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Nevertheless, GUIDE Participants have the option, and are not required, to offer reprieve through an adult day center or a 24-hour facility. Extra GUIDE Break Providers requirements and details surrounding the payment for such services are specified in the Involvement Contract. GUIDE Participants in the brand-new program track that are classified as safety net companies will be eligible to get a one-time infrastructure payment of $75,000 (geographically changed by the Geographic Change Aspect [GAF] to cover some of the in advance costs of developing a brand-new dementia care program.

The infrastructure payment is meant for suppliers who desire to establish brand-new dementia care programs and require resources to get started. GUIDE Participants certified as a safeguard company based upon the proportion of their patient population that is dually eligible for Medicare and Medicaid or get the Part D low-income subsidy.

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To qualify as a GUIDE safeguard supplier, a brand-new program applicant need to have had a Medicare FFS beneficiary population consisted of a minimum of 36% recipients receiving the Part D low-income subsidy or 33.7% beneficiaries who are dually qualified for Medicare and Medicaid. Accepting the infrastructure payment was optional. Neither the Dementia Care Management Payment (DCMP) nor GUIDE reprieve services will be subject to 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 established patient payment rate related to that tier the following month. GUIDE Individuals that withdraw or are ended before the start of the 2nd efficiency year will be needed to repay the entire value of their infrastructure payment to CMS.

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After the second performance year, GUIDE Individuals that withdraw or are ended from the GUIDE Model are not needed to repay the facilities payment. The primary 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 Cost Set Up (PFS) services, including persistent care management and primary care management, transitional care management, advance care preparation, and technology-based check-ins.

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The GUIDE Design is not a total-cost-of-care model, so GUIDE Individuals will continue to expense under traditional Medicare fee-for-service for all services that are not included under the DCMP. Additional details, consisting of a total list of duplicative codes, is offered in the Request for Applications (Table 8, pg. 35). CMS might add or eliminate codes in time to reflect changes in PFS billing codes.

The care team may consist of the beneficiary's medical care supplier, and if not, the care group is required to identify and share info with the beneficiary's main care provider and experts and lay out the care coordination services needed to handle the recipient's dementia and co-occurring conditions. CMS will provide GUIDE Individuals data related to the efficiency measures that CMS utilizes to identify the GUIDE Participant's performance-based modification to the DCMP.GUIDE Individuals in the recognized program track ought to be prepared to start furnishing services under the GUIDE Model on July 1, 2024, and expense for those services during the Design Efficiency Period.

Yes, GUIDE beneficiary and service provider overlap with the Shared Savings Program is permitted. The GUIDE Design is developed to be suitable with other CMS designs and programs that intend to enhance care and decrease costs. CMS believes targeted assistance for individuals with dementia and their caretakers will assist improve population-based care outcomes in general.

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

GUIDE Individuals might take part in numerous CMS Development Center designs or Medicare value-based care efforts to speed up innovation in care delivery, minimize the cost of care, and enhance population health. Individuals and recipients are eligible to take part in the GUIDE Model and the ACO REACH Design. For the rest of CY 2024, ACO REACH will not consist of the Dementia Care Management Payment (DCMP) or Break Service claims in the REACH ACOs' total expense of care expenses or estimation of shared savings/shared losses.

Overlapping participants ought to follow GUIDE billing assistance as set forth below. GUIDE Respite Service claims will not count toward ACO expenses, shared cost savings, or benchmarking in 2025 and for the period of the GUIDE Model.

Since January 1, 2025, GUIDE Participants likewise participating in ACO REACH must stop billing the Medicare Doctor Fee Arrange Services included under the DCMP (See Exhibit 5 in the GUIDE Payment Approach Paper (PDF)). Participants taking part in both designs must follow the GUIDE billing requirements in the GUIDE Involvement Contract and GUIDE Payment Methodology Paper.

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The GUIDE Individual must not bill Medicare separately for the services provided in the detailed assessment. The detailed assessment (and any re-assessments) is covered by the DCMP. If CMS figures out the recipient is not eligible for the GUIDE Model, the GUIDE Individual can bill for an appropriate Medicare-covered expert service that represents the services rendered.