The US Centers for Medicare & Medicaid Services (CMS) recently announced a new, voluntary and nationwide test model. The model is designed to support people living with dementia and their unpaid caregivers. The Guiding an Improved Dementia Experience (GUIDE) Model will focus on dementia-care management and aims to improve the quality of life for people living with dementia. The model will offer care coordination and care management for individuals living with dementia, while providing education, support and respite services for their caregivers. The Guide model will launch on July 1, 2024.
GUIDE Payment Structure
GUIDE Participants can receive three payments: First is an infrastructure payment. GUIDE Participants are eligible for a one-time, lump-sum infrastructure payment to support program development activities. Second is a per-beneficiary, per-month payment. GUIDE Participants will receive a monthly per-beneficiary, per-month payment for providing care management and coordination and caregiver education and support. These monthly payments will be adjusted by a health equity adjustment and a performance-based adjustment. Third is a respite care payment. GUIDE Participants will be able to bill Medicare for respite services for beneficiaries with a caregiver and moderate to severe dementia, up to an annual cap. Respite services are temporary services to beneficiaries in their home, at an adult day center, or at a facility that can provide 24-hour care in order for caregivers to have temporary breaks from their caregiving responsibilities. The goal is to help caregivers continue to provide care, preventing or delaying the need for facility care.
Tracks
The GUIDE model will consist of two tracks, one for established programs and one for new programs. To qualify as an established program, the participant program must (i) have an interdisciplinary care team, (ii) use an electronic health record platform that meets the standards for certified electronic health record technology and (iii) meet care-delivery requirements to be outlined in the RFA. A new program is a program that is not operating a comprehensive, community-based dementia-care program at the time of the model’s announcement. New programs will have a one-year pre-implementation period to establish their programs and will have a performance period that starts on July 1, 2025. The performance period for established programs will begin on July 1, 2024.
Eligibility
Model participants can be either single provider organizations enrolled in the Medicare program, or multiple organizations or partnering providers working together to be able to meet all required services; non-Medicare-enrolled organizations, including community-based organizations (CBOs), may participate in partnership with Medicare-enrolled provider organizations.
Additionally, the main applicant and billing provider must be a Medicare Part B-enrolled provider/supplier, excluding durable medical equipment and laboratory suppliers, who can bill for Medicare Physician Fee Schedule services and agree to meet the care delivery requirements of the model. The primary enrolled provider must include at least one “dementia proficient clinician” defined as able to bill E/M codes and at least one of the following: (1) At least 25% of the clinician’s patient panel comprised of adults with any cognitive impairment, including dementia; (2) At least 25% of the clinician’s patient panel aged 65 years old or older; (3) Have a specialty designation of neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology or geriatric neurology.
Overlaps
While many CMS alternative payment models prohibit or restrict model participants from concurrently participating in different payment models, GUIDE is compatible with other CMS payments models, including the Medicare Shared Savings Program or MSSP; Realizing Equity, Access, and Community Health or REACH; and advanced primary care models such as Primary Care First and the new Making Care Primary Model. GUIDE is not a multi-payor model, and the target population is limited to Medicare fee-for-service beneficiaries, including beneficiaries dually eligible for Medicare and Medicaid.