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GUIDE Individuals have the choice, and are not required, to make offered break through an adult day center or a 24-hour center. Additional GUIDE Reprieve Services requirements and information surrounding the payment for such services are defined in the Participation Contract.

The facilities payment is planned for companies who want to establish new dementia care programs and need resources to begin. GUIDE Participants certified as a safeguard service provider based on the proportion of their client population that is dually qualified for Medicare and Medicaid or receive the Part D low-income aid.

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To certify as a GUIDE safeguard company, a new program candidate should have had a Medicare FFS beneficiary population consisted of a minimum of 36% beneficiaries getting the Part D low-income subsidy or 33.7% recipients 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 beneficiary cost-sharing.

When a lined up beneficiary is re-assessed and appointed to a new tier, the GUIDE Individual will be qualified to bill the G-code for the recognized client payment rate related to that tier the following month. GUIDE Participants that withdraw or are ended before the start of the second efficiency year will be required to pay back the whole value of their infrastructure payment to CMS.

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After the second efficiency year, GUIDE Individuals that withdraw or are ended from the GUIDE Model are not needed to repay the infrastructure payment. The main model 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 Charge Arrange (PFS) services, including chronic 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 design, so GUIDE Individuals will continue to bill under traditional Medicare fee-for-service for all services that are not included under the DCMP. Extra information, including a total list of duplicative codes, is readily available in the Ask for Applications (Table 8, pg. 35). CMS might add or eliminate codes with time to reflect modifications in PFS billing codes.

The care group may consist of the beneficiary's primary care provider, and if not, the care group is needed to determine and share details with the beneficiary's medical care company and experts and outline the care coordination services required to handle the recipient's dementia and co-occurring conditions. CMS will provide GUIDE Participants information related to the efficiency measures that CMS uses to figure out the GUIDE Participant's performance-based change to the DCMP.GUIDE Participants in the recognized program track should be prepared to start furnishing services under the GUIDE Design on July 1, 2024, and bill for those services throughout the Model Efficiency Period.

Yes, GUIDE beneficiary and provider overlap with the Shared Savings Program is allowed. The GUIDE Model is created to be compatible with other CMS designs and programs that aim to enhance care and reduce costs. CMS believes targeted support for individuals with dementia and their caregivers will help improve population-based care results overall.

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As an example, if an ACO is taking part in both the GUIDE Model and the Shared Cost Savings Program during Efficiency Year 2024 and then renews and begins a new contract duration 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 Benchmark Year 3. GUIDE Reprieve Service claims will not be counted toward ACO expenditures, shared cost savings, nor benchmarking start in 2024 for the period of the GUIDE Design.

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

Overlapping individuals ought to follow GUIDE billing guidance as set forth listed below. GUIDE Break Service claims will not count towards ACO expenses, shared savings, or benchmarking in 2025 and for the duration of the GUIDE Design.

Since January 1, 2025, GUIDE Participants also taking part in ACO REACH ought to cease billing the Medicare Doctor Charge Arrange Services included under the DCMP (See Exhibit 5 in the GUIDE Payment Methodology Paper (PDF)). Participants taking part in both designs should follow the GUIDE billing requirements in the GUIDE Participation Arrangement and GUIDE Payment Methodology Paper.

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The GUIDE Individual must not bill Medicare individually for the services offered in the comprehensive evaluation. The detailed evaluation (and any re-assessments) is covered by the DCMP. If CMS identifies the beneficiary is not eligible for the GUIDE Model, the GUIDE Participant can bill for an appropriate Medicare-covered professional service that corresponds to the services rendered.