participants on the GUIDE website in Summertime 2024.

For immediate aid, please find the following resources: and . You might also call 1-800-MEDICARE for specific information on concerns regarding Medicare advantages. For the functions of the GUIDE Model, a caregiver is defined as a relative, or overdue nonrelative, who assists the beneficiary with activities of daily living and/or instrumental activities of everyday living.

People with Medicare should have dementia to be eligible for voluntary alignment to a GUIDE Participant and may be at any stage of dementiamild, moderate, or severe. When a person with Medicare is first assessed for the GUIDE Model, CMS will rely on clinician attestation instead of the existence of ICD-10 dementia medical diagnosis codes on prior Medicare claims.

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They may attest that they have gotten a composed report of a documented dementia diagnosis from another Medicare-enrolled specialist. As soon as a beneficiary is willingly aligned to a GUIDE Individual, the GUIDE Individual should attach 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 consist of 2 tools to report dementia phase the Medical Dementia Rating (CDR) or the Functional Assessment Screening Tool (QUICK) and one tool to report caregiver strain, the Zarit Problem Interview (ZBI).

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

The GUIDE Model needs Care Navigators to be trained to work with caregivers in identifying and managing typical behavioral modifications due to dementia. GUIDE Individuals will also assess the beneficiary's behavioral health as part of the comprehensive 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 deemed disqualified if they no longer meet several of the beneficiary eligibility requirements. This might occur, for instance, if the beneficiary ends up being a long-term assisted living home homeowner, registers in Medicare Benefit, or stops receiving the GUIDE care delivery services from the GUIDE Participant (e.g., since 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 an overall cost of care model and does not have requirements around specific drug treatments.

GUIDE Individuals will be enabled to modify their service location 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 Shipment Solutions to recipients in the recognized service areas. Recipients who live in assisted living settings may qualify for alignment to a GUIDE Participant offered they meet all other eligibility requirements. The GUIDE Individual will recognize the beneficiary's main caretaker and evaluate the caretaker's knowledge, requires, well-being, stress level, and other difficulties, consisting of reporting caretaker strain to CMS utilizing the Zarit Problem Interview.

The GUIDE Design is not a shared savings or overall cost of care model, it is a condition-specific longitudinal care model. In basic, GUIDE Model participants will be paid a monthly dementia care management payment (DCMP) for each beneficiary. The GUIDE Model is designed to be suitable with other CMS accountable care models and programs (e.g., ACOs and advanced medical care designs) that provide health care entities with opportunities to enhance care and decrease spending.

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DCMP rates will be geographically adjusted in addition to an Efficiency Based Adjustment (PBA) to incentivize high-quality care. The GUIDE Model will also pay for a defined amount of break services for a subset of model recipients. Design participants will use a set of brand-new G-codes produced for the GUIDE Design to send claims for the monthly DCMP and the reprieve codes.

Break services will be paid up to an annual cap of $2,500 per beneficiary and will differ in unit costs reliant on the kind of reprieve service utilized. Yes, the regular monthly rates by tier are available below.(New Client Payment Rate)$150$275$360$230$390(Developed 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 aligned recipients.

GUIDE Participants and Partner Organizations will determine a payment arrangement and GUIDE Individuals need to have agreements in place with their Partner Organizations to show this payment plan. GUIDE Individuals will likewise be expected to maintain a list of Partner Organizations ("Partner Organization Roster") and upgrade it as modifications are made throughout the course of the GUIDE Design.