GUIDE Model Frequently Asked Questions

FAQ Topics:

• Background
• Participant Eligibility
• Partner Organizations
• Beneficiaries & Caregivers
• Payment Methodology
• Care Delivery Requirements
• Performance Management
• Data Reporting
• Health Equity
• Application & Timelines
• Other FAQs

Background

1. How does the GUIDE Model align with the Innovation Center’s strategy and priorities?

   The GUIDE Model supports several of the CMS Innovation Center’s strategic objectives, including:

   • Advance Health Equity: The model includes several policies designed to reduce disparities in dementia care. These policies include recruiting and providing support to health care providers that have not historically offered dementia care programs, particularly safety net providers; requiring GUIDE Participants to have health equity plans that include strategies for engaging underserved communities; making a “health equity adjustment” to model payments for the services that GUIDE Participants provide to disadvantaged beneficiaries; and requiring GUIDE Participants to collect certain beneficiary demographic data to identify and address disparities.
   • Support Innovation: The model supports innovation by offering a new program track that includes training and technical assistance and a monthly population-based payment methodology that will enable GUIDE Participants to be innovative in how they deliver team-based care and GUIDE Respite Services. Additionally, beneficiary quality of life and caregiver burden will be measured as part of the model’s performance measure set.

   • Address Affordability: Dementia can create a severe financial burden for people with dementia and their unpaid caregivers. The model aims to address costs by 1) offering a new payment to GUIDE Participants for respite services furnished to certain aligned beneficiaries; and 2) requiring GUIDE Participants to screen beneficiaries for health-related social needs and help navigate them to community-based sources of care. Additionally, a primary goal of the model is delaying long-term nursing home care, which is the biggest source of out-of-pocket costs for people living with dementia.

      

2. Will the GUIDE Model qualify as an Advanced Alternative Payment Model (APM) or Merit-based Incentive Payment System (MIPS) APM?

   CMS expects that the GUIDE Model will qualify as a MIPS APM for the established and new program tracks. However, the new program track will not qualify as a MIPs APM during the pre-implementation period.

    

3. How does the GUIDE Model differ from the PACE Program? 

   One of the main differences between the PACE Program and the GUIDE Model is that the GUIDE Model is specifically tailored to Medicare beneficiaries with dementia and their unpaid caregivers at any stage of disease including mild dementia. PACE is a comprehensive health service for all elderly adults categorized as "nursing home eligible." Most of the beneficiaries who are in PACE are dually eligible for both Medicare and Medicaid while many GUIDE beneficiaries will be enrolled in Medicare but not Medicaid. In addition, unlike PACE, GUIDE is not a total cost-of-care program. Further, the GUIDE Model is a time-limited model test operated by the Center for Medicare and Medicaid Innovation.

Participant Eligibility

1. What types of providers are eligible to participate in the model?

   Health care providers eligible to be GUIDE Participants include Medicare Part B-enrolled providers and suppliers, excluding durable medical equipment (DME) and laboratory suppliers, who are eligible to bill under the Medicare Physician Fee Schedule.

    

2. What are the differences between the two model tracks?

   The GUIDE Model has two tracks: an established program track and a new program track. The established program track is for applicants with a practicing interdisciplinary team at the time of model announcement that has provided at least 6 of the 9 GUIDE Care Delivery Service domains, described in the Participation Agreement, to people living with dementia for at least the past 12 months prior to January 30, 2024. The performance period for the established program track begins July 1, 2024. The new program track has a one-year pre-implementation period beginning July 1, 2024, and a performance period that begins July 1, 2025. GUIDE Participants in the new program track are required to use the pre-implementation period for program development, including hiring and training staff, establishing program workflows and processes, developing referral networks, and building relationships with community-based organizations and respite providers.

    

3. What types of organizations qualify for the new program track?

   The new program track is designed for organizations that do not currently offer comprehensive community-based dementia care, or only recently began offering such care, to give them time and support to develop a new program. Specifically, new programs either did not provide comprehensive dementia care to people living with dementia at time of application (defined as at least 6 of the 9 care delivery domains delivered by an interdisciplinary team as set forth in the Request for Applications), or provide comprehensive dementia care, but had only done so for less than 12 months prior to the deadline for application submissions. New program track applicants did not need to have a Medicare Part B enrolled TIN that was eligible to bill under the Medicare Physician Fee Schedule at the time they applied to the GUIDE Model. CMS anticipates that this track will include (but not be limited to) safety net organizations and providers looking to extend their current service offerings to include dementia care. New program development is intended to help increase beneficiary access to specialty dementia care, particularly in underserved communities.

    

4. Can the roster of practitioners working with the GUIDE Participant change in size and composition during the performance period?

   The GUIDE Practitioner Roster may change in size and composition during the performance period. The Participation Agreement provides additional detail on the steps a GUIDE Participant must take to update their GUIDE Practitioner Roster.

    

5. Can a clinician on a GUIDE Practitioner Roster bill through multiple GUIDE Participant TINs? 
   Yes, a clinician can participate in more than one GUIDE Dementia Care Program and bill through multiple GUIDE Participant TINs.

    

Partner Organizations

1. What are GUIDE Partner Organizations?

   The GUIDE Participant may contract with one or more other providers, suppliers, or organizations, including both Medicare-enrolled and non-Medicare enrolled entities, to meet the care delivery requirements. These providers, suppliers, or organizations will be known as “Partner Organizations.” The GUIDE Participant will be required to maintain a list of Partner Organizations (“Partner Organization Roster”) and update it as changes are made throughout the course of the GUIDE Model.

    

2. Can GUIDE Participants contract with community-based organizations to serve as their GUIDE Partner Organizations?

   Yes, GUIDE Participants may contract with community-based organizations that deliver community-based services and supports in order to deliver respite services and to support other care delivery requirements in the model.

    

3. Can a Partner Organization partner with more than one GUIDE Participant?

   Yes, Partner Organizations can partner with more than one GUIDE Participant. There is no limit on the number of GUIDE Participants that a Partner Organization can support. A Partner Organization must enter into a Partner Organization Arrangement with each GUIDE Participant it supports.

    

4. Can GUIDE Participants add Partner Organizations throughout the duration of the Model?

   Yes, GUIDE Participants may add or remove Partner Organizations throughout the duration of the model. The GUIDE Participant will be required to maintain a list of Partner Organizations (“Partner Organization Roster”) and update it as changes are made throughout the course of the GUIDE Model.

    

5. My organization is interested in partnering with a GUIDE Participant. How can we identify GUIDE Participants in my area?

   CMS will publish a list of GUIDE Participants in Summer 2024.

Beneficiaries & Caregivers

1. What are the beneficiary eligibility requirements for the GUIDE Model?

   A beneficiary is eligible to receive services under the GUIDE Model if they meet the following criteria:

   • Has dementia, as confirmed by attestation from a clinician on the GUIDE Participant’s GUIDE Practitioner Roster;
   • Is enrolled in Medicare Parts A and B (not enrolled in Medicare Advantage, including Special Needs Plans, or PACE programs) and has Medicare as their primary payer;
   • Has not elected the Medicare hospice benefit, and;

   • Is not a long-term nursing home resident.

      

2. How does CMS assign beneficiaries to Model Tiers?

   A beneficiary’s Model Tier is determined based on a combination of their disease stage, whether they have a caregiver, and if applicable, their caregiver's needs. The table below shows a description of the five tiers. GUIDE Participants will report data on disease stage and caregiver status to CMS when a beneficiary is first aligned to  a participant in the model. To ensure consistent beneficiary assignment to tiers across model participants, GUIDE Participants must use a tool from a set of approved screening and measurement tools to measure dementia stage and caregiver burden.

   	Tier	Criteria	Corresponding Assessment Tool Scores
   Beneficiaries with a caregiver	Low complexity dyad tier	Mild dementia	CDR= 1, FAST= 4
   	Moderate complexity dyad tier	Moderate or severe dementia AND Low to moderate caregiver strain	CDR= 2-3, FAST= 5-7  AND  ZBI= 0-60
   	High complexity dyad tier	Moderate or severe dementia AND High caregiver strain	CDR= 2-3, FAST= 5-7  AND  ZBI= 61-88
   Beneficiaries without a caregiver	Low complexity individual tier	Mild dementia	CDR= 1, FAST= 4
   	Moderate to high complexity individual tier	Moderate or severe dementia	CDR= 2-3, FAST= 5-7

3. How are Beneficiaries aligned to the GUIDE Model?

   The GUIDE Model will use a voluntary alignment process for aligning beneficiaries to GUIDE Participants. GUIDE Participants must inform beneficiaries about the model and the services that beneficiaries can receive through the model, and they must document that a beneficiary or their legal representative, if applicable, consents to receiving services from them. GUIDE Participants must then submit the consenting beneficiary’s information to CMS and, within 15 days, CMS will confirm whether the beneficiary meets the model eligibility requirements before aligning the beneficiary to the GUIDE Participant.

   Even after a beneficiary has voluntarily aligned to a GUIDE Participant, beneficiaries will maintain complete freedom of choice to seek care in any hospital or see any physician or health provider that participates in Medicare.

    

4. Can people with Medicare sign up for the GUIDE Model?

   For a person with Medicare to receive services under the model, they must meet certain eligibility requirements. They will also need to find a health care provider that is participating in the GUIDE Model in their community. CMS will publish a list of GUIDE Participants on the GUIDE website in Summer 2024. A person with Medicare or their caregiver could then visit a GUIDE Participant, and after consenting to receiving services from the GUIDE Participant, CMS will confirm whether the individual meets the model eligibility requirements before aligning them to the GUIDE Participant.

   For immediate help, please find the following resources: https://acl.gov/help/getting-started and https://www.alzheimers.gov/. You may also contact 1-800-MEDICARE for specific information on questions regarding Medicare benefits.

    

5. How is “caregiver” defined in the GUIDE Model?

   For the purposes of the GUIDE Model, a caregiver is defined as a relative, or unpaid nonrelative, who assists the beneficiary with activities of daily living and/or instrumental activities of daily living. Depending on the beneficiary’s need, the assistance may be episodic, daily, or occasional.

    

6. Which specific dementia diagnoses qualify people with Medicare to be eligible to voluntarily align to a GUIDE Participant and how will a GUIDE Participant’s attestation that the individual has dementia be verified?

   People with Medicare must have dementia to be eligible for voluntary alignment to a GUIDE Participant and may be at any stage of dementia—mild, moderate, or severe. When a person with Medicare is first assessed for the GUIDE Model, CMS will rely on clinician attestation rather than the presence of ICD-10 dementia diagnosis codes on prior Medicare claims. A clinician on the GUIDE Participant’s Practitioner Roster must attest that based on their comprehensive assessment, beneficiaries meet the National Institute on Aging-Alzheimer’s Association diagnostic guidelines for dementia and/or the DSM-5 diagnostic guidelines for major neurocognitive disorder. Alternatively, they may attest that they have received a written report of a documented dementia diagnosis from another Medicare-enrolled practitioner.

   Once a beneficiary is voluntarily aligned to a GUIDE Participant, the GUIDE Participant must attach an eligible ICD-10 dementia diagnosis code to each Dementia Care Management Payment (DCMP) monthly claim in order for it to be paid by CMS.

    

7. What are the approved screening tools for dementia staging? Can GUIDE Participants use other tools to evaluate beneficiaries?

   The approved screening tools include two tools to report dementia stage – the Clinical Dementia Rating (CDR) or the Functional Assessment Screening Tool (FAST) – and one tool to report caregiver strain, the Zarit Burden Interview (ZBI). CMS may add screening tools throughout the course of the model.

   GUIDE Participants have the option to seek CMS approval to use an alternative screening tool by submitting the proposed tool, along with published evidence that it is valid and reliable and a crosswalk for how it corresponds to the model’s tiering thresholds. CMS has full discretion on whether it will accept the proposed alternative tool. Details on the process for submitting proposed tools and tiering information will be shared with GUIDE Participants after July 1, 2024.

    

8. How does the GUIDE Model address behavioral and psychological symptoms of dementia?

   The GUIDE Model addresses Behavioral and Psychological Symptoms of Dementia (BPSD) through its care delivery requirements and required training for Care Navigator(s). The GUIDE Model requires Care Navigators to be trained to work with caregivers in identifying and managing common behavioral changes due to dementia. GUIDE Participants will also assess the beneficiary’s behavioral health as part of the comprehensive assessment and provide beneficiaries and their caregivers with 24/7 access to a care team member or helpline.

    

9. Can a beneficiary become unaligned from a GUIDE Participant?

   Beneficiaries will remain aligned to the GUIDE Participant until they become ineligible or leave the Model. For example, an aligned beneficiary would be deemed ineligible if they no longer meet one or more of the beneficiary eligibility requirements. This could occur, for example, if the beneficiary becomes a long-term nursing home resident, enrolls in Medicare Advantage, or stops receiving the GUIDE care delivery services from the GUIDE Participant (e.g., because they move out of the program service area, no longer wish to be aligned to the GUIDE Participant, or cannot be contacted/are lost to follow-up).

    

10. Will Alzheimer's treatment and/or medication disqualify beneficiaries?

    The GUIDE Model is not a total cost of care model and does not have requirements around specific drug treatments. A beneficiary will not be disqualified from the model based on their Alzheimer's treatment and/or medication.

     

11. Applicants are required to provide CMS a list of service areas by zip code. Is this list of service areas by zip code limited or can GUIDE Participants expand the list over the course of the model?

    GUIDE Participants will be allowed to revise their service area throughout the duration of the Model. Applicants may select a service area of any size as long as they will be able to provide all of the GUIDE Care Delivery Services to beneficiaries in the identified service areas.

     

12. Are residents of an assisted living facility eligible beneficiaries for the GUIDE Model?

    Beneficiaries who live in assisted living settings may qualify for alignment to a GUIDE Participant provided they meet all other eligibility criteria.

     

13. How is a beneficiary’s caregiver status determined?

    The GUIDE Participant will identify the beneficiary’s primary caregiver and assess the caregiver’s knowledge, needs, well-being, stress level, and other challenges, including reporting caregiver strain to CMS using the Zarit Burden Interview. If the beneficiary comes to the GUIDE Participant without a caregiver, the GUIDE Participant must make a reasonable effort to help identify a caregiver for the beneficiary and put safeguards into its care delivery plan to support the beneficiary continuing to reside in the community.
     

Payment Methodology

1. Is GUIDE a shared savings model?

   The GUIDE Model is not a shared savings or total cost of care model, it is a condition-specific longitudinal care model. In general, GUIDE Model participants will be paid a monthly dementia care management payment (DCMP) for each beneficiary. The GUIDE Model is designed to be compatible with other CMS accountable care models and programs (e.g., ACOs and advanced primary care models) that provide health care entities with opportunities to improve care and reduce spending.

    

2. How will participants be paid under the model?

   The model will pay participants a per beneficiary per month (PBPM) amount, known as a dementia care management payment (DCMP), for providing care management and coordination and caregiver education and support services to beneficiaries and caregivers. DCMP rates will be geographically adjusted and adjusted by a Health Equity Adjustment (HEA) and a Performance Based Adjustment (PBA) to incentivize high-quality care. The GUIDE Model will also pay for a defined amount of respite services for a subset of model beneficiaries.

   Model participants will use a set of new G-codes created for the GUIDE Model to submit claims for the monthly DCMP and the respite codes. Each model tier will have a different DCMP rate to reflect the fact that covered services and care intensity will vary across the tiers. Respite services will be paid up to an annual cap of $2,500 per beneficiary and will vary in unit costs dependent on the type of respite service used.

    

3. Are the rates for the per beneficiary per month Model payments available?

   Yes, the monthly rates by tier are available below.

   	Monthly payment rates for beneficiaries with caregiver			Monthly payment rates for beneficiaries without caregiver
   	Low complexity dyad tier	Moderate complexity dyad tier	High complexity dyad tier	Low complexity individual tier	Moderate to high complexity individual tier
   First 6 months (New Patient Payment Rate)	$150	$275	$360	$230	$390
   After first 6 months (Established Patient Payment Rate)	$65	$120	$220	$120	$215

4. How will Partner Organizations associated with GUIDE Participants be paid?

   GUIDE Participants are responsible for paying Partner Organizations for GUIDE care delivery services that the Partner Organization provides to the GUIDE Participant’s aligned beneficiaries. CMS will not pay Partner Organizations for services provided under the GUIDE Model. GUIDE Participants and Partner Organizations will determine a payment arrangement and GUIDE Participants must have contracts in place with their Partner Organizations to reflect this payment arrangement. GUIDE Participants will also be expected to maintain a list of Partner Organizations (“Partner Organization Roster”) and update it as changes are made throughout the course of the GUIDE Model.

    

5. What are the requirements for offering GUIDE Respite Services?

   The GUIDE Model provides payment for GUIDE Respite Services provided in three types of settings up to an annual cap of $2,500 per beneficiary. The three types of respite covered by the GUIDE Model are respite services provided in the beneficiary’s home, in an adult day center, which includes both medical and social programs, and in a facility that can provide 24-hour care. While the model provides payment to GUIDE Participants for services furnished in these various settings, GUIDE Participants will have some flexibility in the type of respite services that they make available to their beneficiaries. The GUIDE Model requires all GUIDE Participants to make available in-home respite services, either directly or by contracting with a provider of in-home respite. However, GUIDE Participants have the option, and are not required, to make available respite through an adult day center or a 24-hour facility. Additional GUIDE Respite Services requirements and details surrounding the payment for such services are specified in the Participation Agreement.

    

6. What is the infrastructure payment?

   GUIDE Participants in the new program track that are classified as safety net providers will be eligible to receive a one-time infrastructure payment of $75,000 (geographically adjusted by the Geographic Adjustment Factor [GAF]) to cover some of the upfront costs of establishing a new dementia care program. This will be paid at the beginning of the pre-implementation period. The infrastructure payment is intended for providers who want to develop new dementia care programs to serve underserved beneficiaries but need resources to get started.

    

7. How is “safety net provider” defined for the purposes of qualifying for the infrastructure payment?

   GUIDE Participants qualified as a safety net provider based on the proportion of their patient population that is dually eligible for Medicare and Medicaid or receive the Part D low-income subsidy. CMS notified selected applicants whether they met the safety net criteria before the deadline to sign the Participation Agreement. To qualify as a GUIDE safety net provider, a new program applicant must have had a Medicare FFS beneficiary population comprised of at least 36% beneficiaries receiving the Part D low-income subsidy or 33.7% beneficiaries who are dually eligible for Medicare and Medicaid. Accepting the infrastructure payment was optional.

    

8. Will the Dementia Care Management Payment or respite services be subject to beneficiary cost-sharing?

   Neither the Dementia Care Management Payment (DCMP) nor GUIDE respite services will be subject to beneficiary cost-sharing.

    

9. Can GUIDE Participants also use public or privately issued grants to sustain their operations?

   GUIDE does not have any restrictions on participants using other funds to help sustain their operations.

    

10. When a Medicare beneficiary undergoes an assessment that leads to re-assignment to a different model tier, how long will it take for the payment amount to change?

    When an aligned beneficiary is re-assessed and assigned to a new tier, the GUIDE Participant will be eligible to bill the G-code for the established patient payment rate associated with that tier the following month.

     

11. Will organizations that receive the infrastructure payment have to pay back the infrastructure payment if they withdraw from the GUIDE Model?

    GUIDE Participants that withdraw or are terminated before the start of the second performance year will be required to repay the entire value of their infrastructure payment to CMS. GUIDE Participants that withdraw from the GUIDE Model or are terminated during the second performance year will be required to repay half of the infrastructure payment to CMS. After the second performance year, GUIDE Participants that withdraw or are terminated from the GUIDE Model are not required to repay the infrastructure payment.

     

12. What services are separately billable during GUIDE Model participation?

    The primary 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 replace fee-for-service payment for some existing Medicare Physician Fee Schedule (PFS) services, including chronic care management and principal care management, transitional care management, advance care planning, and technology-based check-ins. Therefore, the GUIDE Participant will not be able to bill separately for these services for aligned beneficiaries. The GUIDE Model is not a total-cost-of-care model, so GUIDE Participants will continue to bill under traditional Medicare fee-for-service for all services that are not included under the DCMP. Additional information, including a complete list of duplicative codes, is available in the Request for Applications (Table 8, pg. 35). CMS may add or remove codes over time to reflect changes in PFS billing codes.

     

13. Are GUIDE Participants expected to become the medical home for the patient and address primary care issues as well?

    GUIDE Participants are required to provide care through an interdisciplinary care team. The care team may include the beneficiary’s primary care provider, and if not, the care team is required to identify and share information with the beneficiary's primary care provider and specialists and outline the care coordination services needed to manage the beneficiary's dementia and co-occurring conditions.

     

14. Will GUIDE Participants be able to see the data that the adjustments to the Dementia Care Management Payment (DCMP) are based upon?

    CMS will provide GUIDE Participants data related to the performance measures that CMS uses to determine the GUIDE Participant’s performance-based adjustment to the DCMP.

     

15. When does payment under the model begin?

    GUIDE Participants in the established program track should be prepared to begin furnishing services under the GUIDE Model on July 1, 2024, and bill for those services during the Model Performance Period. GUIDE Participants in the new program track should be prepared to begin furnishing services under the GUIDE Model on July 1, 2025, and bill for those services during the Model Performance Period.

     

16. Is overlap between the GUIDE Model and the Medicare Shared Savings Program (SSP) allowed? If so, why?

    Yes, GUIDE beneficiary and provider overlap with the Shared Savings Program is allowed. The GUIDE Model is designed to be compatible with other CMS models and programs that aim to improve care and reduce spending. CMS believes targeted support for individuals with dementia and their caregivers will help improve population-based care outcomes overall. CMS expects the increased investment and targeted care delivery approach to result in better long-term quality and cost outcomes for beneficiaries with dementia and their caregivers.

     

17. How do the GUIDE payments interact with the 2024 Shared Savings Program payments?

    Shared Savings Program calculations include all Medicare Parts A and B services. Therefore, DCMP and respite services payments will be included in 2024 Shared Savings Program expenditures. As soon as 2024 becomes a benchmark year, DCMPs and respite services will be included in Shared Savings Program benchmark calculations. For example, if an ACO is participating in both the GUIDE Model and the Shared Savings Program during Performance Year 2024 and then renews and starts a new agreement period as of January 1, 2025, that ACO would have their Shared Savings Program benchmark based on 2022, 2023 and 2024, and would have DCMPs and respite care payments in Benchmark Year 3.

     

18. When can GUIDE Participants bill for the comprehensive assessment?

    GUIDE Participants may bill for the comprehensive assessment after CMS determines that the beneficiary is eligible for alignment to the GUIDE Participant and aligns the beneficiary to the GUIDE Participant. The GUIDE Participant must not bill Medicare separately for the services provided in the comprehensive assessment. The comprehensive assessment (and any re-assessments) is covered by the DCMP. If CMS determines 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.

     

19. How is the hourly payment for GUIDE Respite Services calculated?

    The hourly payment for GUIDE Respite Services is calculated annually and has two adjustments. The first is the geographic adjustment factor (GAF). The second is the Home Health Agency market basket less the productivity adjustment. This adjustment is calculated by the CMS Office of the Actuary and can be found here. More information on market basket update timing and dollar amounts will be available in the Payment Methodologies Paper (PMP).

     

20. Are GUIDE Participants required to provide respite services beyond the $2,500 amount?

    GUIDE Participants are not required to provide beneficiaries respite services beyond the respite cap of $2,500.

     

21. Can Partner Organizations bill for duplicative codes covered by the DCMP for GUIDE beneficiaries? Are providers not associated with the GUIDE Model (i.e., neither a GUIDE Participant nor a Partner Organization) allowed to bill for duplicative codes?

    Partner Organizations are not permitted to bill the duplicative codes covered by the DCMP for their GUIDE Participant’s beneficiaries. Providers not participating in or associated with the GUIDE Model may continue to bill Medicare FFS for codes covered by the DCMP as usual.
     

Care Delivery Requirements

1. What are GUIDE Participants required to provide as caregiver education and support?

   GUIDE Participants will be required to administer a caregiver support program. Required services of the caregiver support program will include caregiver skills training, dementia diagnosis information, support group services, and ad hoc one-on-one support calls.

    

2. Will the GUIDE Model support the use of telehealth/digital health for expanding access to care?

   The GUIDE care delivery requirements provide beneficiaries and caregivers with flexibility when receiving care. CMS anticipates that many services under the model could be delivered virtually, which would allow model access for beneficiaries and caregivers in rural areas and other communities without access to specialized dementia care. One example of this is the Comprehensive Assessment care delivery requirement, which is an assessment that may be performed via telehealth or in-person based on the preference of the beneficiary and/or caregiver. Caregiver education and support are additional components of the model that may also be delivered virtually. The only in-person visit requirement is the in-home visit requirement for certain beneficiaries when they are first aligned to a GUIDE Participant.

    

3. What are the specific requirements for Care Navigators?

   Care Navigators are not required to have specific credentials or professional accreditation. A variety of professionals, including but not limited to community health workers, social workers, and registered nurses could fill this role. Individuals who work as Care Navigators must receive training on a variety of specific topics related to dementia. A full list of training requirements is provided in the Request for Applications. Examples of topics that the Care Navigator training must include are: conducting person-centered care planning, providing culturally competent care, and managing behavioral and psychosocial symptoms of dementia. GUIDE Participants will be responsible for ensuring that their Care Navigators receive training that meets the model requirements. GUIDE Participants may either create their own training or use training materials that are available through other organizations as long as these trainings address the GUIDE Model’s required training topics.

    

4. What are the requirements for 24/7 access to care included in the GUIDE Model’s care delivery requirements?

   GUIDE Participants may satisfy this 24/7 access requirement by maintaining an after-hours helpline that the beneficiary or their caregiver may call to speak with either a member of the care team or a third party engaged by the GUIDE Participant to provide after-hours communication. Referring the beneficiary to a publicly available 24/7 helpline is not sufficient to satisfy this care delivery requirement.

    

5. Does a member of the care team need to be available 24/7 through the support line?

   GUIDE Participants must provide either 24/7 access to an interdisciplinary care team member or maintain a 24/7 helpline that the beneficiary and/or their caregiver may call to speak with either a member of the care team or a third party engaged by the GUIDE Participant to provide communication with human support (e.g., not artificial intelligence) during off-duty hours. A third party engaged by the GUIDE Participant to provide communication during off-duty hours shall share with the interdisciplinary care team information of about any communication with a beneficiary and/or their caregiver.

    

6. Can the initial in-home visit be done via telehealth?

   For beneficiaries with a caregiver in the low complexity dyad tier or beneficiaries without a caregiver in the low complexity individual tier, the initial visit may be performed remotely through electronic means. For beneficiaries with a caregiver in moderate or high complexity dyad tiers, or beneficiaries without a caregiver in moderate to high complexity individual tier, the GUIDE Participant must visit the beneficiary at their current residence. While in-person, the GUIDE Participant may facilitate remote participation of the caregiver and other members of the care team.

    

7. How frequently will the GUIDE Participant need to connect with the beneficiary and/or their caregiver?

   GUIDE Participants shall maintain a minimum contact frequency with the beneficiary and/or their caregiver. Minimum contact requirements vary by tier, as follows:

   • Beneficiary with a caregiver
     • Low complexity dyad tier: at least quarterly
     • Moderate complexity dyad tier: at least once a month
     • High complexity dyad tier: at least once a month
   • Beneficiaries without a caregiver
     • Low complexity individual tier: at least once a month

     • Moderate to high complexity individual tier: at least twice a month

        

8. What modalities of communication are acceptable for serving and supporting aligned beneficiaries and caregivers?

   GUIDE Participants can contact the beneficiary and/or caregiver in-person (in-clinic or in-home), by phone, and/or by audio-visual modalities in accordance with the beneficiary’s and/or caregiver’s preferences. Short Messaging Service (SMS) (i.e., texting) may not be used to contact the beneficiary or caregiver to meet the minimum contact frequency but can be used in other communications.

    

9. Does a GUIDE Participant have to support all 5 tiers of the GUIDE Model?

   Yes, a GUIDE Participant must be able to support beneficiaries in each tier.

    

10. Are there additional services expected to be provided to support the beneficiary without a caregiver?

    If the beneficiary does not have a caregiver, the GUIDE Participant must make a reasonable effort to help identify a caregiver for the beneficiary. If the GUIDE Participant and the beneficiary are not able to identify a caregiver, then the caregiver assessment and caregiver education and support care delivery requirements do not apply to that beneficiary, and instead the GUIDE Participant must make additional efforts and put safeguards into its care delivery to support the beneficiary continuing to reside in the community.

     

11. Can GUIDE Participants use data from prior comprehensive assessments or must they be redone to voluntarily align beneficiaries?

    GUIDE Participants are required to complete new comprehensive assessments for purposes of the GUIDE Model before a beneficiary can voluntarily align to the GUIDE Participant for purposes of the GUIDE Model.

     

12. Is there a minimum number of beneficiaries each site must care for in order to be considered as a GUIDE Participant in the model?

    While there is not a minimum number of beneficiaries, CMS encourages GUIDE Participants to have at least 200 beneficiaries aligned by the second performance year and maintain at least 200 aligned beneficiaries throughout the duration of the model.

     

13. What credentials and/or certifications are needed to complete the Home Visit Assessments for beneficiaries?

    Any member of the interdisciplinary care team can perform Home Visit Assessments for beneficiaries. The GUIDE Model is not requiring specific credentials and/or certifications for an individual completing a Home Visit Assessment. GUIDE Participants have discretion in how they operationalize the Home Visit Assessment beyond what is described in Section 1.3 of Appendix B of the Request for Applications (PDF).

     

14. Does the GUIDE Model include funds for transportation to and from appointments?

    The GUIDE Model does not cover the cost of transportation for beneficiaries.

     

Performance Management

1. How will the GUIDE Model establish performance metric benchmarks? 

   To ensure that CMS is setting accurate and meaningful benchmarks for GUIDE Participants, the GUIDE Model will have a “pay for reporting” approach for Performance Year 1 for the non-claims-based measures (quality of life outcome and use of high-risk medications). Based on the data reported during Performance Year 1, CMS will set benchmarks for both measures and keep them constant for the second and third years. For the claims-based measures (total per capita cost and long-term nursing home stay rate), benchmarks for Performance Year 1 will be calculated based on claims data from prior years (e.g., CY 2023). Benchmarks will then be updated for Performance Year 2 based on model Performance Year 1 data. Like the non-claims-based measures, benchmarks will be kept constant for Performance Years 2 and 3, after which time CMS will decide whether to update the benchmarks to ensure continuous improvement.

    

2. Is CMS requiring GUIDE Participants to use a specific survey for the quality of life outcome measure?

   The quality of life outcome measure is based on the PROMIS Scale v1.2 – Global Health. GUIDE Participants will be required to submit survey responses to CMS. The measure specifications are available on the American Academy of Neurology (AAN) website.

    

3. Is performance measured differently for GUIDE Participants in the new program track versus GUIDE Participants in the established program track?

   GUIDE Participants in the new program track will be measured in the same manner as GUIDE Participants in the established program track. GUIDE Participants in the new program track will begin their performance measurement period during their first performance year, beginning July 1, 2025.

    

4. Will GUIDE Participants be removed from the model if they have low performance on the quality measures?

   GUIDE Participants that do not meet measure benchmarks will receive a negative performance-based adjustment (PBA) to the Dementia Care Management Payment (DCMP), but will be permitted to continue participating in the model. 

Data Reporting

1. What kinds of data will the GUIDE Model be sharing with GUIDE Participants, and how?

   CMS will share data feedback with GUIDE Participants through the Data Dashboard which will provide GUIDE Participants with an interactive, user-friendly interface for viewing data for their aligned beneficiaries. Data provided through the dashboard will include utilization and cost data based on claims, as well as quality and sociodemographic data reported by the GUIDE Participant.

    

2. What are the types of data will be collected for the GUIDE Model?

   GUIDE Participants will be required to collect and report information that will allow CMS to monitor and evaluate the model. This will include, but is not limited to:

   • Quality data: GUIDE Participants will report quality data for the non-claims-based performance metrics annually;
   • Care delivery data: GUIDE Participants will answer a series of questions about how the GUIDE Participant is implementing the care delivery requirements of the model;
   • Beneficiary and caregiver assessment data: GUIDE Participants will conduct an initial assessment of potentially eligible beneficiaries and caregivers as applicable, and submit data to CMS that includes beneficiary dementia stage, whether they have a caregiver, and level of burden; and

   • Sociodemographic and health-related social needs data.

      

3. What sociodemographic and health-related social needs (HRSNs) data will GUIDE Participants be required to collect?

   Health-related social needs, or HRSNs, are used to describe individual-level social needs and are individual-level adverse social conditions that negatively impact a person's health or health care. HRSN collection and referrals will be part of the model's broader care delivery requirements for comprehensive assessment and referral for social services and supports. GUIDE Participants will annually report aggregated, domain-level data from HRSN screening domains such as food insecurity, housing instability, transportation needs, utility difficulty, and interpersonal safety, starting after the first model performance year.

   GUIDE Participants will be encouraged but not required to use one of two preferred HRSN screening tools: the Accountable Health Communities (AHC HRSN) screening tool (PDF), or the Protocol for Responding to and Assessing Patient Risk (PRAPARE®) tool. Collecting and reporting beneficiary reported sociodemographic data and HRSN data will help GUIDE Participants identify and address disparities within their patient population and track their progress towards health equity goals over time.

    

4. What are the Health Information Technology (HIT) requirements for GUIDE Participants?

   GUIDE Participants are required to use an electronic health record platform that meets CMS and Office of the National Coordinator for Health Information Technology (ONC) standards for Certified Electronic Health Record Technology (CEHRT) as defined in 42 CFR 414.1305.

Health Equity

1. How does CMS define "underserved communities" as related to the Health Equity Plan under the GUIDE Model?

   Consistent with the Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government dated January 20, 2021, “underserved communities” as used in the GUIDE RFA refers to populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life.

    

2. Will there be support to help GUIDE Participants with creating their Health Equity Plan?

   CMS will provide GUIDE Participants with technical assistance and guiding questions in the Care Delivery Reporting as part of their Health Equity Plan.
    

Application & Timelines

1. Will there be another opportunity to apply to participate in the GUIDE Model in future years?

   At this time, the GUIDE Model has only one application cycle which began in November 2023. CMS intentionally designed the GUIDE Model with the understanding that improving outcomes for dementia patients and evaluating the value of the model may require the full length of the model.

    

Other FAQs

1. How will CMS evaluate the GUIDE Model?

   The evaluation will use a mixed-methods approach to assess model impacts and implementation experience. All GUIDE Participants will be required to cooperate with CMS efforts to conduct an independent evaluation of the model, which may include completion of surveys and participation in interviews, site visits, and other activities that CMS determines necessary to conduct a comprehensive evaluation.

    

2. Are new GUIDE Participants required to stay in the program for 7 years (8 years for an established program)?

   The GUIDE Model is a voluntary model. The GUIDE Participant may terminate participation in the model upon advanced written notice to CMS, in accordance with the Participation Agreement. Until the effective date of termination, the GUIDE Participant must continue to provide model services to aligned beneficiaries and may not accept the voluntary alignment of new beneficiaries. The GUIDE Participant must also notify its aligned beneficiaries of its withdrawal from the GUIDE Model.

    

3. Is this model based on existing dementia care programs?

   The GUIDE Model builds on a substantial body of evidence from both previous CMS models and demonstration projects and external, provider-based dementia care programs. Like the GUIDE Model, these dementia care programs aim to provide comprehensive, interdisciplinary care to people with dementia and their caregivers, with the goal of improving the person and their caregiver’s quality of life while reducing avoidable health care utilization and delaying or avoiding long-term nursing home stays.

    

4. Are GUIDE Participants in the established program track able to participate in learning activities?

   GUIDE Participants in the established program track are permitted to participate in the learning activities offered through the GUIDE Model.

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