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A beneficiary is eligible to receive services under the GUIDE Design if they fulfill the following criteria: Has dementia, as verified 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, including Special Requirements Plans, or PACE programs) and has Medicare as their primary payer; Has not elected the Medicare hospice advantage, and; Is not a long-lasting assisted living home resident.

The table below shows a description of the 5 tiers. GUIDE Individuals will report information on illness phase and caregiver status to CMS when a beneficiary is first aligned to a participant in the model. To make sure constant recipient task to tiers across model participants, GUIDE Individuals need to utilize a tool from a set of approved screening and measurement tools to measure dementia stage and caretaker burden.

GUIDE Individuals must inform recipients about the design and the services that beneficiaries can receive through the model, and they should document that a recipient or their legal agent, if relevant, grant getting services from them. GUIDE Participants need to then send the consenting beneficiary's details to CMS and, within 15 days, CMS will confirm whether the recipient fulfills the design eligibility requirements before lining up the beneficiary to the GUIDE Individual.

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For an individual with Medicare to get services under the design, they need to meet specific eligibility requirements. They will likewise need to find a health care supplier that is taking part in the GUIDE Design in their neighborhood. CMS will publish a list of GUIDE Individuals on the GUIDE site in Summer season 2024.

For immediate assistance, please find the list below resources: and . You might also contact 1-800-MEDICARE for specific information on questions relating to Medicare advantages. For the functions of the GUIDE Design, a caretaker is specified as a relative, or overdue nonrelative, who helps the recipient with activities of everyday living and/or crucial activities of daily living.

People with Medicare should have dementia to be qualified for voluntary positioning to a GUIDE Participant and may be at any stage of dementiamild, moderate, or serious. When an individual with Medicare is first evaluated for the GUIDE Model, CMS will depend on clinician attestation rather than the presence of ICD-10 dementia medical diagnosis codes on prior Medicare claims.

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Alternatively, they might confirm that they have actually received a written report of a recorded dementia medical diagnosis from another Medicare-enrolled professional. Once a beneficiary is willingly lined up to a GUIDE Individual, the GUIDE Participant must attach a qualified ICD-10 dementia medical diagnosis code to each Dementia Care Management Payment (DCMP) monthly claim in order for it to be paid by CMS.The approved screening tools consist of 2 tools to report dementia phase the Scientific Dementia Score (CDR) or the Functional Evaluation Screening Tool (FAST) and one tool to report caregiver strain, the Zarit Burden Interview (ZBI).

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GUIDE Participants have the option to look for CMS approval to utilize an alternative screening tool by submitting the proposed tool, together with published proof that it is legitimate and reputable and a crosswalk for how it corresponds to the design's tiering limits. CMS has complete discretion on whether it will accept the proposed option tool.

The GUIDE Model needs Care Navigators to be trained to work with caregivers in recognizing and managing typical behavioral modifications due to dementia. GUIDE Individuals will likewise examine the recipient's behavioral health as part of the comprehensive assessment and provide beneficiaries and their caregivers with 24/7 access to a care group member or helpline.

An aligned beneficiary would be considered ineligible if they no longer meet one or more of the beneficiary eligibility requirements. This could occur, for instance, if the beneficiary becomes a long-lasting retirement home local, enrolls in Medicare Advantage, or stops receiving the GUIDE care shipment services from the GUIDE Participant (e.g., since they move out of the program service location, no longer dream to be aligned to the GUIDE Participant, 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 particular drug treatments.

GUIDE Participants will be permitted to revise their service location throughout the period of the Model. Applicants might select 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 locations. Beneficiaries who live in assisted living settings may receive alignment to a GUIDE Individual provided they fulfill all other eligibility criteria. The GUIDE Individual will determine the beneficiary's primary caregiver and evaluate the caretaker's understanding, needs, wellness, stress level, and other difficulties, consisting of reporting caregiver pressure to CMS utilizing the Zarit Burden Interview.

The GUIDE Model is not a shared savings or overall cost of care design, it is a condition-specific longitudinal care design. In basic, GUIDE Design 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 responsible care models and programs (e.g., ACOs and advanced primary care models) that provide health care entities with opportunities to enhance care and lower spending.

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DCMP rates will be geographically adjusted as well as an Efficiency Based Change (PBA) to incentivize high-quality care. The GUIDE Design will also spend for a defined quantity of respite services for a subset of model recipients. Design individuals will use a set of new G-codes produced for the GUIDE Design to send claims for the monthly DCMP and the break 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 type of respite service utilized. Yes, the monthly rates by tier are available below.(New Client 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 Organization supplies to the GUIDE Individual's lined up beneficiaries.

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