GUIDE Model Frequently Asked Questions
- Participant Eligibility
- Partner Organizations
- Beneficiaries & Caregivers
- Payment Methodology
- Care Delivery Requirements
- Performance Management
- Data Reporting
- Health Equity
- Application & Timelines
- Other FAQs
1) How does the GUIDE Model align with the Innovation Center’s strategy and priorities?
The GUIDE Model will support the pillars of the CMS Innovation Center Strategy Refresh in the following ways:
- 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 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 participants provide to disadvantaged beneficiaries; and requiring 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, a monthly population-based payment methodology that will enable model 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 will address costs by 1) offering a new payment to participants for respite services furnished to aligned beneficiaries; 2) requiring model 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 Models (APMs) or Merit-based Incentive Payment System (MIPS) APMs?
CMS expects that the GUIDE Model will qualify as a MIPS APM for established and new dementia care provider 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.
1) What types of providers are eligible to participate in the model??
Providers eligible to be GUIDE participants are Medicare Part B-enrolled providers/suppliers, excluding durable medical equipment (DME) and laboratory suppliers, who are eligible to bill under the Medicare Physician Fee Schedule and agree to meet the care delivery requirements of the model as described in the Request for Applications (RFA).) and future participation agreements. The GUIDE Participant must maintain an interdisciplinary care team to meet the care delivery requirements of the GUIDE Model. At a minimum, the interdisciplinary care team must include a “care navigator” and a clinician with “dementia proficiency”. If the participant cannot meet the GUIDE Model care delivery requirements alone, they can contract with other organizations, including both Medicare-enrolled and non-Medicare enrolled entities, to meet the care delivery requirements.
2) What are the differences between the model tracks?
The GUIDE Model will have two tracks: a track for established dementia care programs with a performance period that begins July 1, 2024, and a track for new dementia care programs that begins July 1, 2025, with a one-year pre-implementation period beginning July 1, 2024. New program participants are required to use this 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. All applicants will apply at the same time, and CMS will assign them to either the established program track or the new program track based on the information provided in their application.
3) What types of organizations will 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. New programs either do 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 RFA), or provide comprehensive dementia care, but have only done so for less than 12 months prior to the deadline for application submissions (January 30, 2024). Applicants do not need to have a Medicare Part B enrolled TIN that is eligible to bill under the Medicare Physician Fee Schedule at the time of application to the GUIDE Model, but if selected for participation, the applicant must have an enrolled TIN prior to execution of the Participation Agreement (Spring 2024). 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 dementia. New program development is intended to help to increase beneficiary access to specialty dementia care, particularly in underserved communities.
4) Are Federally Qualified Health Centers (FQHCs) eligible to apply for GUIDE?
Providers that are eligible to be GUIDE participants are Medicare Part B-enrolled providers/suppliers eligible to bill under the Medicare Physician Fee Schedule and that agree to meet the care delivery requirements of the model. While this excludes FQHCs from directly billing for GUIDE Model services, participants can, and are encouraged to, contract with other Medicare providers/suppliers, like FQHCs, to meet the care delivery requirements. These contracted providers/suppliers will be known as “Partner Organizations.”
5) Are practices in ACO REACH or Medicare Shared Savings Program (MSSP) eligible to join GUIDE?
Yes, practices in ACO REACH and SSP are eligible to participate in the GUIDE Model. Beneficiaries in those programs are also eligible to voluntarily align to a GUIDE participant while remaining aligned to ACO REACH, Shared Savings Program ACOs and other total cost of care CMS models. The GUIDE Model is designed to be compatible with other CMS models and programs that provide health care entities with opportunities to improve care and reduce spending.
6) Is there a limit on the number of participants that will be selected?
Not all applicants are guaranteed participation in the model. CMS will need to consider factors critical to ensuring a robust evaluation of the model. CMS may also deny individual clinicians or any other individual or entity participation in the GUIDE Model based on the results of a program integrity review.
7) We are a multi-site health system – do each of our sites have to participate separately or can they participate collectively?
GUIDE participants must be a Part B Medicare-enrolled provider or supplier eligible to bill for Medicare Physician Fee Schedule services. The participant must bill under a single Taxpayer Identification Number (TIN). If a multi-site health system bills under a single TIN, then the health system can participate as one dementia care program. However, if each site bills under different TINs, then each site would need to participate separately.
8) Are home health and/or hospice agencies able to participate in GUIDE as standalone participants?
To participate in the GUIDE Model, a Medicare enrolled home health agency and/or hospice must have or establish a Part B Medicare enrolled TIN that is eligible to bill under the Medicare Physician Fee Schedule. An organization may still apply if it has not yet completed the process of establishing a Part B Medicare enrolled TIN but must have an enrolled TIN prior to execution of the GUIDE Participation Agreement, which will occur in Spring 2024.
9) How do I enroll a Medicare Part B to become a provider?
You can find more information about becoming a Medicare Part B provider on CMS’s website at https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos
10) Is there a role for organizations to assist GUIDE Participants with program implementation and management?
If a GUIDE Participant cannot meet the GUIDE care delivery requirements alone, 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.”
There is not an option to apply to the GUIDE Model as a Partner Organization. Entities interested in becoming a Partner Organization should work directly with applicants or GUIDE Participants. CMS plans to release a list of GUIDE Participants accepted into the model in Summer 2024.
11) What if the clinician with dementia proficiency is not a physician?
If the clinician with dementia proficiency is not a physician, the applicant must identify a physician that serves at least part-time as the medical director who will oversee the quality of care for the program, if accepted to participate in the GUIDE Model.
12) Can the roster of practitioners working with the model 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 GUIDE Participation Agreement will provide additional detail on the steps a GUIDE Participant must take to update their GUIDE Practitioner Roster.
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 expected to maintain a list of Partner Organizations (“Partner Organization Roster”) and keep it up to date throughout the course of the GUIDE Model.
2) Can participants contract with community-based organizations?
Yes, model 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 organizations apply as a Partner Organization and have CMS connect them with model participants?
No, there is not an option to apply as a Partner Organization. Entities interested in becoming a Partner Organization must work directly with GUIDE applicants or participants to become a Partner Organization. CMS plans to release a list of GUIDE participants in summer 2024.
4) Can a Partner Organization or community-based organization partner with more than one participant?
Yes, Partner Organizations can partner with more than one model participant. There is no limit on the number of participants that a Partner Organization can support.
Beneficiaries & Caregivers
1) What are the beneficiary eligibility requirements for the Guiding an Improved Dementia Experience (GUIDE) Model?
Beneficiaries are 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;
- 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 complexity tiers?
A beneficiary’s model tier is determined based on 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. Participants will report data on disease stage and caregiver status to CMS when a beneficiary is first aligned to the model. To ensure consistent beneficiary assignment to tiers across model participants, participants must use a tool from a set of approved screening and measurement tools to measure dementia stage and caregiver burden.
Corresponding Assessment Tool Scores
Beneficiaries with a caregiver
Low complexity dyad tier
CDR= 1, FAST= 4
Moderate complexity dyad tier
Moderate or severe dementia
Low to moderate caregiver strain
CDR= 2-3, FAST= 5-7
High complexity dyad tier
Moderate or severe dementia
High caregiver strain
CDR= 2-3, FAST= 5-7
Beneficiaries without a caregiver
Low complexity individual tier
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 model participants. Participants must inform beneficiaries about the model and the services that they can receive through the model and document that a beneficiary or their legal representative, if applicable, consents to receiving services from the participant. Participants must then submit the consenting beneficiary’s information to CMS and CMS will confirm that the beneficiary meets the model eligibility requirements before aligning them to the participant. Even after a beneficiary has opted in and been aligned to a model 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. Participants will be strongly encouraged, but not required, to have at least 200 aligned beneficiaries by the end of the second model performance year and maintain at least 200 aligned beneficiaries throughout the model.
4) Can beneficiaries sign up for the GUIDE Model?
For a Medicare beneficiary to receive services under the model, they will need to find a health care provider that is participating in the GUIDE Model in their community. CMS will publish a list of model participants on its website in the Summer of 2024. A Medicare beneficiary could then visit a model participant, and after consenting to receiving services from the participant, CMS would be able to confirm whether the beneficiary meets the model eligibility requirements before aligning them to the 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 will be 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) If a beneficiary has multiple caregivers, are the GUIDE Participants required to keep data on each of them?
GUIDE Participants are only required to identify one caregiver for evaluation and reporting data. However, GUIDE Participants are encouraged to involve other caregivers in care delivery to best meet the needs of each beneficiary.
7) Which specific dementia diagnoses qualify beneficiaries to be eligible to voluntarily align in the GUIDE Model and how will a GUIDE Participant’s attestation that a beneficiary has dementia be verified?
Beneficiaries 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. Initially, 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, an ICD-10 diagnosis of dementia will be required. The GUIDE Participant must attach an eligible ICD-10 dementia diagnosis code to each Dementia Care Management Payment (DCMP) claim for it to be paid. The Request for Applications (RFA) lists the eligible ICD-10 dementia diagnosis codes.
8) What are the approved screening tools for dementia staging? Can GUIDE Participants use other tools to tier 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. Additional tools may be added to the approved measurement tool set throughout the course of the Model.
GUIDE Participants have the option to seek CMS approval to use an alternative 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 proposal. Details on the process for submitting proposed tools and tiering information will be shared with GUIDE Participants after July 1, 2024.
9) 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 GUIDE Care navigators to be trained to work with caregivers in identifying and managing common behavioral changes due to dementia. 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.
10) 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 of the beneficiary eligibility requirements. This could occur, for example, by becoming a long-term nursing home resident, enrolling in Medicare Advantage, or if the beneficiary 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).
11) 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.
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
After first 6 months
4) How will partners associated with model participants get paid?
The GUIDE Model Participant will bill for the per beneficiary per month DCMP and respite services. The GUIDE Model Participant will work with the partner organizations to determine any payment arrangement. The participant will be responsible for having contracts and other arrangements in place with their partner organizations to pay for any services that those partner organizations are providing to their aligned beneficiaries. CMS will not pay partner organizations for services under the GUIDE Model, as partner organizations are not model participants.
5) What are the requirements for offering respite services?
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 24-hour facility. While the model provides payment to participants for services furnished in these various settings, participants will have some flexibility in the type of respite services that they make available to their beneficiaries. The model requires all participants to make available in-home respite services, either directly or by contracting with a provider of in-home respite. However, participants have the option, and are not required, to make available respite through an adult day center or a 24-hour facility. The GUIDE Model will pay pays for these three types of respite services, up to an annual cap of $2,500 per beneficiary, per year.
6) What is the infrastructure payment?
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 to cover some of the upfront costs of establishing a new dementia care program 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?
Participants will qualify as a safety net provider based on the proportion of their patient population that is dually eligible for Medicare and Medicaid or receives the Part D low-income subsidy. CMS will notify selected applicants whether they meet the safety net criteria before they sign a Participation Agreement. To qualify as a GUIDE safety net provider, a new program applicant must have 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. The infrastructure payment is 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 Participants may use other funds to help sustain their operations.
10) When a Medicare beneficiary undergoes an assessment that leads to re-assignment to a different complexity tier, how long will it take for the payment amount to change?
When an aligned beneficiary is re-assessed into a new tier, the GUIDE Participant will be eligible to bill the G-code for the established patient payment rate associated with that tier in the following month.
11) Will organizations 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.
12) What do the GUIDE respite services include?
The GUIDE Model provides payment for respite services provided in three types of settings up to an annual cap of $2,500 per beneficiary. The three types of settings 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 24-hour facility. GUIDE Participants are required to make in-home respite services available, either directly or by contracting with a provider of in-home respite.
13) 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 all services not included in the DCMP will continue to be billed under traditional fee-for-service. 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.
14) 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.
15) Will GUIDE Participants be able to see the data that the adjustments to the Dementia Care Monthly Payment (DCMP) are based upon?
GUIDE Participants will be provided monthly reports that will include data on the performance-based adjustment and health equity adjustment. Beneficiary-level claims data on cost and utilization will also be available through the GUIDE data dashboard.
16) When does payment under the model begin?
Dementia Care Management Payments (DCMP) and GUIDE respite payments for aligned beneficiaries will begin Summer 2024 for GUIDE Participants in the established program track and Summer 2025 for GUIDE Participants in the new program track. The performance-based adjustment (PBA) will begin January 1, 2026 for established programs and January 1, 2027 for new programs.
Care Delivery Requirements
1) What do GUIDE participants need to provide as caregiver education and support?
To provide education and support to the caregiver of an aligned beneficiary, 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 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 nearly all model components could be delivered virtually, which will 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 model participant.
3) What are the specific requirements for GUIDE Care Navigators?
GUIDE 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 will be provided in the RFA, but examples of topics that the care navigator training must include are: conducting person-centered care planning, providing culturally competent care, and strategies for managing behavioral and psychosocial symptoms of dementia. Participants will be responsible for ensuring that their care navigators receive training that meets the model requirements. Participants may either create their own training or use training materials that are available through other organizations, as long as these trainings address all of 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?
A participant 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 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 shall 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 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 shall 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 do not apply to that beneficiary, and instead the GUIDE Participant shall make additional efforts and put safeguards into its care delivery to support the beneficiary continuing to reside in the community.
11) Can Dementia Care Programs participating in the GUIDE Model use data from prior comprehensive assessments or must they be redone to voluntarily align beneficiaries?
As beneficiaries voluntarily align, GUIDE Participants are required to complete new comprehensive assessments for purposes of the GUIDE Model.
12) Could a "new" program begin implementation prior to July 1st, 2025 if all design work is completed?
No, GUIDE Participants in the new program track will have a one-year pre-implementation period from July 1, 2024, through June 30, 2025, and the first performance year will begin on July 1, 2025. Beneficiary alignment and payment under the Model will not begin prior to July 1, 2025.
13) Is there a minimum number of beneficiaries each site must care for in order to be considered as a participant in the model?
While there is not a minimum number of beneficiaries, CMS encourages dementia care programs 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.
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.
On an annual basis, CMS will publish a methodology paper that will show the technical specifications and benchmarks for the performance measures. The methodology papers will be made available to GUIDE Participants 30 days before the applicable performance year. Details on the caregiver burden measure benchmark, which will not be phased in until later in the model, will be available in a future methodology paper.
2) For the quality of life outcome measure, is CMS requiring model participants to use a specific survey?
CMS will provide GUIDE Participants with the required survey, which is evidence-based and can be administered by the GUIDE Participant to the beneficiary or caregiver via paper and electronically.
3) Is the performance for participants in the new program track measured differently from 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.
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 adjustment on the performance-based adjustment (PBA) of the Dementia Care Management Payment (DCMP) but will be permitted to continue participating in the model.
1) What kinds of data will the GUIDE model be sharing back with participants, and how?
CMS will share data feedback with participants through a GUIDE Data Dashboard, which will provide 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 participant. Data in the dashboard will be updated periodically.
2) What are the types of data will be collected for this model?
GUIDE participants will be collecting and reporting information that will allow CMS to monitor and evaluate the model. This will include, but is not limited to:
- Quality data: Participants will be annually reporting quality data for the non-claims-based performance metrics;
- Care delivery data: Will consist of a series of questions about how the participant is implementing the model and specifically, the care delivery requirements of the model;
- Beneficiary and caregiver assessment data: 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 (HRSN) data will participants be required to collect?
Health-Related Social Needs, or HRSN, 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. 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 model participants will be encouraged but not required to use one of two preferred HRSN screening tools, the Accountable Health Communities, or AHC HRSN screening tool, or the Protocol for Responding to and Assessing Patient Risk, or PRAPARE tool. Collecting and reporting beneficiary reported sociodemographic data and HRSN data will help participants identify and address disparities within their patient population and track their progress towards health equity goals over time.
4) Our organization has its own electronic health record; will we qualify to apply?
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 at 42 CFR 414.1305.
1) How does CMS define "underserved communities" as related to the Health Equity Plan under the 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?
Application & Timelines
1) When will the Request for Applications be available?
The Request for Applications (RFA) is currently available. You may access the application at: https://www.cms.gov/files/document/guide-rfa.pdf (PDF)
2) What is the Request for Applications (RFA) due date?
The application period for the RFA will close on January 30, 2024.
3) When will the Participation Agreement be available?
For applicants accepted to participate in the GUIDE model, CMS anticipates that the Participation Agreement will be available in Spring 2024. Selected applicants must sign the Participation Agreement prior to the model start date in order to participate in the model.
4) What are minimum application requirements that the applicant will need to submit to CMS (e.g., will they be required to identify all participating Part B providers)?
To be eligible for the Established Program Track, applicants must submit an eligible billing TIN and a proposed GUIDE Practitioner Roster with the NPIs of the Medicare-enrolled physicians and non-physician practitioners who will provide services under the model as part of their application.
New Program Track participants must have an eligible billing TIN and at least one NPI by the deadline to execute a Participation Agreement, which will occur in Spring 2024, before the start of the pre-implementation period. As part of their application, applicants to the New Program Track must also submit a plan for implementing a dementia care program that includes strategies for staffing, development of program protocols and workflows, training, and development of a referral network, as well as identifying a program director who will have primary accountability for implementing their dementia care program.
5) 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 beginning in November 2023. CMS intentionally designed the 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.
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 committed to staying 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. 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, if they received the payment. 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, if they received the payment.
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.