GUIDE Request for Applications

U.S. Department of Health & Human Services

Centers for Medicare & Medicaid Services

Center for Medicare & Medicaid Innovation

Patient Care Models Group

7500 Security Boulevard

Baltimore, MD 21244

Guiding an Improved Dementia Experience

Request for Applications

Version: 1

Last Modified: November 7, 2023

Contents

MODEL SUMMARY ................................................................................................................................. 4

BACKGROUND ........................................................................................................................................ 7

SCOPE AND DURATION ......................................................................................................................... 10

GUIDE PARTICIPANTS ........................................................................................................................... 11

Participation Requirements ........................................................................................................... 13

Application .................................................................................................................................... 15

GUIDE Model Eligibility Criteria ..................................................................................................... 15

Program Integrity Screening ......................................................................................................... 16

Participant Withdrawal Policy....................................................................................................... 17

BENEFICIARY ELIGIBILITY AND BENEFICIARY ALIGNMENT .................................................................... 18

Overview ....................................................................................................................................... 18

Beneficiary Eligibility ..................................................................................................................... 18

Beneficiary Outreach and Engagement ......................................................................................... 19

Beneficiary Alignment ................................................................................................................... 20

Model Tiers ................................................................................................................................... 22

CARE DELIVERY ..................................................................................................................................... 24

Care Delivery Requirements .......................................................................................................... 24

Care Team Requirements .............................................................................................................. 26

Care Navigator Training ................................................................................................................ 27

Care Delivery Reporting ................................................................................................................ 28

PERFORMANCE MEASUREMENT ........................................................................................................... 29

PAYMENT DESIGN ................................................................................................................................. 32

Dementia Care Management Payment ......................................................................................... 33

Health Equity Adjustment ............................................................................................................. 36

Performance-Based Adjustment .................................................................................................... 37

Respite Payment ........................................................................................................................... 42

Payment Examples ........................................................................................................................ 45

Infrastructure Payment ................................................................................................................. 47

HEALTH EQUITY STRATEGY ................................................................................................................... 50

Health Equity Plan Requirement ................................................................................................... 50

Health Equity Data Collection Requirement .................................................................................. 51

LEARNING SYSTEMS STRATEGY............................................................................................................. 52

DATA ..................................................................................................................................................... 52

Data Reporting Requirements ....................................................................................................... 52

Data Sharing ................................................................................................................................. 53

PARTICIPANT MONITORING, AUDITING, AND TERMINATION STRATEGY ............................................. 54

EVALUATION ......................................................................................................................................... 54

AUTHORITY TO TEST THE MODEL ......................................................................................................... 54

Authority to Test the Model .......................................................................................................... 54

Waiver and OIG Safe Harbor Authority ......................................................................................... 55

Benefit Enhancement and Beneficiary Engagement Incentive ...................................................... 55

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) ALTERNATIVE PAYMENT MODEL (APM) AND

ADVANCED APM STATUS ...................................................................................................................... 56

PROGRAM OVERLAPS AND SYNERGIES ................................................................................................. 56

Overlaps with Shared Savings Program and Innovation Center ACO Models ................................ 57

Overlaps with the BPCI Advanced and Comprehensive Care for Joint Replacement (CJR) Models . 57

Overlaps with Innovation Center models that have care management payments ........................ 58

Appendix A: Participant Application Guidance and Questions ............................................................. 59

Appendix B: Care Delivery Requirements ............................................................................................. 67

Appendix C: Example Patient Assessment and Alignment Form ........................................................... 76

Model Summary

This Request for Applications (RFA) introduces the Guiding an Improved Dementia Experience (GUIDE)

model, a new Center for Medicare and Medicaid Innovation (Innovation Center) model from the Centers

for Medicare & Medicaid Services (CMS). The GUIDE Model will test whether providing an alternative

payment methodology for participating dementia care programs to deliver a package of care

management and coordination, caregiver education and support, and GUIDE Respite Services to

Medicare beneficiaries with dementia and their caregivers

reduces expenditures while preserving or

enhancing quality of care.

The GUIDE Model is designed to enhance quality of care by improving quality of life for people with

dementia and reducing burden and strain on their caregivers. It is expected to reduce Medicare and

Medicaid expenditures primarily by preventing or delaying long-term nursing home stays, and

secondarily by reducing hospital, emergency department, and post-acute care utilization.

The GUIDE Model is a key deliverable from President Biden’s April 2023 Executive Order on Increasing

Access to High-Quality Care and Supporting Caregivers, as well as key goals of the National Plan to

Address Alzheimer’s Disease.

Key Model Elements:

• Scope and Duration: The GUIDE Model will be an 8-year voluntary model that is offered

tionwide, and will run from July 1, 2024 through June 30, 2032 (“Model Performance

Period”). The GUIDE Model will have two participant tracks, one for established dementia care

programs and one for new dementia care programs. The first performance year for the

established program track will begin on July 1, 2024. The new program track will have a one-

year pre-implementation period that begins on July 1, 2024, and its first performance year will

begin on July 1, 2025.

• Participants: GUIDE Participants will be Medicare Part B-enrolled providers or suppliers

(excluding durable medical equipment (DME) and laboratory suppliers) that establish Dementia

Care Programs (“DCPs”) to provide ongoing, longitudinal care to people with dementia (“GUIDE

Participant”). A GUIDE Participant must participate in the GUIDE Model under a single, Medicare

Part B-enrolled Taxpayer Identification Number (TIN) that is eligible to bill for Medicare

Physician Fee Schedule (PFS) services. A GUIDE Participant must meet the care delivery

requirements described in the “Care Delivery” section of this RFA but may choose to partner

with other organizations, including both Medicare-enrolled providers and suppliers and non-

Medicare enrolled entities, such as community-based organizations, to meet these

requirements.

For purposes of the GUIDE Model, the term “caregiver” is defined as a relative, or an 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.

• Beneficiary Eligibility and Beneficiary Alignment: Eligible beneficiaries will be community-

dwelling

Medicare FFS beneficiaries, including beneficiaries dually eligible for Medicare and

Medicaid, who have dementia. Beneficiaries will be aligned to GUIDE Participants through a

voluntary alignment process in which they are informed about the GUIDE Model and consent to

receive services from a specific GUIDE Participant. Aligned beneficiaries will maintain freedom of

choice with respect to their physicians or practitioners.

• Model Tiers: Beneficiaries will be assigned to one of five model tiers based on the complexity of

their needs, and, if applicable, their caregiver needs. Model services, care intensity, and

payment will vary by model tier. GUIDE Participants must re-assess each beneficiary at least

once per year, and CMS may re-assign beneficiaries to a different model tier based on the

results of the re-assessment.

• Care Delivery: The GUIDE care delivery approach includes 1) a standardized package of services

that GUIDE Participants must provide to beneficiaries and their caregivers (as applicable to

individual beneficiary and caregiver needs) (“GUIDE Care Delivery Services”); 2) an

interdisciplinary care team to deliver these services; and 3) a standardized training requirement

for care navigators who are part of the interdisciplinary care team. GUIDE Care Delivery Services

encompass nine care delivery domains: comprehensive assessment, care planning, ongoing

monitoring and support, medication reconciliation and management, 24/7 access to a care team

member or helpline, care coordination and transitional care management, referrals and

coordination for services and supports, caregiver education and support, and GUIDE Respite

Services. The interdisciplinary care team must include, at a minimum, a “care navigator,” and a

clinician with “dementia proficiency” who is eligible to bill Medicare Part B evaluation and

management services (E/M).

The terms “care navigator” and “dementia proficiency” are

defined in the section titled “Care Team Requirements.”

• Performance Measurement: CMS plans to measure GUIDE Participant performance on five

performance measures, including quality, patient experience, utilization, and cost metrics: Use

of High-Risk Medications in Older Adults; Quality of Life Outcome for People with Neurological

Conditions; Caregiver Burden; Total Per Capita Cost; and Long-Term Nursing Home Stay rate.

The caregiver burden and long-term nursing home stay rate are new metrics that will be

developed for use in the GUIDE Model.

• Per Beneficiary Per Month Payment: GUIDE Participants will be able to bill Medicare for a per

beneficiary per month Dementia Care Management Payment (“DCMP”). CMS will pay the DCMP

For the purposes of the GUIDE Model, the term “community-dwelling” is defined as living in a personal home,

assisted living facility, group home, or other community setting. A beneficiary will still be considered community-

dwelling for the purposes of the model if they are admitted to an acute care hospital or receive post-acute care in

skilled nursing facility. A beneficiary will no longer be considered community-dwelling if the person becomes a

long-term nursing home resident, defined as having a nursing home stay that is not covered under the Medicare

skilled nursing facility benefit.

See “Care Delivery” section for more detailed criteria for the care navigator role and the definition of “dementia

proficiency”.

to GUIDE Participants for furnishing the GUIDE Care Delivery Services to aligned beneficiaries

(with the exception of GUIDE Respite Services, which will be paid for under a separate

payment). The GUIDE Participant’s DCMP amount will depend on the aligned beneficiary’s

model tier; each of the five model tiers will have a different DCMP rate. The DCMP will be

adjusted by a performance-based adjustment tied to the five model performance metrics, as

well as a health equity adjustment. The health equity adjustment will increase the DCMP paid to

the GUIDE Participant for low-income aligned beneficiaries from underserved communities and

it will decrease the DCMP paid to the GUIDE Participant for higher income aligned beneficiaries

from more advantaged communities. The health equity adjustment is intended to provide an

incentive for GUIDE Participants to deliver care to beneficiaries from underserved communities.

The GUIDE Model is not a total cost of care model and GUIDE Participants may continue to bill

for all services not included in the DCMP under traditional Medicare FFS.

• Payment for GUIDE Respite Services: GUIDE Participants will be able to bill the Innovation

Center for up to $2,500 per aligned beneficiary per year for GUIDE Respite Services. Only certain

aligned beneficiaries will be eligible for GUIDE Respite Services (see Requirements for Aligned

Beneficiaries to be Eligible to Receive GUIDE Respite Services under the “Respite Payment”

section of this RFA). GUIDE Participants must offer in-home GUIDE Respite Services but may also

choose to offer adult day center and facility-based respite.

• Health Equity: To address disparities in dementia care, GUIDE Participants will be required to

develop and implement a Health Equity Plan that identifies disparities in outcomes in their

patient populations and strategies to reduce these disparities over the course of their

participation in the GUIDE Model. GUIDE Participants will also be required to collect and report

data on beneficiaries’ sociodemographic characteristics and health-related social needs (though

beneficiaries will always have the option to opt out of sharing their data). This data will help

GUIDE Participants identify and address disparities within their patient population and track

their progress towards health equity goals over time.

• Data Reporting and Sharing: In addition to the sociodemographic and health-related social

needs data described above, GUIDE Participants will also be required to report quality and care

delivery data on an annual basis. This information will be used to assess GUIDE Participant

performance and inform the model evaluation. GUIDE Participants will also receive data from

CMS, primarily in the form of a Data Dashboard. The Data Dashboard will provide GUIDE

Participants with an interactive, user-friendly interface for viewing claims-based utilization data

for their aligned beneficiaries, updated monthly, available and aggregated across the GUIDE

Participant’s entire aligned population.

Background

6.7 million Americans currently live with Alzheimer’s disease or another form of dementia, a number

that is projected to grow to nearly 14 million by 2060.

Despite the high prevalence of dementia—

roughly 11 percent of U.S. adults over the age of 65 and nearly 35 percent over the age of 85 have

dementia

—many people with dementia are not consistently receiving high quality, high value care.

People with dementia experience poor outcomes across an array of metrics, including high rates of

hospitalization, ED visits, and post-acute care utilization,

6,7

high rates of depression, behavioral and

psychological symptoms of dementia (BPSD),

and poor management of other co-occurring

conditions.

9,10

As the condition progresses, many people with dementia will need long-term services and

supports, including care in a nursing facility or home and community-based services.

With support and collaboration, primary care can play an important role in improving care delivered to

people with dementia, including providing person-centered care and coordinating across providers to

manage a person’s co-occurring conditions.

However, the primary care setting often lacks the

resources to independently provide the intensive services that people with dementia need—services

such as identifying and helping connect to services and supports, addressing behavioral symptoms, and

re-stabilizing after an acute health event.

Dementia not only affects quality of life for people with the disease—it also significantly impacts quality

of life for caregivers. Many caregivers for people with dementia, who are often Medicare beneficiaries

themselves, report high levels of stress and depression,

which negatively affect their overall health and

increase their risk for serious illness, hospitalization, and mortality.

13,14

Dementia also imposes a large

financial burden on beneficiaries and their families: out-of-pocket spending in the last five years of life,

including for long term services and supports, is higher for people with dementia compared to those

Alzheimer's Association. 2023 Alzheimer's Disease Facts and Figures.

https://www.alz.org/media/documents/alzheimers-facts-and-figures.pdf

Ibid.

Lin P-J, Fillit HM, Cohen JT, Neumann PJ, et al. Potentially avoidable hospitalizations among Medicare

beneficiaries with Alzheimer’s and related disorders. Alzheimer’s & Dementia. January 2013. 9(1): 30-38.

Feng Z, Coots LA, Kaganova Y and Wiener JM. Hospital and ED Use Among Medicare Beneficiaries with Dementia

Varies by Setting and Proximity to Death. Health Affairs. April 2014. 33(4).

Lyketsos, CG, Lopez O, Jones B, et al. Prevalence of Neuropsychiatric Symptoms in Dementia and Mild Cognitive

Impairment: Results from the Cardiovascular Health Study. JAMA. September 2002. 288(12): 1475-1483.

Zhao Y, Kuo T-C, Weir S, et al. Healthcare costs and utilization for Medicare beneficiaries with Alzheimer’s. BMC

Health Services Research. May 2008.

Thorpe CT, Thorpe JM, Kind AJH, et al. Receipt of Diabetes Monitoring in Older Adults with Co-Morbid Dementia.

Journal of the American Geriatric Society. April 2012. 60(4): 644-651.

Boustani M, Schubert C, and Sennour Y. The challenge of supporting care for dementia in primary care. Clin

Interv Aging. December 2007. 2(4).

Teri L, McKenzie G, Logsdon RG, McCurry SM, Bollin S, et al. Translation of two evidence-based programs for

training families to improve care of persons with dementia. Gerontologist. 2012. 52: 452–459.

Schubert CC, Boustani M, Callahan CM, Perkins AJ, Hui S, et al. Acute care utilization by dementia caregivers

within urban primary care practices. Journal of General Internal Medicine. 2008: 23: 1736–1740.

Schulz R, Martire LM. Family caregiving of persons with dementia: prevalence, health effects, and support

strategies. American Journal of Geriatric Psychiatry. 2004. 12: 240–249.

without dementia ($61,522 vs. $34,068), and people with dementia end up spending a significantly

higher share of their total family assets on care in the last five years of life (32% vs 11%).

15,16

All of these issues are exacerbated for certain racial and ethnic groups. Black and Hispanic populations

have a higher prevalence of dementia,

17,18

but they also are less likely to receive a timely diagnosis,

have more unmet needs,

are more likely to experience high caregiving demands, and spend a higher

share of their family assets on dementia care.

21,22,23, 24

Though much of the financial burden of dementia falls on beneficiaries and their caregivers through out-

of-pocket spending, dementia also drives higher costs for federal health care programs. Two recent

studies have estimated that, on average, a person with dementia will have an additional $12,000-

$15,700 in total Medicare costs and an additional $8,800-$31,000 in total Medicaid costs over the 5

years after diagnosis.

25,26

Driven by this evidence of the enormous burden that dementia imposes on individuals, families,

caregivers, and society at large, numerous federal groups and agencies have sought to identify

interventions that can improve care and outcomes for people with dementia and their caregivers. Many

of these federal partners have identified care coordination and caregiver education and support

programs like the GUIDE Model as promising interventions. For example, the GUIDE Model is consistent

with recommendations in the National Plan to Address Alzheimer’s Disease, which is the nation’s

roadmap for addressing dementia that includes input from ASPE, OASH, NIA, CMS, CDC, ACL, HRSA,

Hudomiet P, Hurd M, Rohwedder S. The relationship between lifetime out-of-pocket medical expenditures,

dementia, and socioeconomic status in the US. The Journal of the Economics of Aging. 2019. 14.

Kelley AS, McGarry K, Gorges R, Skinner JS. The Burden of Health Care Costs for Patients with Dementia in the

Last 5 Years of Life. Annals of Internal Medicine. November 2015.

Lennon, et al. Black and white individuals differ in dementia prevalence, risk factors, and symptomatic

presentation. Alzheimer’s and Dementia. 2021.

Lines, LM and Wiener JM. Racial and Ethnic Disparities in Alzheimer’s Disease: A Literature Review. Office of the

Assistant Secretary for Planning and Evaluation (ASPE). 31 January 2014.

Gianattasio KZ, Prather C, Glymour MM, et al. Racial disparities and temporal trends in dementia misdiagnosis

risk in the United States. Alzheimer’s & Dementia. December 9, 2019.

Black BS, Johnston D, Leoutsakos J, et al. Unmet needs in community-living persons with dementia are common,

often non-medical and related to patient and caregiver characteristics. International Psychogeriatrics. November

2019. 31(11).

Friedman EM, Shih RA, Langa KM, Hurd MD. US prevalence and predictors of informal caregiving for dementia.

Health Affairs Project Hope. 2015. 34(10):1637–41.

Lines LM, Wiener JM. Racial and Ethnic Disparities in Alzheimer’s Disease: A Literature Review. Report prepared

for Office of Disability, Aging and Long-Term Care Policy in the Office of the Assistant Secretary for Planning and

Evaluation. February 2014. Contract #HHSP23320100021WI.

Hudomiet et al. (2019).

Kelley et al. (2015).

White L, Fishman P, Basu A, et al. Medicare expenditures attributable to dementia. Health Services Research.

2019. 54: 773-781.

Coe NB, White L, Oney M, et al. Public spending on acute and long-term care for Alzheimer's disease and related

dementias. Alzheimer's & Dementia. 20 January 2022.

AHRQ, SAMHSA, FDA, IHS, and ACF

and is informed by the Advisory Council on Alzheimer’s Research,

Care, and Services. The National Plan recommends that CMS explore the effectiveness of new models of

care for people with Alzheimer’s disease and related dementias, and that CMS implement and evaluate

care coordination models for people with dementia.

It is also consistent with a 2021 National Academies for Science, Engineering, and Medicine (NASEM)

consensus report recommending that collaborative dementia care models and multi-component

caregiver support programs should be implemented and evaluated in multiple and varied real-world

settings.

The GUIDE Model also builds on lessons learned from the Department of Veteran Affairs (VA) Program

of General Caregiver Support Services (PGCSS), which has experience implementing numerous caregiver

education and support interventions, including caregiver skills trainings, individual and group counseling,

peer support mentoring, and respite services.

The GUIDE Model is consistent with Executive Order 14095 signed on April 18, 2023, “Increasing Access

to High-Quality Care and Supporting Caregivers”, which directed the Secretary of Health and Human

Services to “consider whether to select for testing by the Center for Medicare and Medicaid Innovation

an innovative new health care payment and service delivery model focused on dementia care that

would include family caregiver supports such as respite care.”

Finally, 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 aimed 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.

Overall, there is evidence that dementia care programs improve beneficiary and caregiver experience of

care, increase self-reported caregiver efficacy, and lower caregiver stress.

31,32

Office of the Assistant Secretary for Planning and Evaluation (ASPE), Office of the Assistant Secretary for Health

(OASH), National Institute on Aging (NIA), Centers for Medicare & Medicaid Services (CMS), Centers for Disease

Control and Prevention (CDC), Administration for Community Living (ACL), Health Resources and Services

Administration (HRSA), Agency for Healthcare Research and Quality (AHRQ), Substance Abuse and Mental Health

Services Administration (SAMHSA), Food and Drug Administration (FDA), Indian Health Service (IHS), and

Administration for Children and Families (ACF).

National Plan to Address Alzheimer’s Disease: 2022 Update. U.S. Department of Health and Human Services.

https://aspe.hhs.gov/sites/default/files/documents/59cefdd628581b48b2e389891a675af0/napa-national-plan-

2022-update.pdf

NASEM Committee on Care Interventions for Individuals with Dementia and Their Caregivers. 2021.

Factsheet: Department of Veterans Affairs Program of General Caregiver Support Services. March 2022.

https://www.caregiver.va.gov/pdfs/FactSheets/CSP_PGCSS_Fact_Sheet.pdf

NASEM Committee on Care Interventions for Individuals with Dementia and Their Caregivers. Meeting the

Challenge of Caring for Persons Living with Dementia and Their Care Partners and Caregivers: A Way Forward.

Washington, DC: The National Academies Press. 2021.

Agency for Healthcare Research and Quality. Care Interventions for People with Dementia and Their Caregivers.

Comparative Effectiveness Review Number 231. August 2020.

CMS has previously tested five dementia care models or demonstrations: four dementia care projects

funded through the Innovation Center’s Health Care Innovation Awards (HCIA),

and a multi-site

Medicare demonstration.

According to a synthesis of evaluation results conducted by the Innovation

Center’s Research and Rapid Cycle Evaluation Group (RREG),

key findings across the five projects were

that: 1) access to dementia care resources improved beneficiaries’ and caregivers’ experience of care; 2)

caregivers reported increased efficacy in their caregiving abilities and lower stress; 3) there was a

significant reduction in long-term nursing home stays in one project; and 4) there were non-significant

reductions in Medicare expenditures, ED visits, and hospitalizations in several projects. The evaluation

followed beneficiaries during their period of enrollment in each project, which varied from 12 to 36

months on average.

The GUIDE Model is designed to investigate whether 1) defining a specific package of dementia care

services, 2) tiering the intervention intensity based on a person’s needs and targeting high-intensity care

to those with the greatest need, 3) providing access to GUIDE Respite Services, and 4) using a longer,

eight-year performance period (as compared to previous dementia care demonstrations) could improve

outcomes or our ability to detect improved outcomes.

Scope and Duration

The GUIDE Model will be an 8-year voluntary national model that is offered in all states, U.S. territories,

and the District of Columbia. The Model Performance Period will begin on July 1, 2024 and end on June

30, 2032. The GUIDE Model will have two participant tracks, one for established dementia care

programs and one for new dementia care programs. CMS will assign selected applicants to either the

established program track or the new program track. The purpose of the two tracks is to allow

established programs to begin their performance in the GUIDE Model on July 1, 2024, while giving

organizations that do not currently offer a comprehensive community-based dementia care program,

including safety net organizations, time and support to develop a new program. New program

development is intended to help to increase beneficiary access to specialty dementia care, particularly in

underserved communities.

The first performance year for the established program track will begin on July 1, 2024. The new

program track will have a one-year pre-implementation period that begins on July 1, 2024. The first

performance year for the new program track will begin on July 1, 2025 and both tracks will continue

through June 30, 2032. Table 1 illustrates the timeline for both tracks.

Health Care Innovation Awards. Centers for Medicare & Medicaid Services.

https://innovation.cms.gov/innovation-models/health-care-innovation-awards

Newcomer R, Miller R, Clay T, Fox P. Effects of the Medicare Alzheimer’s disease demonstration on Medicare

expenditures. Health Care Financ Rev. 1999. 20:45–65.

CMS Innovation Center. Dementia Care Projects: Synthesis of Evaluation Results, 1989-2020. December 2022.

https://innovation.cms.gov/data-and-reports/2022/dementia-care-synthesis-1989-2020

Table 1. Model Timeline for Established Program and New Program tracks

Nov. ’23-

Jan. ‘24

July 2024-

June 2025

July ’25-

June ‘26

July ’26-

June ‘27

July ’27-

June ‘28

July ’28-

June ‘29

July ’29-

June ‘30

July ’30-

June ‘31

July ’31-

June ‘32

Established

Program

Track

Application

Period

Performance

Year (PY) 1

PY 2 PY 3 PY 4 PY 5 PY 6 PY 7 PY 8

New

Program

Track

Application

Period

Pre-

Implementation

(PI) Period

PY 1 PY 2 PY 3 PY 4 PY 5 PY 6 PY 7

The application period will close on January 30, 2024. Applicants will be notified as to whether they

have been selected for participation in the GUIDE Model in Spring 2024. Onboarding for all selected

GUIDE Participants will take place in Spring 2024 and the GUIDE Model will begin on July 1, 2024.

GUIDE Participants

A GUIDE Participant will be a Medicare Part B-enrolled provider or supplier, excluding DME and

laboratory suppliers, that establishes a DCP to provide ongoing, longitudinal care to people with

dementia. The GUIDE Participant must participate under a single, Medicare Part B-enrolled Taxpayer

Identification Number (TIN) that is eligible to bill under the PFS.

The GUIDE Participant will be identified by a single TIN that is used to bill for GUIDE Model services, plus

the National Provider Identifiers (NPIs) of individual Medicare-enrolled physicians and other non-

physician practitioners who have re-assigned their billing rights to the GUIDE Participant’s billing TIN.

The GUIDE Participant will be required to maintain this list of physicians and non-physician practitioners

(“GUIDE Practitioner Roster”) and keep it up to date throughout the course of the GUIDE Model, as it will

be used to determine who is eligible to bill for GUIDE Model payments.

Contracting with Providers, Suppliers, and/or Organizations to Meet Care Delivery Requirements

A GUIDE Participant must meet the care delivery requirements described in the “Care Delivery” section

of this RFA. 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.”

For example, a multispecialty practice may contract with a Medicare enrolled home health agency to

have an occupational therapist, who is employed by the home health agency, provide some of the

required care delivery services.

In another example, a primary care physician may contract with a community-based memory care clinic,

that is not a Medicare enrolled provider, in order to provide some of the required care delivery services.

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.

Both Medicare-enrolled and non-Medicare enrolled entities may contract with more than one GUIDE

Participant.

Examples of Dementia Care Programs

Example 1: A single Medicare provider forms a DCP

In this example, the DCP is established by a multi-specialty practice and model services are billed under

the practice’s TIN. The multi-specialty practice meets all care delivery requirements of the GUIDE Model,

including in-home GUIDE Respite Services, without a Partner Organization.

Example 2: A Medicare provider partners with several other Medicare providers to form a DCP

In example two, the DCP is established by a geriatrics practice, which is the GUIDE Participant. The

geriatrics practice partners with an occupational therapy practice and a home health agency to meet the

care delivery requirements of the GUIDE Model. The occupational therapy practice and the home health

agency are considered Partner Organizations within the DCP. All model services are billed by the GUIDE

Participant, in this case the geriatrics practice’s TIN, and all practitioners must re-assign their billing

rights to this TIN.

Example 3: Medicare-enrolled provider establishes a new Part B enrolled TIN to form a DCP

In example three, a home health agency establishes a new Medicare Part B-enrolled practice for the

purposes of participating in GUIDE. The Part B-enrolled practice is the GUIDE Participant, and model

services are billed under the practice’s TIN.

Example 4: A community-based provider partners with a primary care practice to form a DCP

In example four, a community-based memory care clinic, without a Part B-enrolled provider on staff,

partners with a Part B-enrolled primary care practice to meet the care delivery requirements of the

GUIDE Model. The Part B-enrolled primary care practice is the GUIDE Participant, and model services

are billed under the primary care practice’s TIN.

Participation Requirements

An applicant that is accepted to participate in the GUIDE Model will become a GUIDE Participant upon

execution of a Participation Agreement with CMS. The Participation Agreement will set forth the terms

of the GUIDE Model and each party’s obligations under the GUIDE Model.

GUIDE Participants must meet the following requirements, among others specified in the Participation

Agreement, throughout the performance period of their assigned track (e.g., July 1, 2024 - June 30, 2032

for the established program track and July 1, 2025 - June 30, 2032 for the new program track):

• Meet the interdisciplinary care team, care delivery, and training requirements, as described in

the Participation Agreement (see the “Care Delivery” section and appendix B of this RFA).

• 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.

• The GUIDE Participant has the flexibility to provide most model services virtually or in-person (in

office or in the beneficiary’s home) but must conduct an initial home visit in-person for aligned

beneficiaries who have moderate to severe dementia.

• The GUIDE Participant is required to make available for eligible beneficiaries GUIDE Respite

Services in the beneficiary’s home. The GUIDE Participant has the option, but is not required to,

offer eligible beneficiaries GUIDE Respite Services at an adult day center or a facility that can

provide 24-hour care. More details regarding GUIDE Respite Services can be found in the

“Respite Payment” section of this RFA.

• Maintain an up-to-date GUIDE Practitioner Roster and Partner Organization Roster.

• Comply with all model reporting requirements, including care delivery, sociodemographic data,

and quality reporting.

GUIDE Participants in the new program track will be required to use the one-year pre-implementation

period, from July 1, 2024 to June 30, 2025, for program development, including hiring and training staff,

establishing program work flows and processes, developing provider networks, and building

relationships with community-based organizations and respite suppliers and providers, as applicable.

GUIDE Participants in the new program track will not be required to meet the GUIDE Model’s care

delivery, care team, and Certified Electronic Health Record Technology (CEHRT) requirements until two

months before the beginning of their first performance year (by May 1, 2025). GUIDE Participants in the

new program track will be required to submit baseline care delivery reporting, a Proposed GUIDE

Practitioner Roster and, if applicable, a Proposed Partner Organization Roster by May 1, 2025 to enable

CMS to verify that they have met these requirements. CMS will conduct a program integrity screening

based on the proposed rosters. CMS will terminate from the GUIDE Model any GUIDE Participants in the

new program track who fail to meet these requirements by May 1, 2025. GUIDE Participants, who

receive an infrastructure payment and are then terminated from the GUIDE Model under the provisions

of this paragraph, are required to re-pay the infrastructure payment to CMS (see “Infrastructure

Payment” section of this RFA).

Additional comprehensive participation requirements will be set forth in the Participation Agreement.

ONC has proposed to require USCDI Version 3 in certified health IT products by January 1, 2025. Participants will

be required to use certified health IT that has been updated to a required version of the United States Core Data

for Interoperability (USCDI) Version 3, where applicable for certified functionality required under the CEHRT

definition at 42 CFR 414.1305, by the deadline finalized by ONC.

Application

Application questions, including deadlines and contact information, can be found in Appendix A.

pplicants must submit all application materials via an online portal available on the GUIDE Model

website at https://innovation.cms.gov/innovation-models/guide

by the deadline. It is the responsibility

of the applicant to ensure that they include all required information in their application.

Applicants seeking to withdraw their application must submit an electronic withdrawal request to CMS

ia the following mailbox: GUIDEModelTea[email protected]ov. The request must be submitted as a PDF on

the organization’s letterhead and must be signed by a corporate official authorized to bind the

applicant. It should include: the applicant organization’s registered name; the organization’s primary

point of contact; the full and correct address of the organization; and a description of the nature of the

withdrawal.

GUIDE Model Eligibility Criteria

To be selected for participation in the GUIDE Model, applicants must first meet the eligibility criteria, as

escribed below. Then, if accepted, CMS will assign the selected applicants to either the established

program track or the new program track based on the information provided in the application.

CMS will accept applicants that meet eligibility requirements for either the established program track or

he new program track taking into consideration eligibility for the relevant track, the results of the

program integrity screening, model size considerations, and other reasons.

Established Program Track

To be eligible for the established program track, an applicant must:

• Be a legal entity formed under applicable state, federal, or Tribal law, that is authorized to

conduct business in each state in which it operates;

• Be a Medicare Part B enrolled provider or supplier (excluding DME and laboratory suppliers)

hat is eligible to bill under the Medicare Physician Fee Schedule at the time of application;

• Have a currently practicing interdisciplinary team at the time of model announcement that has

rovided at least 6 of the 9 care delivery domains described in the “Care Delivery” section, for at

least the past 12 months prior to the deadline for application submissions, to people living with

dementia;

• Submit the NPIs of the Medicare-enrolled physicians and non-physician practitioners who they

re proposing to provide services under the GUIDE Model (“Proposed GUIDE Practitioner

Roster”);

• If applicable, submit a proposed list of the Partner Organizations with whom they would like to

partner in order to meet the care delivery requirements of the GUIDE Model (“Proposed Partner

Organization Roster”); and

• 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.

New program track

To be eligible for the new program track, an applicant must:

• Be a legal entity formed under applicable state, federal, or Tribal law, that is authorized to

conduct business in each state in which it operates;

• Attest that prior to execution of the Participation Agreement (in Spring 2024), it will have

established a single, Part B enrolled TIN that is eligible to bill under the Medicare Physician Fee

Schedule for the purposes of GUIDE Model participation;

• Either 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 described in the “Care Delivery”

section, delivered by an interdisciplinary team), or provide comprehensive dementia care, but

have only done so for less than 12 months prior to the deadline for application submissions.

• Describe, in their application, plans to implement a dementia care program that include:

Strategies for staffing;

Development of program protocols and workflows;

Training;

Development of a provider network; and

Identifying a program director who will have primary accountability for implementing

the dementia care program.

Applicants do not need to have a Medicare Part B enrolled TIN that is eligible to bill under the PFS at the

time of application to the GUIDE Model, but if selected for participation, the applicant must have one

prior to execution of the Participation Agreement. Signed Participation Agreements will be due back to

CMS in Spring 2024.

Program Integrity Screening

CMS will conduct a Program Integrity (PI) screening of all applicants (including practitioners submitted

on an applicant’s Proposed GUIDE Practitioner Roster) and their Proposed Partner Organizations Roster

as part of the application review process. CMS may deny selection to an otherwise qualified applicant

based on information found during PI screening of the applicant or any other relevant individuals or

entities associated with the applicant. For Medicare enrolled providers, the PI review may include the

following, without limitation, with respect to the applicant and Medicare enrolled Partner

Organizations:

ONC has proposed to require USCDI Version 3 in certified health IT products by January 1, 2025. Participants will

be required to use certified health IT that has been updated to a required version of the United States Core Data

for Interoperability (USCDI) Version 3, where applicable for certified functionality required under the CEHRT

definition at 42 CFR 414.1305, by the deadline finalized by ONC.

• Confirmation of current Medicare enrollment status as relevant and history of adverse

nrollment actions;

• Identification of Medicare and Medicaid debt;

• Review of performance in, and compliance with the terms of, other CMS models, demonstration

programs, and initiatives;

• Review of compliance with Medicare and Medicaid program requirements;

• Review of billing history and any administrative audits, investigations, or other activities

conducted regarding suspicious billing or other potential program fraud and abuse; and

• Review of any administrative, civil, or criminal actions related to program integrity or other

fac

tors relevant to participation in an initiative involving Federal funds.

The PI review may include the following, without limitation, with respect to the non-Medicare enrolled

Partner Organizations:

• Confirmation of current licensure or certification with the state, in which they are providing

ervices;

• Review of any criminal actions of the organization and its leadership, including related to

rogram integrity or other factors relevant to participation in an initiative involving Federal

funds.

In addition, CMS may also screen parent organizations to support an informed selection process and

dentify business practice, solvency, and program integrity concerns. Information evaluated may include,

but is not limited to: ownership, executive leadership, and care delivery experience.

If an applicant is selected for the new program track, CMS will conduct an additional program integrity

creening of the applicant’s Proposed GUIDE Practitioner Roster and Proposed Partner Organization

Roster when this information is submitted by the May 1, 2025 deadline as explained above under

“Participation Requirements”.

CMS will conduct program integrity screenings throughout the application period, after selecting

articipants, and during the performance period, and may deny or terminate participation in the GUIDE

Model based on the results of a program integrity screening or other information obtained regarding an

individual’s or entity’s history of program integrity issues at any point during or after the application and

selection processes.

Participant Withdrawal Policy

The GUIDE Participant may terminate its participation in the GUIDE Model upon advance written notice

o CMS, which must specify the effective date of termination. The GUIDE Participant must provide

advance written notice at least 180 days prior to the effective date of termination. 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.

Beneficiary Eligibility and Beneficiary Alignment

Overview

The GUIDE Model is designed to serve community-dwelling

Medicare FFS beneficiaries, including

beneficiaries dually eligible for Medicare and Medicaid, who have dementia. 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.

The GUIDE Participant will develop provider networks and conduct outreach and engagement to recruit

eneficiaries for the GUIDE Model. GUIDE Participants in the established program track are required to

offer the opportunity to voluntarily align to their DCP to all beneficiaries with dementia to whom they

already provide dementia care services. CMS will also employ several outreach strategies to supplement

GUIDE Participants’ beneficiary recruitment activities (see “Beneficiary Outreach and Engagement”

section below for more detail).

The GUIDE Model will use a voluntary alignment process for aligning beneficiaries to GUIDE Participants.

e beneficiary will learn about the GUIDE Model through a GUIDE Participant’s recruitment activities or

CMS’s outreach strategies and the beneficiary will have to consent to receive services from a specific

GUIDE Participant to be aligned to that GUIDE Participant. Even after a beneficiary has opted in and

been aligned to a GUIDE Participant, the GUIDE Model does not impact or restrict a beneficiary’s ability

to choose to receive health services from any provider or supplier.

Beneficiary Eligibility

A beneficiary must meet the following criteria to be eligible for voluntary alignment to a GUIDE

articipant:

• Has dementia, as confirmed by attestation from a clinician on the GUIDE Participant’s GUIDE

ractitioner Roster (see “Dementia Diagnosis Attestation” for more information);

• Enrolled in Medicare Parts A and B;

• Not enrolled in Medicare Advantage, including Special Needs Plans (SNPs);

• Have Medicare as their primary payer;

• Not enrolled in the Program of All-Inclusive Care for the Elderly (PACE);

• Has not elected the Medicare hospice benefit; and

• Not a long-term nursing home resident (defined as residence in a nursing home that is not paid

or under the Medicare skilled nursing facility benefit)

“Community-dwelling” is defined as living in a personal home, assisted living facility, group home, or other

community setting and excludes beneficiaries who become a long-term nursing home resident, defined as a

nursing facility stay that is not covered under the Medicare skilled nursing facility benefit. Beneficiaries will still be

considered community-dwelling for purposes of this model if they are admitted to an acute care hospital or

receive post-acute care in skilled nursing facility.

Basic personal everyday activities that include bathing, dressing, transferring, toileting, mobility and eating.

Activities related to independent living, including preparing meals, managing money, shopping for groceries or

personal items, performing light or heavy housework, and communication.

Beneficiaries who are enrolled in PACE or have elected hospice will not be eligible for alignment to a

UIDE Participant because PACE and hospice services could overlap significantly with the services that

will be provided under the GUIDE Model.

Dementia Diagnosis Attestation

Beneficiaries must have dementia to be eligible for alignment to a GUIDE Participant but may be at any

tage of dementia—mild, moderate, or severe (note that mild cognitive impairment is not a dementia

diagnosis and is not sufficient to meet this eligibility criteria). To confirm that beneficiaries have

dementia that makes them eligible for the GUIDE Model, CMS will rely on clinician attestation rather

than prior claims-based ICD-10 dementia diagnosis codes.

A clinician on the GUIDE Participant’s GUIDE

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.

Beneficiary Outreach and Engagement

To maximize the number of beneficiaries who receive services through the GUIDE Model, the GUIDE

del will use a three-pronged approach to identifying and recruiting potentially eligible beneficiaries:

1) Provider Networks: GUIDE Participants will develop provider networks with primary care

roviders, neurologists, hospitalists, hospital discharge planning staff, community-based

organizations, and other relevant groups in the community. Organizations from those networks

may recommend beneficiaries who already have a dementia diagnosis as well as beneficiaries

with suspected dementia but no formal diagnosis to the GUIDE Participant. GUIDE Participants

will work with network organizations to develop appropriate referral criteria and protocols. Any

networks, criteria, and protocols must comply with all applicable fraud and abuse laws.

2) CMS data sharing based on claims: Following a request by the GUIDE Participant, CMS will use

laims data from a three-year historical look-back period that falls within the five years prior to

the start date of the Model Performance Period, to identify beneficiaries who received Medicare

services from a GUIDE Participant, have claims-based ICD-10 dementia diagnosis codes, and are

eligible for the GUIDE Model. Using these criteria, CMS will offer GUIDE Participants a one-time

opportunity to request, prior to the GUIDE Participant’s first performance year, a list of eligible

Medicare FFS beneficiaries with dementia diagnosis codes. The list would include beneficiaries

to whom the GUIDE Participant provided services during the three-year historical lookback

As discussed in more detail under the section titled Payment Design, after a beneficiary is voluntarily aligned to

the GUIDE Participant, the GUIDE Participant must attach an eligible ICD-10 dementia diagnosis code to each

DCMP claim for the claim to be paid.

McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease:

Recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic

guidelines for Alzheimer's disease. Alzheimers & Dementia. May 2011; 7(3): 263–269.

Sachdev PS, Blacker D, Blazer DG, et al. Classifying neurocognitive disorders: the DSM-5 Approach. Nature

Reviews Neurology. 30 September 2014.

period, but who are not currently aligned to the GUIDE Participant. GUIDE Participants will be

able to

use this data to supplement their existing data to reach out to beneficiaries with

dementia who they are serving or have already served. CMS will not automatically align these

beneficiaries to the GUIDE Participant— these beneficiaries must still voluntarily align to the

GUIDE Participant.

3) Beneficiary Outreach Letter: CMS will send targeted outreach letters to eligible beneficiaries

with d

ementia diagnosis codes in their claims’ history, informing them about the GUIDE Model

and how to voluntarily align with a GUIDE Participant in their area, enabling them to self-identify

for the GUIDE Model. Mailings will use sensitive, beneficiary-friendly language and will not

include information about available in-kind beneficiary incentives. This beneficiary identification

pathway is part of the GUIDE Model’s health equity strategy.

To support this outreach, GUIDE Participants will be required to submit to CMS and maintain a

zip-code

based service area encompassing the zip codes from which the GUIDE Participants are

willing to accept beneficiaries. In defining a service area, GUIDE Participants should keep in mind

the GUIDE Model requirements to provide a home visit and GUIDE Respite Services to

beneficiaries in certain model tiers and make referrals to community-based services and

supports. CMS will list multiple GUIDE Participants in the targeted outreach letters if there is

more than one GUIDE Participant in a service area. The beneficiary may decide, in their sole

discretion, which GUIDE Participant to contact if the beneficiary is interested in the GUIDE

Model.

Beneficiary Alignment

After a potentially eligible beneficiary is identified through one of the three pathways described above,

the next s

tep is for the GUIDE Participant to schedule the person with dementia, or suspected dementia,

for an initial comprehensive assessment visit. The GUIDE Participant may choose to do an initial pre-

screening call to rule out beneficiaries who are ineligible for the GUIDE Model, but this is not required.

During the initial comprehensive assessment visit, which is similar to the Medicare service identified by

CPT code 99483, Cognitive Assessment and Planning,

the GUIDE Participant’s interdisciplinary care

team will assess the beneficiary and their caregiver (if applicable) across a number of required domains,

including cognitive function, functional status, clinical needs, behavioral and psychosocial needs, and

caregiver burden, with the goal of confirming a dementia diagnosis and creating a comprehensive care

plan.

During the assessment, if the interdisciplinary care team determines that the beneficiary has dementia

and ma

y be eligible to be aligned to the GUIDE Participant, then the care team must obtain the

beneficiary’s consent to voluntarily align to the GUIDE Participant. If the beneficiary, or their legal

representative if applicable,

consents, the GUIDE Participant will electronically submit a Patient

Cognitive Assessment and Care Plan Services. Centers for Medicare and Medicaid Services.

https://www.cms.gov/cognitive

If the GUIDE Participant finds that the beneficiary lacks capacity to consent to voluntarily align to a participant,

the GUIDE Participant will identify and recognize the beneficiary’s legal representative, if any, who has the

Assessment and Alignment form to CMS (see Appendix C for a sample Patient Assessment and

Alignment form).

If after the initial assessment, the interdisciplinary care team determines that the beneficiary requires

further testing to confirm a diagnosis, they may refer the beneficiary for such testing. If further testing

confirms a dementia diagnosis, the GUIDE Participant could offer the beneficiary the opportunity to

voluntarily align and submit a Patient Assessment and Alignment form to CMS at that time. If the

interdisciplinary care team assesses a beneficiary, or refers a beneficiary for additional diagnostic

testing, and determines that the beneficiary does not have dementia, the GUIDE Participant can bill for

an appropriate Medicare-covered professional service that corresponds to the service rendered.

The Patient Assessment and Alignment form will include an attestation from a practitioner on the GUIDE

Participant’s GUIDE Practitioner Roster that the beneficiary has dementia. CMS will use the information

submitted on the Patient Assessment and Alignment form to confirm the beneficiary’s eligibility for

alignment to the GUIDE Participant. If CMS finds that the beneficiary is eligible, then CMS will align the

beneficiary to the GUIDE Participant. Figure 1 summarizes the entire beneficiary identification and

voluntary alignment process.

Beneficiary alignment will occur on a rolling, ongoing basis for the first seven years of the GUIDE Model

(July 1, 2024-June 30, 2031). GUIDE Participants will be encouraged to meet a minimum threshold of

200 aligned beneficiaries by the end of their second performance year and maintain this alignment level

throughout the rest of the Model Performance Period.

Beneficiaries will remain aligned to the GUIDE Participant until they become ineligible. For example, an

aligned beneficiary would be deemed ineligible if they no longer meet one of the beneficiary eligibility

requirements or stop receiving model 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).

To support an organized wind-down of model operations and ensure that all aligned beneficiaries

receive meaningful support from the GUIDE Model, new beneficiaries may not be aligned during the

eighth and final year of the GUIDE Model (July 1, 2031-June 30, 2032).

authority to make health care decisions for the beneficiary (i.e., health care power of attorney, court appointed

legal guardian, etc.), and obtain the legal representative’s consent, acting on behalf of the beneficiary, to

voluntarily align the beneficiary to the GUIDE Participant. The GUIDE Participant will record such legal

representative’s authority to make health care decisions for the beneficiary by keeping a copy of the respective

court order, medical power of attorney, or other relevant document granting the legal representative’s authority

in the beneficiary’s file.

Figure 1: New Beneficiary Identification, Eligibility Check, and Voluntary Alignment Process

Model Tiers

CMS will assign aligned beneficiaries to one of five “model tiers,” based on a combination of their

disease stage, whether they have a caregiver, and if applicable, the degree of burden their caregiver is

experiencing. Beneficiary and caregiver complexity, and correspondingly, care intensity and payment,

will increase by tier. See Table 2 for a description of the five tiers.

To ensure consistent beneficiary assignment to tiers across GUIDE Participants, the GUIDE Participant

must use a tool from a set of approved screening tools to measure dementia stage and caregiver

burden. Approved tools have established scoring thresholds that correspond to mild, moderate, and

severe disease stage or caregiver burden. Alternatively, the GUIDE Participant will 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 GUIDE Model’s tiering

thresholds.

The GUIDE Participant receives notification from CMS about whether the

beneficiary is eligible.

Model participant has initial visit with beneficiary and caregiver (if applicable)

and performs comprehensive assessment, including patient history, cognitive

assessment, symptom list, medication history, and caregiver assessment.

CMS uses information submitted on the alignment form to check eligibility in

Medicare systems (e.g., beneficiary is enrolled in Parts A and B, not in hospice)

Identification

Initial

Comprehensive

Assessment Visit

Enrollment Form

to CMS

CMS Eligibility

Check

Beneficiaries are identified in one of three ways:

• Provider referral

• CMS claims-based data sharing with model participants

• Beneficiary self-referral letter sent by CMS

Beneficiaries are identified in one of three ways:

• Provider referral

• CMS claims-based data sharing with model participants

• Beneficiary self-referral letter sent by CMS

Beneficiaries are identified in one of three ways:

• Provider networks

• CMS claims-based data sharing with GUIDE Participant

• Beneficiary outreach letter sent by CMS

Identification

Initial

Comprehensive

Assessment Visit

GUIDE Participant has initial visit with beneficiary and caregiver (if applicable)

and performs comprehensive assessment, including patient history, cognitive

assessment, symptom list, medication history, and caregiver assessment.

At the end of the visit, if the beneficiary consents, the GUIDE Participant

electronically submits a Patient Assessment and Alignment form to CMS

attesting to dementia diagnosis and providing basic beneficiary identifying

information, dementia stage, and caregiver status.

Beneficiary

Alignment Form

to CMS

CMS uses information submitted on the Patient Assessment and Alignment

form to check eligibility in Medicare systems (e.g., beneficiary is enrolled in

Parts A and B, not in hospice, MA, PACE, etc.)

CMS Eligibility

Check

Beneficiary

Alignment

The GUIDE Participant will administer the approved screening tools during the initial comprehensive

assessment and submit the resulting scoring data as part of the Patient Assessment and Alignment form.

The GUIDE Participant must additionally electronically submit the individual responses to the caregiver

assessment to CMS.

CMS will use this data to assign beneficiaries to a model tier, per the tiering

criteria outlined in Table 2. The GUIDE Participant will be informed of a beneficiary’s model tier

assignment at the same time the GUIDE Participant is informed that a beneficiary is eligible and has

been aligned to them.

The approved measurement tool set will initially include two tools to report dementia stage – the

Clinical Dementia Rating (CDR)

and the Functional Assessment Screening Tool (FAST)

– and one tool

to report caregiver strain, the Zarit Burden Interview (ZBI).

Table 2 shows how these tools correspond

to model tier criteria. For dementia staging tools (the CDR and the FAST), the selected tools include

measures of both cognitive function and activities of daily living (ADL) and/or instrumental activities of

daily living (IADL), as ADL/IADL function is an important determinant of level of need for people with

dementia. Additional tools may be added to the approved measurement tool set throughout the course

of the GUIDE Model. While these are the only specified assessment tools that CMS requires for model

tiering and quality measure development, participants may use other assessment tools necessary to

meet the care delivery requirements.

Table 2: Five Model Tiers and Assignment Criteria

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

CMS will use the caregiver assessment responses to inform the caregiver burden measure development and the

Model’s evaluation.

Morris JC. Clinical Dementia Rating: A Reliable and Valid Diagnostic and Staging Measure for Dementia of the

Alzheimer Type. International Psychogeriatrics. 10 January 2005.

Sclan SG and Reisberg B. Functional Assessment Staging (FAST) in Alzheimer’s Disease: Reliability, Validity, and

Ordinality. International Psychogeriatrics. 07 January 2005.

Bedard M, Molloy DW, Squire L, et al. The Zarit Burden Interview: A New Short Version and Screening Version.

The Gerontologist. October 2021. 41(5): 652-657.

Care Delivery

The GUIDE Model will promote high-quality dementia care by defining and requiring GUIDE Participants

to use a comprehensive, standardized care delivery approach for providing care to aligned beneficiaries

and their caregivers. The GUIDE care delivery approach includes 1) a standardized package of services

that the GUIDE Participant must provide to beneficiaries and their caregivers as relevant to the

beneficiary’s preferences and needs based on the person-centered plan (“GUIDE Care Delivery

Services”), 2) an interdisciplinary care team to deliver these services, and 3) a standardized training

requirement for care navigators who are part of the interdisciplinary care team.

Care Delivery Requirements

CMS will require the GUIDE Participant to provide GUIDE Care Delivery Services to its aligned

beneficiaries, as applicable and appropriate to each individual beneficiary’s needs. Table 3 summarizes

the GUIDE Care Delivery Services under nine domains. See Appendix B for detailed requirements of each

care delivery domain.

Table 3. Summary of Required Care Delivery Activities by Domain

Domain

Required Activities by Domain

Comprehensive

Assessment

• Initial comprehensive assessment that includes clinical, behavioral and

psychosocial, and advance care planning domains, as well as caregiver needs and

capabilities and home visit

• Reassessments for beneficiary and caregiver at least once per year

Care Plan

• Develop a comprehensive person-centered care plan that addresses all

assessment domains and is led by the beneficiary

• If the GUIDE Participant is not a primary care practice, ensure the primary care

provider has access to the beneficiary’s person-centered care plan

24/7 Access

• Beneficiary has 24/7 access to an interdisciplinary care team member or help line

(may be a 3

party vendor during off-duty hours)

• Help line must be available to receive ad hoc one-on-one support calls from the

caregiver

Ongoing Monitoring and

Support

• Care navigator is primary point of contact

• GUIDE Participant maintains a minimum contact frequency with the beneficiary

and/or their caregiver. Minimum contact requirements vary by model tier, as

follows:

- Beneficiaries 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

Care Coordination and

Transitional Care

Management

• If the GUIDE Participant is not a primary care practice, the GUIDE Participant

must coordinate with the beneficiary’s primary care provider

• Refer beneficiary to specialists to address co-occurring conditions, as needed

• Ensure receipt of information back from specialist to add to care plan

• Support the beneficiary in transitions between personal home and care settings

Referral and

Coordination of Services

and Supports

• Maintain or have access to inventory of local/community services

• Refer and connect beneficiaries to community-based services and supports

• For dually eligible beneficiaries, coordinate the delivery of any community-based

services and supports with beneficiary’s Medicaid HCBS/LTSS case manager, if

applicable

Medication

Management and

Reconciliation

• Clinician with prescribing authority must review beneficiary’s medications

• Any resulting medication changes must be shared and confirmed with the

beneficiary’s PCP and other relevant specialists

Caregiver Education and

Support

• Administer a caregiver support program, which must include:

- caregiver skills training - dementia diagnosis information

- support group services - ad hoc one-on-one support calls

• GUIDE Participant must provide dementia diagnosis information and ad hoc

support calls directly, but may contract with a vendor or a community-based

organization to provide caregiver skills training and/or refer caregivers to

external support group services

Respite

• Referral and coordination of in-home respite care

• Option to refer to adult day centers or facility-based respite providers

The GUIDE Care Delivery Services are the minimum services that the GUIDE Participant is required to

offer beneficiaries. The GUIDE Participant must be able to provide the GUIDE Care Delivery Services at

varying levels of intensity depending on model tier and the beneficiary’s individual needs. The GUIDE

Participant may offer certain additional services outside of the GUIDE Care Delivery Services, including

the in-kind beneficiary engagement incentive permitting GUIDE Participants to use their own funds to

provide environmental modifications to the beneficiary’s home. See section titled, “Authority to Test

the Model”, for more information regarding this beneficiary engagement incentive.

As highlighted in Table 3, the delivery of services will be guided by the creation and maintenance of a

person-centered care plan, which will detail 1) the beneficiary’s goals, strengths, preferences and needs,

2) the results from the comprehensive assessment, 3) recommendations for service providers and

community-based services and supports, including which individual or program is responsible for

payment of each service provider, and 4) the caregiver’s options and preferences for education and

support services (if there is a caregiver). The care plan will also identify the beneficiary’s primary care

provider and any specialists and outline the care coordination services and specialists that are needed to

manage the beneficiary’s dementia and co-occurring conditions.

The requirements also recognize the critical role that caregivers play in caring for people with dementia

by offering caregiver education and support services, as well as including the caregiver, with the

For purposes of the GUIDE Model, the term “community-based services and supports” is defined as services and

supports delivered to individuals living in their personal home, assisted living facility, group home, or other

community setting that create or maintain the individual’s ability to safely live in the community. For example, this

term includes, but is not limited to, such services and supports as transportation, home-delivered meals or

groceries, environmental modifications, in home care/assistance, and exercise and socialization activities.

Based on our conversations with stakeholders, we anticipate that most beneficiaries will identify a caregiver.

Nevertheless, beneficiaries without caregivers may still receive services under the model. Under such

circumstances, the domains of Caregiver Assessment and Caregiver Education and Support will not apply to that

beneficiary, as a caregiver is not involved to receive those services. Instead, the GUIDE Participant must make

additional efforts and put safeguards into its care delivery services to support beneficiaries without a caregiver.

beneficiary’s consent, or the consent of the beneficiary’s legal representative if applicable, in discussions

bout the beneficiary’s diagnosis, care, and needs. The GUIDE Participant must administer a caregiver

support program that is based on the caregiver’s needs as identified through the comprehensive

assessment and is responsive to ongoing changes in need. The minimum level of services available to

the caregiver should include caregiver skills training, dementia diagnosis information, and support

services. For support services, at a minimum, the GUIDE Participant must include ad hoc one-on-one

support calls with a member of the care team and referral to support group services.

Care Team Requirements

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” who is eligible to bill Medicare Part B evaluation and management services

(E/M), such as a physician, nurse practitioner, physician assistant, or clinical nurse specialist. The

interdisciplinary care team may also include additional members, such as a pharmacist or behavioral

health specialist, at the GUIDE Participant’s discretion.

Care Navigator: To serve as a care navigator under the GUIDE Model, an individual must satisfy the

raining requirements described under the section titled “Care Navigator Training.” CMS is not requiring

individuals to have specific professional backgrounds or certifications to work as a Care Navigator,

though CMS believes that registered nurses, licensed clinical social workers, and community health

workers would all be well-suited to this role. The care navigator must be an individual and not artificial

intelligence.

Clinician with dementia proficiency: A clinician will qualify as having “dementia proficiency” if they can

eet at least one of the following criteria:

i. Attest to having at least 25 percent of their patient panel (regardless of payer) at some

ime in the past 5 years comprised of adults with any cognitive impairment, including

dementia; or

ii. Attest to having at least 25 percent of their patient panel (regardless of payer) at some

time in the past 5 years comprised of adults aged 65 years old or older; or

iii. Have a specialty designation of neurology, psychiatry, geriatrics, geriatric psychiatry,

ehavioral neurology, or geriatric neurology.

To be eligible for the established program track, an applicant must attest that their care team includes a

linician that meets “dementia proficiency” qualifications when they apply to participate in the GUIDE

Model. Participants in the new program track must complete this attestation when they submit their

Proposed GUIDE Practitioner Roster before the start of their first performance year. If the clinician with

dementia proficiency is not a physician, the GUIDE Participant must have an additional part-time

medical director who is a physician oversee the quality of care for its dementia care program.

Care Navigator Training

A comprehensive training program is necessary to support the individuals in the care navigator role,

rticularly since this role can be filled by a non-practitioner lay person such as a community health

worker.

The purpose of the training is to provide a foundation for care navigators prior to delivering

services to beneficiaries. The GUIDE Participant must deliver this one-time training when a care

navigator joins the care team, regardless of the care navigator’s professional background.

This

required training will also promote consistency of the model intervention by ensuring that care

navigators are receiving training on a standardized set of topics across all GUIDE Participants.

The GUIDE Participant must develop and administer care navigator training that covers certain required

pics, as outlined below and described in the Participation Agreement. To the extent possible, the

GUIDE Participant may use a combination of training programs that are already available to meet this

requirement.

An applicant with an established dementia care program may already provide staff trainings that are

largely consistent with the proposed training topics, but they may need to modify, or add to, their

training program to comply with model requirements. GUIDE Participants in the new program track

must develop a training program to comply with model requirements by the start of their first

performance year.

CMS will support GUIDE Participants in both the established program track and the new program track

obtaining training and support resources through webinars, affinity groups and written materials. The

GUIDE Model will also provide an online platform for GUIDE Participants to engage with each other to

discuss forums, conferences, and other additional learning opportunities.

The GUIDE Participant’s care navigator training curriculum must address the following topics:

Table 4. Required Care Navigator Training Topics

Topic

Further detail of topic

Background on

Dementia

Overview of dementia as a medical condition; Progression of disease and balancing

dementia with other co-morbidities

Overview of

Assessments

Assessments available related to dementia; Recommendations for a successful

assessment

Care Plan

What is a care plan; Including beneficiary in the development of plan

Person-Centered

Planning

What person-centered planning means; How to incorporate into planning

Challenging Behaviors

Behavioral symptom management; Common behavioral changes due to dementia

and how to address

For an overview of the benefits that community health worker programs can bring to health care organizations

and the people they serve, see On the Front Lines of Health Equity: Community Health Workers. U.S. Department

of Health and Human Services. April 2021. https://www.cms.gov/files/document/community-health-worker.pdf

If an established dementia care program has staff that took training on a model’s required topic in the past five

years and has continued to work for the program during this time, the staff will not need to retake the training on

that topic for the purposes of the model.

Functional Needs

What are activities of daily living (ADLs) and instrumental activities of daily living

(IADLs); Evaluation of ADLs and IADLs; Common changes in ADLs and IADLs due to

dementia and how to address; Medication monitoring and maintaining a medication

schedule

Advanced Care Planning

What is an advance medical directive and POLST form; How to assist beneficiary in

advance care planning

Decision-Making

Capacity

What is capacity for medical decision-making; What it means when a beneficiary

does not have capacity for medical decision-making; supported decision-making

Safety

Considerations for safety at home, in public, and driving; elder abuse, neglect, and

financial exploitation; access to weapons and dangerous substances

Communication

Communication strategies for persons with dementia and their caregivers

Coordination of medical

care and community

services

Communication with clinical providers; Supporting beneficiary in transitions

between settings; Accessing community-based services and supports, including

respite services; Working with case managers and other coordinators to address

gaps and duplication in a beneficiary’s community-based services and supports

Supporting a Caregiver

Caregiver strain and support (e.g.: peer-to-peer support, support group, 1:1

support); In-home caregiver training and importance of caregiver education

Diversity in Dementia

Treating dementia and communicating with diverse populations in a culturally

competent way

The training must be a minimum of 20 hours, including a minimum of 10 hours of didactic instruction

plus a minimum of 10 hours of experiential training, e.g., job shadowing of experienced care navigators,

supervised interactions with beneficiaries, case studies, or on-the-job training. The minimum of 10 hours

of didactic instruction may be live or a web-based training. The minimum of 10 hours of experiential

training must be live, not asynchronous. The GUIDE Participant must develop an assessment for care

navigators to take after the training to ensure comprehension.

Care navigators must take an additional 2 hours of training each year. This training may be developed

d offered by the GUIDE Participant or be a continuing education training offered by a third party.

Care Delivery Reporting

The GUIDE Participant will complete care delivery reporting at least once per year, which will consist of a

ries of questions about how they are implementing the care delivery requirements of the GUIDE

Model, including how frequently they are interacting with aligned beneficiaries and their caregivers and

what care modalities they are using. Care delivery reporting will also include a Health Equity Plan

section, as discussed in the “Health Equity Strategy” section.

GUIDE Participants in the established program track will be required to complete their first care delivery

porting during a 60-day window that will begin one month before the start of the Model Performance

Period (June 1, 2024—July 31, 2024). This “baseline” care delivery reporting will enable CMS to

understand GUIDE Participants’ capabilities at the beginning of the GUIDE Model and assess how they

evolve over time. Beginning in their second performance year, established program track participants

will complete care delivery reporting, including health equity plan submission, annually at the start of

each performance year.

GUIDE Participants in the new program track will be required to complete their first care delivery

reporting by May 1, 2025, which is two months before the beginning of their first performance year. This

reporting will be used to determine whether new program track participants are able to meet the care

delivery requirements of the GUIDE Model before starting their first performance year. Beginning in

their second performance year, new program track participants will be required to complete care

delivery reporting, including health equity plan submission, on the same timeline as established

participants (i.e., annually at the start of each performance year).

Figure 2: Care Delivery Reporting Timeline

Performance Measurement

CMS will adjust GUIDE Participants’ monthly DCMP based on the GUIDE Participant’s performance on a

set of performance metrics that align with the GUIDE Model’s goals, so that GUIDE Participants are

financially rewarded when they achieve these goals for their aligned beneficiaries and held accountable

when they do not.

Performance Metrics

To the extent possible, the CMS Innovation Center aims to minimize provider burden and create

alignment across CMS by selecting performance measures for the GUIDE Model that are already being

used in other CMS programs. In particular, the CMS Innovation Center aims to align to the extent

feasible with the MIPS Value Pathway (MVP) called “Supportive Care for Neurodegenerative Conditions

MVP” (“Neuro MVP”), which focuses on the clinical theme of promoting high quality care for patients

with cognitive-based neurological disorders, including but not limited to dementia.

CMS will also develop two new metrics to assess GUIDE Participant performance: a measure of caregiver

burden and a metric of long-term nursing home utilization.

CMS intends to eventually include five measures in the GUIDE performance measure set: one clinical

quality process measure, two patient-reported outcome measures, one cost measure, and one

utilization measure. Table 5 provides an overview of the five measures and is followed by a more

detailed discussion of each measure. The five measures in the performance measure set will be used to

adjust GUIDE Participants’ monthly payments. CMS plans to phase in the use of these measures over

time. See the “Performance-Based Adjustment” section for details on how this adjustment will be

calculated.

Table 5: GUIDE Performance Measure Set

Measure Name Aligned Model Goals MIPS, NQF

Measure?

Neuro

MVP?

Measure Type &

Mode

Use of High-Risk Medications in

Older Adults

Improve beneficiary quality

of life; reduce hospital and

ED utilization

MIPS: Yes, #238

NQF: Yes, #0022

Yes Process

CQM

eCQM

Quality of Life Outcome for

People with Neurological

Conditions

Improve beneficiary quality

of life

MIPS: Yes,

#AAN22

NQF: No

Yes PROM

Survey (Registry)

Caregiver Burden Measure Reduce caregiver burden MIPS: No

NQF: No

No PROM

Survey

Total Per Capita Cost (TPCC) Reduce cost of care MIPS: Yes

NQF: Yes, #3575

No Cost

Claims-based

New: Rate of beneficiaries

entering a long-term nursing

home stay

Prevent or delay long-term

nursing home stays; reduce

cost of care (or maintain

budget neutrality)

MIPS: No

NQF: No

No Utilization

Claims-based

Use of high-risk medications in older adults (MIPS #238, NQF #0022)

: Medication-related issues,

including prescription of contraindicated medications and non-adherence to recommended

medications, are common among people with dementia and can lead to avoidable hospitalizations and

ED use.

55,56

This process measure assesses the percentage of patients 65 years of age and older who

were ordered two or more high-risk medications. This measure is part of the Neuro MVP.

Quality of life outcome for people with neurological conditions (MIPS #AAN22): Beneficiary quality of

life will be the primary patient-reported outcome measure (PROM) for the GUIDE Model. This PROM

measures the percentage of patients whose quality-of-life assessment results are maintained or

improved during the measurement period, and is reported through a registry. This measure is part of

the Neuro MVP.

Caregiver Burden Measure: Reducing caregiver burden is another primary model objective, for which

there is not an existing outcomes measure. CMS will develop a measure of this purpose and use a

Link to the Neuro MVP measure specifications: https://qpp.cms.gov/mips/explore-mips-value-pathways/M0004

El-Saifi N, Moyle W, Jones C, and Tuffaha H. Medication Adherence in Older Patients with Dementia: A

Systematic Literature Review. Journal of Pharmacy Practice. May 2017. 31(3).

Wucherer D, Thyrian JR, Eichler T et al. Drug-related problems in community-dwelling primary care patients

screened positive for dementia. International Psychogeriatrics. August 2017.

survey-based tool to capture the burden and strain caregivers encounter in their caregiving role. The

measu

re development process could take several years.

Total per capita cost (TPCC) (NQF #3575): The TPCC measure will measure performance on costs and

incen

tivize reductions in a variety of avoidable utilization categories, including hospital, ED, and post-

acute care. TPCC is a MIPS measure.

Rate of beneficiaries entering a long-term nursing home: A metric of long-term nursing home stays is

impor

tant because nursing home delay or avoidance is expected to be a key source of model savings.

There is no existing performance measure that fully captures long-term nursing home stays in older

adults (existing measures are specified for Medicaid managed care, and either include primarily short-

term nursing home stays or are more appropriate for adults with intellectual and developmental

disabilities).

Rather than fully develop a new, validated performance measure, CMS will calculate a

performance rate and benchmarks using CMS administrative data, which will allow CMS to incorporate

this metric into the performance-based payment adjustment more quickly (i.e., in the first or second

model performance year). Specifically, CMS will use the CMS Minimum Data Set file to identify

beneficiaries residing in a nursing home whose stay is not covered under the Medicare skilled nursing

facility benefit.

Performance Benchmarks

CMS will compare GUIDE Participants’ scores on the five model performance metrics to performance

bench

marks in order to determine their performance-based adjustment (see “Payment Design” section

for more information on the PBA). CMS will calculate performance benchmarks that are specific to the

GUIDE Model (in other words, CMS will not use benchmarks from other programs, such as MIPS). Where

possible, when measures are claims-based, CMS will calculate benchmarks from a blend of both GUIDE

Participants and non-participants.

For non-claims-based measures, where non-participant data is unavailable, CMS will calculate

bench

marks from GUIDE Participant data alone. For such measures, in later years of the GUIDE Model,

CMS may consider modifying benchmarks as more data becomes available.

To ensure that CMS is setting accurate and meaningful benchmarks for GUIDE Participants, the GUIDE

Model wil

l have a “pay for reporting” approach for the first year of the Model Performance Period for

the non-claims-based measures (beneficiary quality of life and high-risk medication utilization). Viewing

the distribution of data from this year will allow CMS to set appropriate performance benchmarks for

future years. Based on the data reported in the first year of the Model Performance Period, CMS will set

benchmarks for each measure and keep them constant for the second and third years. For example, for

the quality-of-life measure, GUIDE Participants in the established program track will receive credit for

reporting quality data for July 1, 2024 – June 30, 2025. CMS will use this data to calculate performance

benchmarks. These benchmarks will be used to assess performance for GUIDE Participants in both the

new and established program tracks in the second and third years of the Model Performance Period.

After the third year, based on the two additional years of quality data, CMS will decide whether to

CMS SMD# 22-003 RE: Home and Community-Based Services Quality Measure Set:

https://www.medicaid.gov/federal-policy-guidance/downloads/smd22003.pdf

continue to hold the benchmarks constant or update the benchmark for future years. Participants in the

new program track will not have pay for reporting, since their first performance year will be the second

year of the Model Performance Period, when benchmarks have been established.

For the claims-based measures (TPCC and Long-Term Nursing Home Stay Rate), benchmarks for the first

year of the Model Performance Period will be calculated based on claims data from prior to the Model

(e.g., CY 2022). Benchmarks will then be updated for the second year based on data from the first year.

Benchmarks will be kept constant for the third year, after which time CMS will decide whether to update

the benchmarks.

On an annual basis, CMS will publish a methodology paper with the technical specifications and

benchmarks for the performance measures. The methodology paper will be made available to GUIDE

Participants 30 days before the applicable performance year.

Table 6: GUIDE Performance Metric Benchmarks

Measure Benchmark group Timing

Use of High-Risk Medications

in Older Adults

GUIDE Participants -Pay for reporting PY 1

-PY 2 and PY 3 benchmark based on PY 1 data

-CMS to decide how to update benchmarks

after PY 3 and publish information in the

annual methodology paper

Quality of Life Outcome for

People with Neurological

Conditions

GUIDE Participants -Pay for reporting Year 1

-PY 2 and PY 3 benchmark based on PY 1 data

-CMS to decide how to update benchmarks

after PY 3 and publish information in the

annual methodology paper

Caregiver Burden Measure GUIDE Participants Pending measure development process

Total Per Capita Cost GUIDE Participants and non-

participants within a

geographic region

-Based on CY 2023 data for PY 1

-PY 2 and PY 3 benchmark based on PY 1 data

-CMS to decide how to update benchmarks

after PY 3 and publish information in the

annual methodology paper

Rate of beneficiaries with a

long-term nursing home stay

GUIDE Participants and non-

participants

-Based on CY 2023 data for PY 1

-PY 2 and PY 3 benchmark based on PY 1 data

-CMS to decide how to update benchmarks

after PY 3 and publish information in the

annual methodology paper

Payment Design

The GUIDE Model will include a monthly per beneficiary care management payment: the Dementia Care

Management Payment (DCMP). CMS will adjust the DCMP for health equity and performance on a set of

performance measures. The GUIDE Model will also include two other payments: a payment for GUIDE

Respite Services and a one-time infrastructure payment for safety net providers in the new program

track (if eligible).

The five main components of the GUIDE Model’s payment methodology are:

1) Monthly DCMP (tiered by patient complexity);

2) A health equity adjustment to the DCMP;

3) A performance-based payment adjustment to the DCMP;

4) A payment for GUIDE Respite Services; and

5) A one-time infrastructure payment for safety net providers in the new program track (if eligible)

Dementia Care Management Payment

The DCMP is designed to offer GUIDE Participants more flexibility to deliver personalized dementia care

an is possible under traditional FFS. It will cover a more comprehensive set of services than existing

care management codes, be less burdensome to bill, and allow for payment to members of the

interdisciplinary care team who are otherwise not eligible to bill for Medicare services. The DCMP also

will not be subject to beneficiary cost sharing. GUIDE Participants will continue to bill for all services not

included in the DCMP under traditional FFS.

GUIDE Participants will use a set of new G-Codes created for the GUIDE Model to submit claims for the

nthly DCMP. The DCMP is intended to cover the GUIDE Care Delivery Services (with the exception of

GUIDE Respite Services, which is paid for under a separate respite payment).

Each model tier will have a different DCMP rate to reflect the fact that covered services and care

tensity will vary across the tiers. For example, for tiers that include beneficiaries without a caregiver,

the DCMP does not incorporate payment for caregiver education and support. However, the DCMP

rates also reflect the fact that beneficiaries without a caregiver are expected to have more intensive

care needs than beneficiaries at a similar disease stage who have a caregiver.

The DCMP rate will also be higher for the first six months that a beneficiary is aligned to a GUIDE

Part

icipant to reflect the high intensity of initial program activities, such as the comprehensive

assessment, home visit, and establishment and implementation of a new care plan. Beginning in the

seventh month after the beneficiary is aligned to a GUIDE Participant, the DCMP rate for that beneficiary

will be lower. Each model tier will have two G-codes, for a total of 10 DCMP G-codes: a “new patient”

code for the first six months that a beneficiary is aligned to the GUIDE Participant and an “established

patient” code for after the first six months. Table 7 shows the DCMP G-code base rates, by model tier

and length of alignment.

The GUIDE Participant will be responsible for billing the correct G-code for each aligned beneficiary each

nth, based on the beneficiary’s model tier and length of alignment. The GUIDE Participant must

attach an eligible ICD-10 dementia diagnosis code to each DCMP claim for it to be paid; DCMP claims

without an eligible ICD-10 diagnosis code will be denied.

In order to support accurate billing, CMS will

provide each GUIDE Participant with a monthly beneficiary alignment file that lists all the beneficiaries

Initial list of eligible ICD-10 dementia diagnosis codes will include: F01.50, F01.511, F01.518, F02.80, F02.811,

F02.818, F03.90, F03.911, F03.918, G30.0, G30.1, G30.8, G30.9, G31.1, G31.2, G31.01, G31.09, G31.83. Eligible

code list may change over time to reflect updates to ICD-10 codes.

aligned to that GUIDE Participant, their model tier assignment, and the length of their alignment to the

GUIDE Participant.

Table 7: Per Beneficiary Per Month (PBPM) Base Payment Rates

Beneficiaries with

Caregiver: Low

Complexity Dyad

Tier

Beneficiaries with

Caregiver:

Moderate

Complexity Dyad

Tier

Beneficiaries with

Caregiver: High

Complexity Dyad

Tier

Beneficiaries

without

Caregiver: Low

Complexity

Individual Tier

Beneficiaries

without Caregiver:

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

The DCMP rates above represent base payment rates and will be adjusted for geographic variation in

costs as well as cost growth over time.

To account for geographic variation in costs, CMS will adjust the DCMP base rates by the Medicare

Geographic Adjustment Factor (GAF) for each DCMP claim submitted by a GUIDE Participant. The GAF

applied to the DCMP is a weighted geographic adjustment based on all services in the Medicare PFS. It

summarizes the combined impact of the 3 Geographic Practice Cost Index (GPCI) expense categories

(work, practice expense, malpractice) on a locality’s (state or metropolitan region’s) physician

reimbursement level.

To account for cost growth over time, CMS will annually update the DCMP base rates by the Medicare

Economic Index (MEI)

, a measure of physician practice cost growth calculated by the CMS Office of the

Actuary.

Movement between tiers

The GUIDE Participant will be required to re-assess aligned beneficiaries on at least an annual basis. The

GUIDE Participant will have the discretion to re-assess beneficiaries more frequently; however, CMS will

only accept aligned beneficiary re-assessments from a GUIDE Participant once every 180 days for

purposes of the beneficiary moving between tiers. Based on the results of the re-assessment, CMS could

assign aligned beneficiaries to either a higher or lower tier, leading to either an increase or decrease in

payment rates. When an aligned beneficiary is re-assessed into a new tier, in the following month the

GUIDE Participant will be eligible to bill the G-code for the established patient payment rate associated

with that tier. The GUIDE Participant will submit re-assessment results to CMS using the Patient

Assessment and Alignment Form (see Appendix C).

Cost-sharing for the DCMP

Updated GAF amounts are published annually as part of the Medicare Physician Fee Schedule regulation

addenda: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/pfs-federal-

regulation-notices

For further information on MEI calculations visit https://www.cms.gov/newsroom/fact-sheets/effect-medicare-

economic-index-mei-physician-update

The DCMP amount will cover both face-to-face and non-face-to-face services in one lump sum. Cost

sharing for non-face-to-face services like chronic care management codes has historically been a

significant barrier to utilization of these services. CMS will waive the standard 20% coinsurance for the

DCMP and CMS will pay the GUIDE Participant 100% of the appropriate DCMP rate rather than 80% for

purposes of the GUIDE Model.

Additional Guidance on billing duplicative FFS codes

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. CMS will provide GUIDE

Participants, who are participating in multiple CMS Innovation Center models, with additional

instruction related to billing these services (see section titled, “Program Overlaps and Synergies”). Table

8 provides the set of services that GUIDE Participants will not be able to bill for aligned beneficiaries.

CMS may add or remove codes from this list over time to reflect changes in Physician Fee Schedule

billing codes.

Table 8: Medicare Physician Fee Schedule Services Included Under DCMP

Service Type

HCPCS Codes

Advance care planning

99497, 99498

Welcome to Medicare and Annual Wellness Visits

G0402, G0438, G0439

Home Health Care Plan Oversight

G0181

Hospice Care Plan Oversight

G0182

Cognitive Assessment and Planning

99483

Technology-based check-in services

G2012, G2252

Transitional Care Management

99495-99496

Chronic Care Management

99487, 99489-99491, 99437, 99439, G0506

Principal Care Management

99424–99427

Administration of patient-focused health risk assessment (HRA)

96160

Administration of caregiver-focused HRA

96161

Depression screening

G0444

Group Caregiver Behavior Management/ Modification Training

Services* 96202, 96203

Caregiver Training Services under a Therapy Plan of Care

established by a PT, OT, SLP* 97550, 97551, and 97552

Community Health Integration Services*

G0019, G0022

Principal Illness Navigation Services*

G0023, G0024, G0140, and G0146

Administration of a Standardized, Evidence-based Social

Determinants of Health Risk Assessment* G0136

* Services listed on the 2024 Physician Fee Schedule proposed rule which will become effective on or

after January 1, 2024.

Health Equity Adjustment

The GUIDE Health Equity Adjustment (HEA) is designed to provide additional resources to GUIDE

Participants to deliver care to beneficiaries from underserved communities. CMS will calculate an HEA

for each beneficiary that is aligned to a GUIDE Participant, based on the beneficiary’s health equity

score. The HEA will be calculated annually, and then applied to the DCMP for each beneficiary as a

monthly adjustment. The HEA is intended to be budget neutral to minimize the financial impact on the

overall model.

The HEA will be calculated using a composite methodology that includes both area-level and beneficiary-

level measures of deprivation. Specifically, the HEA will be composed of four measures: state and

national comparison Area Deprivation Index (ADI), which are measured at the census block group

level, and Low-Income Subsidy (LIS) status and dual eligibility (DE), which are beneficiary-level measures.

CMS will calculate an Equity Score for every beneficiary b and their corresponding geography g in the

aligned population:

In the above formula, National ADI

is the ADI national percentile of the census block group the

beneficiary resided in on their first day of eligibility and can range from 1 to 100. State ADI

is the ADI

state decile of the census block group the beneficiary resided in on their first day of eligibility, and can

range from 1 to 10, corresponding to the state decile. CMS is using LIS and DE as the beneficiary-level

variables. CMS is including both measures even though CMS expects significant overlap between these

two measures because the objective of this policy is to increase access regardless of a beneficiary’s full

or partial dual status. LIS

represents LIS status and is equal to 1 if the beneficiary receives the LIS, and

0 otherwise. Similarly, DE

represents dual eligibility and is equal to 1 if the beneficiary is dually eligible

and 0 otherwise. The possible range of health equity scores is from 0 to 40. In the case of a maximum

score, a beneficiary’s National ADI would contribute 25%, State ADI would contribute 25%, and LIS or DE

status would contribute 50% to the overall score. The equity score formula weights are designed to help

CMS most accurately identify underserved populations. The contribution of each factor to the final score

balances geographic deprivation in low-income states, geographic deprivation in high-income states,

and individual-level income status. LIS/DE is weighted more generously than the area-level measures to

ensure that beneficiary-level measures are meaningfully contributing to the beneficiary’s overall equity

score. CMS may revisit this weighting based on the geographic makeup of participants.

CMS will calculate beneficiary health equity scores and percentiles annually, before the start of the

performance year in which they are applied. Because beneficiaries will not be aligned to GUIDE

Participants at the time of model launch, the first health equity adjustments will not be applied to the

DCMP until the start of the second year of the Model Performance Period, and will be determined based

Census block groups are the next level above census blocks in the geographic hierarchy that is used by the U.S.

Census Bureau to report aggregated census data. A census block group is a combination of census blocks.

on data from the first year of the Model Performance Period. Beneficiary health equity scores and

percentiles will be reassessed each subsequent year. Table 9 shows how health equity scores are

translated into an adjustment to the monthly DCMP.

Table 9. Equity Score Percentiles and Associated Health Equity Adjustment Amounts

Equity Score Percentile Health Equity Adjustment to DCMP

≥80

percentile of equity scores +$15

-79

percentile of equity scores $0

0-50

percentile of equity scores -$6

This adjustment methodology is designed to provide a material incentive for GUIDE Participants to care

for underserved beneficiaries and to be budget neutral while limiting the magnitude of any downward

adjustments. CMS may elect to add other measures to the GUIDE Model’s HEA in future performance

years.

Performance-Based Adjustment

The performance-based adjustment (PBA) will increase or decrease GUIDE Participants’ monthly DCMPs,

depending on how they performed on the GUIDE Model’s five performance metrics during the previous

performance year (see the “Performance Measurement” section for more information on the

performance metrics and benchmarks). The PBA will be applied as an ongoing percentage adjustment to

each GUIDE Participant’s monthly DCMP. Once all the performance metrics are fully phased in, GUIDE

Participants can increase their DCMP amount by up to 10% through high performance or decrease their

DCMP by as much as -3.5% for poor performance.

Timing of PBA

The GUIDE Participant’s performance during a given performance year will affect their payment in

future years. Specifically, the GUIDE Participant’s performance will be calculated beginning three

months after the end of the performance year to allow time for reporting and claims run-out, and the

resulting PBA will be applied to the GUIDE Participant’s DCMP beginning six months after the end of the

performance year, and continuing for 12 months. In other words, there is a six-month lag between the

end of the performance year and when results begin to affect payment. For example, for the established

program track, the first performance year will be July 2024 through June 2025 and the resulting PBA will

be applied from January 2026 through December 2026. Figure 3 demonstrates this timeline. The new

program track will follow the same timeline but beginning one year later and with one less performance

year.

Figure 3: Timing of Performance Year and Corresponding Performance-Based Adjustment

Calendar Year 2025 2026 2027 2028 2029 2030 2031 2032

Established

Program

Track

PY 1

7/2024 –

6/2025

PY 2

7/2025 –

6/2026

PY 3

7/2026 –

6/2027

PY 4

7/2027 –

6/2028

PY 5

7/2028 –

6/2029

PY 6

7/2029 –

6/2030

PY 7

7/2030 –

6/2031

PY 8

7/2031 –

6/2032

PBA 1

1/2026-

12/2026

PBA 2

1/2027-

12/2027

PBA 3

1/2028-

12/2028

PBA 4

1/2029-

12/2029

PBA 5

1/2030-

12/2030

PBA 6

1/2031-

12/2031

PBA 7

1/2032-

06/2032

New

Program

Track

Pre-

Implement-

ation Year

PY 1

7/2025 –

6/2026

PY 2

7/2026 –

6/2027

PY 3

7/2027 –

6/2028

PY 4

7/2028 –

6/2029

PY 5

7/2029 –

6/2030

PY 6

7/2030 –

6/2031

PY 7

7/2031 –

6/2032

PBA 1

1/2027-

12/2027

PBA 2

1/2028-

12/2028

PBA 3

1/2029-

12/2029

PBA 4

1/2030-

12/2030

PBA 5

1/2031-

12/2031

PBA 6

1/2032-

06/2032

PBA Domains, Measures, and Weights

Each of the GUIDE Model’s five performance measures will be assigned to one of four domains: care

coordination and management, beneficiary quality of life, caregiver support, and utilization.

Each domain, and each measure within a domain, is associated with a minimum and maximum potential

PBA amount that GUIDE Participants can earn. How much of the potential PBA amount GUIDE

Participants earn for a given measure is determined by their performance. The amount that GUIDE

Participants earn for each measure will then be added together to determine their total PBA.

As discussed in more detail below, scoring works differently for domains with a single measure versus

domains with multiple measures. There will also be a distinct scoring approach for the two pay-for-

reporting measures in the first year of the Model Performance Period.

Scoring for domains with a single measure

For the three domains with a single measure (care coordination and management, beneficiary quality of

life, and caregiver support), there will be four performance categories – fail, no adjustment, pass, and

exceed. The performance thresholds and associated percentage payment adjustments are as follows:

Table 10: Measure Performance Categories and Associated Payment Adjustments for Domains with a

Single Measure

Performance Category Percentage Adjustment Earned

Fail -1%

No adjustment 0%

Pass 1.5%

Exceed 3%

Note: Please see the “Performance Measurement” section for more information on how CMS will set the

performance benchmarks that determine the cut-off points between each category.

Scoring for the utilization domain

CMS will establish pass/fail benchmarks for the measures in the utilization domain. As shown in Table

11, for each measure in the utilization domain, the GUIDE Participant will receive 1.5% positive

adjustment for a pass or a 0.5% negative adjustment for a fail, for a maximum of possible score in the

overall domain of a three percent positive adjustment (+3%) or a one percent negative adjustment (-

1%).

Table 11: Measure Performance Categories and Associated Payment Adjustments for Utilization

Domain

Performance Category Percentage Adjustment Earned

Fail -0.5%

Pass 1.5%

Scoring for Pay-for-Reporting in First Year of the GUIDE Model

As discussed in the “Performance Measurement” Section, in the first year of the Model Performance

Period, CMS will use a pay-for-reporting methodology for the two non-claims-based measures—high-

risk medication utilization and beneficiary quality of life. This means that GUIDE Participants in the

established program track will receive full credit for reporting measure data, regardless of their

performance. For the high-risk medication measure, the maximum PBA potential for reporting will be

+1%. For the quality-of-life measure, the maximum PBA potential for reporting will be +2%. GUIDE

Participants will receive a 0% adjustment for any measure they fail to report.

Table 12: Pay-for-Reporting Payment Adjustments

Performance Measure Percentage Adjustment Earned

for Reporting

Percentage Adjustment Earned

for Non-Reporting

High-risk medication utilization +1%

Beneficiary quality of life +2%

Summary of PBA Domains, Measures, and Associated PBA Potential

Table 13 summarizes how the measures will be assigned to domains and an associated PBA potential

once all of the quality metrics are fully phased in.

Table 13: PBA Domains, Measures, and Weights in later Model Performance Years, Once All

Performance Measures are Phased In

Domain Domain

Weight

Measure Name Percent of

total domain

Percent of

total PBA

Associated PBA

Potential

Care coordination

and management

10% Use of High-Risk

Medications in Older

Adults

100% 10% -.5% – +1%

Beneficiary

quality of life

30% Quality of Life Outcome

for People with

Neurological Conditions

100% 30% -1% – +3%

Caregiver support 30% New: Caregiver Burden

Measure

100% 30% -1% – +3%

Utilization 30% Total Per Capita Cost 50% 15% -.5% – +1.5%

Rate of beneficiaries

entering a long-term

nursing home

50% 15% -.5% – +1.5%

Total PBA Potential -3.5% to +10%

As a result of measure phase-ins and the development time for certain measures, we anticipate that the

maximum PBA adjustment will be no more than 6% and no lower than -1% in the first year of the Model

Performance Period, and no more than 7% and no lower than -2.5% in the second year of the Model

Performance Period. Tables 14 and 15 show how domain weights will differ in the first two years of the

GUIDE Model.

Table 14: PBA Domains, Measures, and Weights for First Year of the GUIDE Model

Domain Domain

Weight

Measure Name Percent of

total domain

Percent of

total PBA

Associated PBA

Potential

Care

coordination

and

management

16% Use of High-Risk

Medications in Older

Adults

100% 16% 0% - +1%

Beneficiary

quality of life

34% Quality of Life Outcome

for People with

Neurological Conditions

100% 34% 0% - +2%

Utilization 50% Total Per Capita Cost 50% 25% -.5% – +1.5%

Rate of beneficiaries with

a long-term nursing home

stay

50% 25% -.5% – +1.5%

Total PBA Potential -1% to +6%

Table 15: PBA Domains, Measures, and Weights for Second Year of the GUIDE Model (e.g., PY 2 for the

established program track and PY 1 for the new program track)

Domain Domain

Weight

Measure Name Percent of

total domain

Percent of

total PBA

Associated PBA

Potential

Care

coordination

and

management

14% Use of High-Risk

Medications in Older

Adults

100% 20% -.5% – +1%

Beneficiary

quality of life

43% Quality of Life Outcome

for People with

Neurological Conditions

100% 40% -1% – +3%

Utilization 43% Total Per Capita Cost 50% 21.5% -.5% – +1.5%

Rate of beneficiaries with

a long-term nursing home

stay

50% 21.5% -.5% – +1.5%

Total PBA Potential -2.5% to +7%

Example PBA Calculations

Example #1:

In the first year of the GUIDE Model, one measure will be under development, and two measures will be

pay-for-reporting. Table 16 shows an example PBA calculation for the first year of the GUIDE Model.

Table 16: Example PBA calculation for established program in first year of the GUIDE Model

Domain Measure Performance Achieved PBA

Care Coordination and

Management

High-risk medications Data reported (Pass) +1%

Beneficiary quality of life Quality of life outcome Data reported (Pass) +2%

Caregiver Support Caregiver Burden Measure

(in development)

n/a n/a

Utilization TPCC measure Fail -0.5%

Long-term nursing home stay

rate

Pass +1.5%

Total PBA Earned +4%

Example #2:

Table 17 shows an example PBA calculation for a GUIDE Participant once all performance measures are

lly phased in.

Table 17: Example PBA calculation once all performance measures are fully phased in

Domain

Measure

Performance Achieved

PBA

Care Coordination and

Management

High-risk medications

Pass

+1%

Beneficiary quality of life

Quality of life outcome

Exceed

+3%

Caregiver Support

Caregiver Burden Measure

Exceed

+3%

Utilization

TPCC measure

Pass

+1.5%

Long-term nursing home stay rate

Pass

+1.5%

Total PBA Earned

+10%

Respite Payment

GUIDE Participants must provide, or contract with another organization to provide, in-home GUIDE

Res

pite Services to aligned beneficiaries who are eligible to receive GUIDE Respite Services

(see

below, Eligibility Requirements for Aligned Beneficiaries to Receive GUIDE Respite Services). GUIDE

Participants may also choose to provide, or contract with another organization to provide, GUIDE

Respite Services provided in an adult day center

or a facility that can provide 24-hour care. The GUIDE

Participant has the flexibility to use a combination of any or all of these respite options for each

beneficiary eligible to receive GUIDE Respite Services.

The GUIDE Participant will bill for GUIDE Respite Services by submitting claims using three new respite

G-co

des created for the GUIDE Model, one for each setting of care (in-home, adult day, and facility-

based). Respite payments will not be made on a claim-by-claim basis; instead, CMS will aggregate the

respite payments and make one monthly respite payment for all GUIDE Respite Services billed in the

preceding month.

The in-home respite G-code will cover a 4-hour unit of service and be paid at $104; the adult day respite

G-c

ode will cover an 8-hour unit paid at $78; the facility-based respite G-code will cover a 24-hour unit

paid at $260. The GUIDE Participant can bill as many or as few of the codes as needed for an eligible

beneficiary, up to a per beneficiary annual cap of $2,500.

In order to help the GUIDE Participant track

GUIDE Respite Services are temporary services provided to a beneficiary in their home, at an adult day center, or

at a facility that can provide 24-hour care, for the purpose of giving the caregiver a break from caring for the

beneficiary.

Adult day center, as used herein, refers to adult day care, adult medical day care, adult day services, adult day

health centers, and other commonly used terms that describe centers that provide care for older adults similar to

the entities listed here.

The GUIDE respite allotment of $2,500 per year equates to roughly 96 hours of in-home GUIDE Respite Services

per year, paid at a rate of $26 per hour. If the GUIDE respite allotment were used solely at an adult day center, it

how close beneficiaries are to the annual cap, CMS will provide the GUIDE Participant with a monthly

payment file showing the amount of GUIDE Respite Services that each aligned beneficiary has used in

the year to-date.

The respite G-codes and the annual respite cap will be geographically adjusted using the same

methodology as the DCMP; they will be updated annually by the amount of the Home Health Agency

market basket less the productivity adjustment (a metric that is calculated by the CMS Office of the

Actuary for the Home Health Prospective Payment System to measure cost growth for home health

agencies).

The respite payment will not have beneficiary cost sharing and will be paid at 100% of the

determined amounts.

The GUIDE Participant must bill for all GUIDE Respite Services rendered to aligned beneficiaries. If the

GUIDE Participant provides GUIDE Respite Services by contracting with another organization, the GUIDE

Participant is responsible for entering into a contract with the organization, billing for the GUIDE Respite

Services, and then reimbursing the organization.

As detailed in paragraph 6.2 of the GUIDE Care Delivery Services, for dually eligible beneficiaries who

receive respite care through a state Medicaid program, the GUIDE Participant shall contact and attempt

to coordinate the delivery of GUIDE Respite Services with the beneficiary’s Medicaid state agency

and/or Medicaid managed care plan’s case manager. GUIDE Respite Services are intended to be additive

to, and not duplicative of, any available Medicaid respite care benefit offered to dually eligible

beneficiaries. The GUIDE Participant is prohibited from billing under both the GUIDE Model and

Medicaid for the same unit of respite (e.g., billing under both the GUIDE Model and Medicaid for the

same 24-hour nursing home stay).

Eligibility Requirements for Aligned Beneficiaries to Receive GUIDE Respite Services

An aligned beneficiary must meet the following requirements in order to be eligible to receive GUIDE

Respite Services:

i. have a caregiver; and

ii. be assigned to either the moderate complexity dyad tier or the high complexity dyad tier.

Requirements for Respite Providers to Provide GUIDE Respite Services

As discussed under the section titled “Program Integrity Screening”, CMS will conduct a program

integrity screening of all applicants and their proposed Partner Organizations, which includes any

Medicare-enrolled and non-Medicare enrolled respite providers, as part of the application review

process. CMS will confirm that the GUIDE Participant, or the contracted organization furnishing GUIDE

Respite Services, complies with the qualifications to provide GUIDE Respite Services under the GUIDE

Model.

would cover 32 days of adult day per year; if it were used solely for facility-based care, it would cover roughly 10

days of facility-based care per year.

Additional information regarding the Home Health Agency market basket and productivity adjustment can be

found at: https://www.cms.gov/research-stat

istics-data-and-systems/statistics-trends-and-

reports/medicareprogramratesstats/marketbasketdata.

The GUIDE Participant must also ensure that they, or the contracted organization furnishing GUIDE

Respite Services, complies with the qualifications to provide GUIDE Respite Services under the GUIDE

Model, and that any direct care workers that provide in-home GUIDE Respite Services meet the

requirements listed below, at all times that the GUIDE Participant, or organization, is providing GUIDE

Respite Services.

In order to qualify to provide GUIDE Respite Services under the GUIDE Model, in-home respite

providers, adult day centers, and facilities that can provide 24-hour care must be one of the following:

i. a Medicare-certified facility that can provide 24-hour care or a Medicare-certified provider

that provides in-home respite services;

ii. a Medicaid-certified adult day center, Medicaid-certified facility that can provide 24-hour

care, or a Medicaid-certified provider that provides in-home respite services; or

iii. a company or organization licensed or certified with the state, in which they are providing

services, to provide one of the following services:

a. respite,

b. home care,

c. residential services,

d. adult day services, or

e. residential facility or group home (not a private residence).

In addition, any direct care workers that provide in-home GUIDE Respite Services must:

i. be at least 18 years old,

ii. have passed a background check,

iii. be licensed or certified as a direct care worker in the state in which they are providing

services if such licensure or certification is a requirement to work as direct care worker in

the state, and

iv. meet the training requirements to be a direct care worker, if any, of the state in which they

are providing services.

If the GUIDE Participant, or the contracted organization furnishing GUIDE Respite Services, loses their

Medicare certification, Medicaid certification, state license or state certification, they will no longer be

permitted to provide GUIDE Respite Services. The GUIDE Model will not pay, and GUIDE Participants

may not bill, for GUIDE Respite Services provided by a GUIDE Participant, or a contracted organization

furnishing GUIDE Respite Services, that loses their Medicare certification, Medicaid certification, state

license or state certification.

Example GUIDE Respite Services Claim:

The following is an example claim for GUIDE Respite Services calculated over one month. This example is

illustrative in nature and intended to give applicants a baseline understanding of how the respite

payments will be calculated.

Beneficiary B has a caregiver and is in the severe model tier. This claim is for one month’s worth of

GUIDE Respite Services.

In Home Care: 4-Hour unit 16 hours (4 units) $104 $416

Adult Day Center: 8-Hour Unit 8 hours (1 unit) $ 78 $ 78

Facility: 24-Hour Unit 48 hours (2 units) $ 260 $ 520

Total GUIDE Respite Services

$ 1,014

*The GAF is also calculated for the respite payments but do not count towards the total annual cap.

To calculate the amount of the GUIDE respite payment available for the GUIDE Participant to furnish the

GUIDE Respite Services under the GUIDE Model for rest of the year: $2500 - $1014 = $1486

Payment Examples

The first two payment examples below show how total GUIDE Model payments will be calculated for an

individual aligned beneficiary over the course of a full performance year. The third example shows how

total GUIDE Model payments will be calculated for a GUIDE Participant’s total aligned beneficiary

population. The examples assume that all beneficiaries are newly aligned in the first month of the

performance year, and therefore are eligible for the new patient DCMP rate for the first six months of

the year and the established patient DCMP rate for the next six months. All examples are assumed to

occur after the PBA and HEA are fully phased in but reflect the current base rate and do not account for

future MEI updates. In the first example, the beneficiary is in a tier that is eligible for GUIDE Respite

Services, and the example assumes that she reaches the respite cap for the year. In the second example,

the beneficiary is in a tier that is not eligible for GUIDE Respite Services. The third example assumes that

all beneficiaries eligible for GUIDE Respite Services reach their respite cap for the year. Examples are

rounded to the nearest dollar.

Payment Example #1: Beneficiary in the Moderate Complexity Tier with Caregiver

Payment Example #2: Beneficiary in the Moderate/Severe Complexity Tier without Caregiver

Note: Example 3 is a stylized example and does not include the HEA, which is a beneficiary level

adjustment. The HEA could increase or decrease participants’ total payment. It also assumes that all

patients are aligned at the beginning of the year as new patients.

Payment Example #3: Dementia Care Program

Infrastructure Payment

In addition to technical assistance and support, GUIDE Participants in the new program track that are

classified as safety net providers will be eligible to receive an infrastructure payment to cover some of

the upfront costs of establishing a new dementia care program. This payment is intended for GUIDE

Participants who want to develop new dementia care programs to serve underserved beneficiaries but

need upfront resources to get started. The infrastructure payment will be a one-time payment of

$75,000 made at the beginning of the pre-implementation period. The payment will be geographically

adjusted using the same PFS GAF that will be used to adjust the DCMP.

The infrastructure payment is intended to assist GUIDE Participants in the new program track that

qualify as safety net providers with: 1) hiring, 2) training, 3) developing program workflows, protocols,

community partnerships, and materials, 4) community outreach and engagement, and 5) electronic

health record technology adaptations. Infrastructure payment funds may only be used for costs in these

five categories. GUIDE Participants will be required to report on how they used infrastructure funds as

part of their care delivery reporting.

GUIDE Participants will be required to pay the infrastructure payment back to CMS if they withdraw or

are terminated 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 whole 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.

Safety net provider eligibility determination

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

(LIS) or 33.7% of beneficiaries who are dually eligible for Medicare and Medicaid. These thresholds are

based on the safety net definition that the Innovation Center has developed to assess and track safety

net provider participation in its models.

CMS will use Medicare claims to assess the composition of an

applicant’s Medicare FFS beneficiary population and determine whether they meet the safety net

criteria. CMS will notify the selected applicant of whether they meet the GUIDE safety net criteria before

the deadline to sign their Participation Agreement.

If an applicant plans to create a new TIN for the purposes of participating in the GUIDE Model, then in

order to be assessed for the GUIDE safety net provider criteria, at time of application, the applicant must

provide to CMS a Proposed GUIDE Practitioner Roster that is as similar as possible to the Proposed

GUIDE Practitioner Roster that the applicant will submit two months prior to their first Performance

Year (see section titled, “Participation Requirements” for more information on application requirements

for GUIDE Participants in the new program track) if accepted to participate in the Model. The Proposed

GUIDE Practitioner Roster must include at least one clinician with dementia proficiency and list the

historical TIN(s) under which each practitioner(s) on their Proposed GUIDE Practitioner Roster has

previously billed for Part B services.

At the time of the GUIDE safety net provider eligibility determination, CMS will deem a beneficiary to be

part of an applicant’s beneficiary population in the following order of precedence:

1) If the beneficiary selected, on Medicare.gov, one of the Medicare-enrolled physicians or non-

physician practitioners listed on the applicant’s Proposed GUIDE Practitioner Roster;

2) If the applicant or one or more practitioners from the applicant’s Proposed GUIDE Practitioner

Roster furnished the plurality of the beneficiary’s qualifying CPT/HCPCS code services (see Table

18 for a list of CPT or HCPCS Codes Used to Identify Applicant’s Beneficiary Population) over the

past two years; or

3) If the applicant or one or more practitioners from the applicant’s Proposed GUIDE Practitioner

Roster billed the beneficiary’s most recent claim (if that claim was for an Annual Wellness Visit

or a Welcome to Medicare Visit) during the most recently available 24-month period.

At the time of determination, CMS will also confirm whether each applicable beneficiary:

1) Received a qualifying service from the GUIDE Participant (defined at the TIN level – please see

paragraph above on the GUIDE Model’s policy for applicants who create a new TIN for purposes

of participating in the GUIDE Model) during the lookback period (see Table 18 below);

Person-Centered Innovation–An Update on the Implementation of the CMS Innovation Center’s Strategy–

Supplemental Document. November 7, 2022. https://innovation.cms.gov/media/document/cmmi-strategy-imp-

update-tech

2) Has both Medicare Parts A and B;

3) Has Medicare as their primary payer; and

4) Was not enrolled in a Medicare Advantage plan.

The following list of patient encounter codes will be used to identify an applicant’s beneficiary

population according to the process outlined above for purposes of the GUIDE safety net provider

determination:

Table 18. HCPCS Codes Used to Identify Applicant’s Beneficiary Population

Service

Code

Office/Outpatient Visit E/M

99201-99205, 99211-99215, G2212

Nursing Facility, FQHC, and RHC Services

99304-99310; 99315, 99316- 99318

Complex Chronic Care Coordination Services

99487

Chronic Care Management (CCM) Services

99489-99491, 99437, 99439, G2058

Principal Care Management (PCM)

99424-99427, G2064, G2065

Transitional Care Management Services

99495-99496

Home Care/Domiciliary Care E/M

99324-99328, 99334-99337, 99339-99345,

99347-99350

Online Digital E/M

99421-99423

Audio-Only Telephone E/M

99441-99443, G2252

Technology-based check-in services

G2010, G2012, G2252

Advance Care Planning

99497, 99498

Depression, substance use disorder, and alcohol

misuse screening and counseling services

G0396-G0397, G0442-G0444

Welcome to Medicare and Annual Wellness Visits

G0402, G0438, G0439

Assessment/care planning for patients requiring

CCM services

G0506

Care management services for behavioral health

conditions

99484

Cognition and functional assessment for patient

with cognitive impairment

99483

Administration of patient-focused health risk

assessment (HRA)

96160

Administration of caregiver-focused HRA

96161

Psychiatric Collaborative Care Model

99492-99494, G0511, G0512, G2214

Outpaent clinic visit for assessment and

management (for crical

access hospital-based outpaent primary care

pracces)

G0463

Health Equity Strategy

The Innovation Center believes that equitable care is a key component of achieving high-quality care for

beneficiaries and is therefore critical to the GUIDE Model’s success. CMS defines health equity as: “the

attainment of the highest level of health for all people, where everyone has a fair and just opportunity

to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity,

socioeconomic status, geography, preferred language, or other factors that affect access to care and

health outcomes.”

The term “underserved communities” 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.

Along with the health equity adjustment to model payments, the new program track and infrastructure

payment for safety net providers, the Referral and Coordination of Services and Supports domain in care

delivery, and the requirement for care navigator training to include a cultural competency domain, the

GUIDE Model has two additional model requirements which are designed to promote health equity:

1) Health Equity Plan Requirement

2) Health Equity Data Collection Requirement

Health Equity Plan Requirement

GUIDE Participants will be required to develop and implement a Health Equity Plan. The purpose of a

Health Equity Plan is for each GUIDE Participant to identify disparities in outcomes in their patient

populations and implement initiatives to measure and reduce these disparities over the course of the

GUIDE Model.

On an annual basis, GUIDE Participants will be required to report on the progress of their Health Equity

Plan as a section of the GUIDE Model’s care delivery reporting. The focus of health equity planning will

be on improving quality of care for underserved beneficiaries and addressing health disparities. GUIDE

Participants will be required to set goals and monitor progress over time, identifying and selecting

evidence-based interventions for addressing health disparities and achieving equitable outcomes. The

Innovation Center will provide a framework for Health Equity Plans, and will review, but not assess,

plans submitted by GUIDE Participants.

The first Health Equity Plan will be due as part of the baseline care delivery reporting (see “Care

Delivery” section for more information about reporting timeline). The first Health Equity Plan must focus

specifically on beneficiary outreach and engagement as a precursor to more comprehensive annual

Health Equity Plans. The goal of the first Health Equity Plan will be to encourage GUIDE Participants to

CMS Framework for Health Equity 2022-2023. Centers for Medicare and Medicaid Services. April 2022.

https://www.cms.gov/files/document/cms-framework-health-equity-2022.pdf

Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal

Government. January 20, 2021. https://www.whitehouse.gov/briefing-room/presidential-

actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-

the-federal-government/

develop and implement strategies to reach potentially eligible beneficiaries from historically

underserved communities from the outset of the GUIDE Model.

GUIDE Participants will be required to prepare and submit comprehensive Health Equity Plans beginning

in the second care delivery reporting period, at the start of GUIDE Participants’ second performance

year, and update the plans annually thereafter.

Health Equity Plans may not propose or use actions that selectively target beneficiaries based on race,

ethnicity, national origin, disability, religion, or sex. In addition, Health Equity Plans must comply with all

applicable non-discrimination laws, including section 1557 of the Affordable Care Act, Title IX of the

Education Amendments of 1972, Title VI of the Civil Rights Act of 1964, and Section 504 of the

Rehabilitation Act. GUIDE Participants will be permitted to identify beneficiaries for health equity plan

interventions based on other factors, including but not limited to medical history, health status, health

needs, disability status, or income, provided the GUIDE Participant and other individuals or entities

performing functions or services related to the Health Equity Plan comply with all applicable non-

discrimination laws and regulations.

Health Equity Data Collection Requirement

CMS will require all GUIDE Participants to collect and report certain beneficiary-reported

sociodemographic data and health-related social needs (HRSN) data from their aligned beneficiaries

willing to share this information. To avoid discouraging beneficiaries from accessing care from GUIDE

Participants, beneficiaries are not required to share this data with their providers. GUIDE Participants

are not required to report this data to CMS for any beneficiary who chooses not to disclose them.

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.

Some GUIDE Participants may

already be collecting HRSNs from their beneficiaries, but it is important that all GUIDE Participants

collect this information to provide adequate services, plan for future interventions, and increase quality

of care. HRSN collection and referrals will be part of the GUIDE Model’s broader care delivery

requirements for comprehensive assessment and referral for social services and supports.

GUIDE Participants will be encouraged to use one of two preferred HRSN screening tools: the

Accountable Health Communities (AHC) HRSN Screening tool

or the Protocol for Responding to and

Assessing Patient’s Assets, Risks, and Experiences (PRAPARE) tool.™

GUIDE Participants will be

required to annually report HRSN data that is aggregated across aligned beneficiaries and includes

domains such as: food insecurity, housing instability, transportation needs, utility difficulty, and

interpersonal safety. This data collection will allow CMS and GUIDE Participants to evaluate health

inequities and disparities in GUIDE communities.

The Accountable Health Communities Health-Related Social Needs Screening Tool. Center for Medicare and

Medicaid Innovation. https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf

PRAPARE Screening Tool. https://prapare.org/the-prapare-screening-tool/

GUIDE Participants will also be required to collect and report a core set of sociodemographic measures

n an annual basis from their aligned beneficiaries willing to share this information. The data elements

in this core set will use standardized United States Core Date for Interoperability (USCDI) definitions.

Example measures are race, ethnicity, sex assigned at birth, disability status, and preferred language.

Learning Systems Strategy

The GUIDE learning system will include: 1) a learning community for all GUIDE Participants, and 2) virtual

coaching and facilitation provided by CMS for GUIDE Participants in the new program track.

The GUIDE Participant Learning Community will:

• Facilitate the provision of technical assistance, reaching GUIDE Participants with written

aterials and communication about the GUIDE Model payment, requirements, deadlines, and

conditions for participation.

• Capture, document, and disseminate tactics and strategies in the provision of comprehensive

ementia care.

• Foster peer-to-peer sharing of tools, experience, and tactics.

• Provide opportunities for GUIDE Participants to convene and share experiences and resources

regionally or nationally, through existing in-person meetings or new virtual meetings.

• Provide opportunities for learning and peer-to-peer sharing of strategies for improving health

quity.

Coaching and facilitation for GUIDE Participants in the new program track will use a virtual group

oaching approach. CMS will offer coaching sessions in group settings to allow GUIDE Participants to

learn from each other’s experiences and include brief didactics (how-tos) and case-based learning with

cases presented by GUIDE Participants to expert faculty on challenges, questions, etc. that arise as they

establish their dementia care programs. Topics for the coaching sessions could include developing a

caregiver support program or a care navigator training program. Coaching sessions will occur during the

pre-implementation period and the first performance year for the new program track.

Data

Data Reporting Requirements

In accordance with 42 CFR 403.1110(b), any entity participating in the testing of an Innovation Center

odel is required to collect and report such information, including “protected health information” as

defined in 45 CFR 160.103, as the Secretary determines is necessary to monitor and evaluate the GUIDE

Model. Below is a list of all data elements that the GUIDE Participant will be required to report to CMS.

• Beneficiary and Caregiver Assessment Data (See Beneficiary Eligibility and Beneficiary Alignment

section)

• Quality Data (See Performance Measurement section)

• Care Delivery Reporting (See Care Delivery section)

• Sociodemographic Data (See Health Equity Data Collection Requirement section)

• Health-related social needs (See Health Equity Data Collection Requirement section)

Data Sharing

Data sharing is an important tool for helping GUIDE Participants understand how they are doing relative

to other GUIDE Participants, track their performance over time, identify trends, and target areas for

improvement. GUIDE Participants will be strongly encouraged to use data sharing provided under the

GUIDE Model to i) assess their model implementation; ii) measure effects on quality of care; and iii)

develop data-based strategies to improve both model implementation and quality of care. The model

learning system will support GUIDE Participants in understanding how to use their data for quality

improvement efforts. Under the GUIDE Model, there will be two primary sources of data sharing:

1) Data Dashboard: The primary platform that CMS will use to share data with GUIDE Participants

is through the GUIDE Data Dashboard. The Data Dashboard will provide GUIDE Participants with

an interactive, user-friendly interface for viewing claims-based utilization data for their aligned

beneficiaries, updated monthly. Data will be available and aggregated across the GUIDE

Participant’s entire aligned population, for domains including hospitalizations, physician

services, and post-acute care. The Data Dashboard will also incorporate quality and

sociodemographic data reported by GUIDE Participants, so that they can view key data points

within a single tool. The Data Dashboard will also show GUIDE Participants how they compare to

peer organizations on important quality and utilization outcomes.

2) Monthly payment and beneficiary alignment files: On a monthly basis, CMS will provide GUIDE

Participants with a beneficiary alignment and payment file. The beneficiary alignment file will

show which beneficiaries are aligned to the GUIDE Participant, their model tier assignment, and

other beneficiary-level data. The payment file will provide data on GUIDE payment amounts for

each aligned beneficiary and aggregated across the GUIDE Participant’s total aligned beneficiary

population.

The data sharing and data analytics in the GUIDE Model will comply with all applicable laws, including

the privacy and security requirements promulgated under the Health Insurance Portability and

Accountability Act of 1996 (HIPAA). GUIDE Participants will be required to submit a HIPAA-Covered Data

Disclosure Request and Attestation (DRA) form to request the specific types of data that the GUIDE

Participants will need to perform certain health care operations activities related to the GUIDE Model

and will attest that the data requested is the minimum necessary to perform those activities, consistent

with HIPAA rules and regulations. CMS will provide the DRA to be completed by the Participant.

All GUIDE Participants will be required to provide beneficiaries and their caregivers with information

about how to modify their data sharing preferences and opt out of claims data sharing of beneficiary-

identifiable information for care coordination and quality improvement purposes.

In the event the Innovation Center develops new, center-wide data sharing strategies, including data

aggregation, during the Model Performance Period, CMS will also strive to align GUIDE data sharing with

these strategies as appropriate. CMS will also consider publicly reporting performance data as part of

our Innovation Center model data sharing initiative.

Participant Monitoring, Auditing, and Termination Strategy

CMS will monitor GUIDE Participants on a regular, ongoing basis. CMS will use GUIDE Participant care

delivery reporting, beneficiary and caregiver assessment data, GUIDE Practitioner Rosters, Partner

Organization Rosters, claims, cost, utilization, and quality data in its monitoring strategy.

Regular program monitoring may result in audits of select GUIDE Participants. Data that GUIDE

Participants submit to CMS, performance on utilization and quality measures, referral and billing

patterns, and other practice information may trigger an audit of GUIDE Participants with anomalous

findings. CMS may also randomly select GUIDE Participants for audit.

GUIDE Participants will be informed of the possibility of being selected for an audit and will be required

to maintain copies of all documentation related to their use of model payments and their

implementation of the GUIDE Model in case of an audit. More information related to the GUIDE Model’s

record retention policy will be provided in the Participation Agreement.

CMS reserves the right to terminate a GUIDE Participant’s Participation Agreement at any time during

the term of the Participation Agreement for reasons associated with poor performance, program

integrity issues, non-compliance with the terms and conditions of the Participation Agreement, or as

otherwise specified in the Participation Agreement or required by section 1115A(b)(3)(B) of the Social

Security Act.

Evaluation

All GUIDE Participants will be required to cooperate with CMS efforts to conduct an independent,

federally-funded evaluation of the GUIDE 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. The evaluation will use a mixed-methods approach to assess both model

impact and implementation experience.

Authority to Test the Model

The GUIDE Model will be operated under Section 1115A of the Social Security Act (the Act) (added by

Section 3021 of the Affordable Care Act) (42 U.S.C. 1315a). Section 1115A of the Act establishes the

Innovation Center for the purpose of testing innovative payment and service delivery models to reduce

Medicare and Medicaid expenditures while preserving or enhancing the quality of care furnished to

beneficiaries of such programs.

Section 1115A(b)(2) of the Act requires the Secretary “to select models to be tested from models where

the Secretary determines that there is evidence that the model addresses a defined population for

CMMI Model Data Sharing Model Participation Data Initiative. Center for Medicare and Medicaid Innovation.

https://resdac.org/cms-data/files/cmmi-model-data-sharing-cmds-model-participation-data-initiative

which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures.”

The GUIDE Model addresses a defined population (community-dwelling, Medicare FFS beneficiaries,

including beneficiaries dually eligible for Medicare and Medicaid, who have dementia) for which there

are deficits in care resulting in both poor outcomes and potentially avoidable expenditures in

unnecessary hospital, emergency department (ED), and post-acute care utilization.

Waiver and OIG Safe Harbor Authority

Under section 1115A(d)(1) of the Act, the Secretary of Health and Human Services may waive such

requirements of Titles XI and XVIII and of sections 1902(a)(1), 1902(a)(13), 1903(m)(2)(A)(iii), and certain

provisions of section 1934 of the Act as may be necessary solely for purposes of carrying out section

1115A with respect to testing models described in section 1115A(b).

For this model and consistent with the authority under section 1115A(d)(1), the Secretary may consider

issuing waivers of certain fraud and abuse provisions in sections 1128A, 1128B, and 1877 of the Act. No

fraud or abuse waivers are being issued in this document; fraud and abuse waivers, if any, would be set

forth in separately issued documentation. Any such waiver would apply solely to the GUIDE Model and

could differ in scope or design from waivers granted for other programs or models. Thus,

notwithstanding any provision of this RFA, GUIDE Participants must comply with all applicable laws and

regulations, except as explicitly provided in any such separately documented waiver issued pursuant to

section 1115A(d)(1) specifically for the GUIDE Model.

In addition to or in lieu of a waiver of certain fraud and abuse provisions in sections 1128A and 1128B of

the Act, CMS may determine that the anti-kickback statute safe harbor for CMS-sponsored model

arrangements and CMS-sponsored model patient incentives (42 C.F.R. § 1001.952(ii)) is available to

protect remuneration exchanged pursuant to certain financial arrangements or patient incentives

permitted under the GUIDE participation documentation. No such determination is being issued in this

document. Such determination, if any, would be set forth in documentation separately issued by CMS.

Benefit Enhancement and Beneficiary Engagement Incentive

The GUIDE Model will use the authority under section 1115A(d)(1) of the Act to make available the

telehealth benefit enhancement and the environmental modification beneficiary engagement incentive.

Telehealth benefit enhancement

If necessary during the Model Performance Period, CMS intends to make available to GUIDE Participants

a conditional waiver of (1) the “originating site” requirements at section 1834(m)(4)(C) of the Social

Security Act and 42 CFR § 410.78(b)(3)–(4) with respect to telehealth services furnished to eligible

beneficiaries; (2) the “originating site” requirement in the eligible telehealth individual provision at

section 1834(m)(4)(B) of the Social Security Act with respect to telehealth services being “furnished at

an originating site”; and (3) the “originating site” facility fee provision in section 1834(m)(2)(B) of the

Social Security Act and 42 CFR § 414.65(b) with respect to telehealth services furnished to an aligned

beneficiary at their home.

Environmental modification beneficiary engagement incentive

CMS also intends to permit GUIDE Participants to use their own funding to provide in-kind

nvironmental modifications to the beneficiary’s home of a total value of up to $1,000 per beneficiary

per year. Environmental modifications will contribute to a safer home environment for the beneficiary

and provide the beneficiary with tools to continue to live at home.

The environmental modification shall be either (i) an item purchased by the Participant and delivered to

he Beneficiary or (ii) the Participant will arrange and pay for installation of the environmental

modification by a handy worker or home improvement contractor. The environmental modification

must have a reasonable connection to the beneficiary’s health care and not promoted or marketed to

potential beneficiaries. Depending on the beneficiary’s needs, environmental modifications could

include expenses for modifications such as grab bars, flexible shower head, safer flooring, signs, or

improved lighting.

This beneficiary engagement incentive will be optional for GUIDE Participants to make available to

aligned beneficiaries. If the GUIDE Participant offers this beneficiary engagement incentive, it must be

offered in addition to the care delivery requirements detailed in Appendix B and in accordance with the

requirements described in the Participation Agreement. The GUIDE Participant will be required to retain

certain documentation in conjunction with the provision of this in-kind incentive.

Merit-Based Incentive Payment System (MIPS) Alternative Payment Model (APM) and

Advanced APM Status

MIPS APM: An Innovation Center model may be considered a MIPS APM if it meets two criteria: 1)

participants in the Model (“APM Entities”) participate under an agreement with CMS or through a law or

regulation; and 2) the APM bases payment on quality measures and cost/utilization. CMS requires

GUIDE Participants to sign a participation agreement with CMS and bases payment on utilization and

quality measures through the performance-based adjustment. Therefore, the GUIDE Model will satisfy

both MIPS APM criteria and is expected to qualify as a MIPS APM.

Advanced APM: A model (or track within a model) must meet three specific criteria to be considered an

dvanced APM: 1) require use of Certified Electronic Health Record Technology (CEHRT), 2) provide for

payment based on performance on MIPS-comparable quality measures, and 3) require participants to

bear a more than nominal amount of financial risk. We do not expect GUIDE to qualify as an Advanced

APM because it does not meet the financial risk standard.

Because we expect the GUIDE Model to be a MIPS APM, we also expect that any MIPS-eligible clinician

ho is included on a GUIDE Participant’s GUIDE Practitioner roster will be eligible for voluntary scoring

under the APM Performance Pathway as described at 42 CFR § 414.1367.

Program Overlaps and Synergies

CMS will allow organizations (identified at the TIN level) to participate in both the GUIDE Model and all

other current Innovation Center models for which they meet the eligibility criteria, as well as the

Medicare Shared Savings Program (Shared Savings Program). Individual practitioners (identified at the

NPI level) and Partner Organizations will also generally be permitted to be part of a GUIDE Practitioner

oster or Partner Organization Roster and furnish services under other current Innovation Center

models and the Shared Savings Program. Current and future Innovation Center models may establish

their own model overlaps policies with the GUIDE Model as well. The following sections discuss overlap

policies for three types of models and programs: Shared Savings Program and Innovation Center ACO

models; BPCI Advanced and Comprehensive Care for Joint Replacement (CJR) Models; and Innovation

Center models that have care management payments.

Overlaps with Shared Savings Program and Innovation Center ACO Models

Participant overlap

CMS will allow participant overlap at the TIN and NPI level with the ACO Realizing Equity, Access, and

ommunity Health (REACH) model, the Shared Savings Program, and the three Comprehensive Kidney

Care Contracting (CKCC) Options in the Kidney Care Choices (KCC) Model.

Beneficiary overlap

Eligible beneficiaries may simultaneously be aligned to the GUIDE Model and attributed to participants

n ACO REACH, the Shared Savings Program, or the CKCC options in KCC. For beneficiaries who are

aligned to both a GUIDE Participant and a participant in ACO REACH, the Shared Savings Program, or the

CKCC Options of the KCC model, the GUIDE Model will share beneficiary-level data on GUIDE Model

payments with each of these programs, allowing them the flexibility to account for these payments in

their benchmarking or spending calculations.

In 2024, the Innovation Center’s Total Cost of Care Models will not include the DCMP and respite

ayments in the shared savings calculations. Beginning in July 2025 or July 2026, the DCMP (including

the performance-based adjustment, health equity adjustment, and the respite payments) made to a

GUIDE Participant for an aligned beneficiary may be included in an ACO’s expenditures and benchmarks.

Beginning July 1, 2024, the DCMP and respite payments made to a GUIDE Participant for an aligned

eneficiary will count towards the shared savings/losses in the Medicare Shared Savings Program. In

future years, GUIDE payments may be included in ACO benchmark and expenditure calculations.

Overlaps with the BPCI Advanced and Comprehensive Care for Joint Replacement (CJR) Models

Participant overlap

The GUIDE Model will allow participant overlap with the BPCI Advanced model at the TIN level.

owever, given the differing clinical focuses of these models and the GUIDE Model, we would expect

this type of overlap to be rare.

Beneficiary overlap

Eligible beneficiaries may simultaneously be aligned to a GUIDE Participant and a participant in the BPCI

dvanced and CJR models. GUIDE Model payments will not be incorporated into BPCI Advanced or CJR

episode reconciliation calculations. CJR overlap will only be relevant for 6 months, as CJR is scheduled to

end in December 2024.

Overlaps with Innovation Center models that have care management payments

Participant overlap

The DCMP includes care coordination services similar to other Innovation Center models such as Primary

Care First (PCF), Making Care Primary (MCP), the Maryland Primary Care Program (MDPCP), the

Enhancing Oncology Care Model (EOM), and Kidney Care First (KCF). GUIDE will permit participant

overlap at the TIN and NPI level with PCF, MCP, MDPCP, EOM, and KCF.

Beneficiary overlap

Eligible beneficiaries may simultaneously be aligned to a GUIDE Participant in the GUIDE Model and

attributed or aligned to participants in active CMMI models, including ACO Reach, Kidney Care Choices,

Making Care Primary, Maryland Total Cost of Care Model, Primary Care First, and Vermont All Payer

Model. The same provider or supplier cannot receive payment for care coordination under the GUIDE

Model and another model for treating the same beneficiary who may be aligned or attributed to both

models. If such an overlap occurs, the GUIDE Model will reconcile the overlap amount for that provider

retrospectively. If only the beneficiary, and not the provider, or only the provider and not the

beneficiary, overlaps with two models that have care management payments, then no payment will be

recouped.

Appendices

Appendix A: Participant Application Guidance and Questions

This document is not the application to be filled out by the applicant; this is a list of the questions that

may be found in the online application portal and is provided for reference only. The online application

portal can be accessed via a link on the GUIDE Model website: https://innovation.cms.gov/innovation-

models/guide. All GUIDE applications must be submitted through the online application portal by 11:59

pm Eastern Daylight Time on January 30, 2024.

CMS may seek additional information from applicants to the GUIDE Model after the application period

closes. Not all applicants are guaranteed participation in the GUIDE Model. In selecting participants,

CMS will consider factors critical to ensuring a robust evaluation of the GUIDE 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.

CMS will safeguard the information provided in accordance with the Privacy Act of 1974, as amended (5

U.S.C. § 552a). For more information, please see the CMS Privacy Policy at https://www.cms.gov/

privacy.

For questions regarding the GUIDE Model or the GUIDE application process, email

[email protected].

Complete Profile (Section 1)

Organization Information (Tab 1)

1. GUIDE Model Applicant Information

Legal Business Name:

Doing Business As (DBA):

Organization TIN/EIN:

Street Address:

City:

State:

ZIP Code:

Website, if applicable:

2. How would you define your organization (Check all that apply or check N/A if your

organization is not on this list):

. Physician Group Practice/Clinic

. Health System

. Accountable Care Organization (ACO)

. Hospice Agency

. Home Health Agency (HHA)

. Other Group Practice/Clinic

. N/A

3. Did the applicant submit a Letter of Interest (LOI) for the GUIDE Model? (Optional) (A Letter

of Interest is not a requirement to apply for the Model, this information will only be used for

tracking purposes)

. Yes

. No

If yes, please note the number on your LOI submission _______

4. Provide an executive summary describing the applicant including the history/context of

applicant’s interest in the Model, the applicant’s strategies and goals for forming a

dementia care program, and the applicant’s fit with the Model’s goals. [5000 character

limit]

5. Explain how participation in the GUIDE Model will allow your organization to deliver

comprehensive dementia care to the populations you serve. Include how your participation

in the GUIDE Model will expand your care model to additional populations, if relevant. [5000

character limit]

6. Is your organization currently or formerly part of, operated, managed, or led by an entity

that is participating in or plans to participate in a CMS initiative listed below? Check all that

apply and enter dates:

Example:

• Kidney Care Choices Model: 1/2022 to 1/2023

• ACO REACH: 1/2022 to present

• Enhancing Oncology Model: 1/2024 to 1/2026

. Enhancing Oncology Model: ______ to _______

. ACO Realizing Equity, Access, and Community Health (ACO REACH) Model: ______ to

_______

. Bundled Payments for Care Improvement (BPCI) Advanced Model: ______ to _______

. Comprehensive Care for Joint Replacement Model: ______ to _______

. ESRD Treatment Choices (ETC) Model: ______ to _______

. Making Care Primary (MCP): ______ to _______

. Comprehensive Kidney Care Choices Model: ______ to _______

. Maryland Total Cost of Care Model: ______ to _______

. Medicare Shared Savings Program (MSSP): ______ to _______

. Primary Care First (PCF): ______ to _______

. Vermont All Payer Model:______ to _______

. Other (Please specify) [[Text box]]: ______ to _______

. None

7. I certify that I am applying with a TIN that is enrolled in Medicare Part B and eligible to bill

under the Medicare Physician Fee Schedule (PFS), or that prior to the execution of the

Participation Agreement I will establish a TIN that is enrolled in Medicare Part B and eligible

to bill under the PFS.

Please select one:

. Yes, I certify that I am applying with a TIN that is enrolled in Medicare Part B and eligible

to bill under the PFS.

. Yes, I certify that prior to execution of the Participation Agreement, I will establish a TIN

that is enrolled in Medicare Part B and eligible to bill under the PFS. Help Text to option:

I understand that if I do not establish a Medicare Part B TIN that is eligible to bill under

the PFS prior to execution of the Participation Agreement, my organization will not be

able to participate in the Model.

. I cannot certify that I am applying with a TIN, or that I will establish a TIN prior to

execution of the Participation Agreement, that is enrolled in Medicare Part B and eligible

to bill under the PFS.

8. I certify that my organization is a recognized legal entity formed under applicable state,

federal, or tribal law and authorized to conduct business in each state in which it operates.

. Yes.

8a. Attach a copy of a certificate of incorporation or other documentation that demonstrates

that the applicant is recognized as a legal entity by the state in which it is located. [Allow

attachments]

9. To the best of your knowledge, has your organization, your organization’s parent company,

or anyone employed by your organization or parent company had a final adverse legal

action (as defined on page 11 of the

Medicare Enrollment Application for Physicians and

Non-Physician Practitioners, CMS-855i) or been the subject of an investigation by,

prosecution by, or settlement with the Health and Human Services Office of the Inspector

General, U.S. Department of Justice, or any other Federal or State enforcement agency in

the last five years relating to allegations of failure to comply with applicable Medicare or

Medicaid billing rules, the Anti-Kickback Statute, the physician self-referral prohibition, or

any other applicable fraud and abuse laws? Failure to disclose could be grounds for

application denial or immediate termination from the initiative.

. Yes

. No

9a. If yes, please explain the legal actions, investigations, prosecutions, and/or settlements; the

agency involved; and the resolution, if any. [3000 character limit]

10. Please check here to opt out of consideration for the GUIDE safety net provider designation

for infrastructure payment consideration per the definition provided in the RFA. (Optional)

. Yes, I wish to opt out of consideration for the GUIDE safety net provider designation.

Ownership Interest

11. Please complete the “Ownership” attachment to provide CMS with a full and complete

understanding of the ownership interests in the applicant, as well as the ownership interests

in the entities with an ownership interest in the applicant. Each party with at least 5%

ownership interest in the applicant should be listed.

*If the privately held company with an ownership or control interest in the applicant is a

subsidiary of another privately held company, please list the parent company(ies) and

ownership interests in that privately held company.

Organization Contacts (Tab 2)

This section asks for organization contact information. Please use the explanations provided to identify

the most appropriate person for each contact field and enter their most current contact information.

If the applicant has a program director who will have primary accountability for implementing the

dementia care program, please include it here.

1. For Primary Application Contact/Secondary Application Contact (Optional)/Program Director

(Optional)

First Name:

Last Name:

Title/Position:

Contact Type: (Primary/Secondary/Program Director)

Phone Number:

Email Address:

Street Address:

City:

State:

ZIP Code:

Complete Application (Section 2)

Staffing and Interdisciplinary Care Team (Tab 1)

1. Describe the interdisciplinary team(s) that the applicant organization will use to deliver

services under the GUIDE Model, including the number and types of staff members and

whether members of the team will be co-located or spread across multiple locations. Please

specify whether the interdisciplinary team currently includes a care navigator and where

staff will need to be hired, and include a hiring plan for these identified staff. Responses

should enable application reviewers to determine whether and how the applicant will meet

the interdisciplinary care team requirements described in the Care Delivery section of the

RFA. [5000 character limit]

2. Describe the training that your organization currently provides for staff that deliver care to

people with dementia and their caregivers. If the organization does not currently provide

training, please describe how the organization will meet the care navigator training

requirements. Describe whether and how the applicant will modify this training to meet the

care navigator training requirements of the GUIDE Model, as described in the Care

Navigator Requirements listed in the RFA. [5000 character limit]

3. Does your organization plan to partner with a Medicare Part A or Part B enrolled health care

organization, identified by a different Taxpayer Identification Number or CMS Certification

Number (CCN), such as a physician practice, federally qualified health center, home health

provider, or occupational or physical therapy practice, to meet the Model’s care delivery

requirements?

. Yes

. No

4. Complete the attachment to submit the applicant organization’s Proposed GUIDE

Practitioner Roster, including all historic TINs that any practitioner has used to bill for

Medicare services in the two years prior to November 17, 2023. [Allow attachments]

Note: This is optional, but to be eligible for the Established Program track or designated a

safety net provider under the New Program Track, at time of application the applicant must

provide a Proposed GUIDE Practitioner Roster with the historical TIN(s) under which the

practitioner(s) on their Proposed GUIDE Practitioner Roster have previously billed for Part B

services (see section the Infrastructure Payment section of the RFA).

5. Complete the attachment to submit the applicant organization’s Proposed GUIDE Partner

Organization Roster, including the organization’s TIN. [Allow attachments]

Care Delivery (Tab 2)

The following questions are about your organization’s care delivery methods. Answer each question as

carefully and accurately as possible, based on the current and planned activities if you are accepted to

participate in the GUIDE Model. Your responses will help to determine whether your organization is

assigned to the established program track or the new program track.

1. Has your organization, through an interdisciplinary team that includes at a minimum a care

navigator and a clinician with dementia proficiency, provided any of the following services

to people with dementia for the past 12 months or longer? (check all that apply):

. Comprehensive assessment

. Care planning

. 24/7 access

. Ongoing monitoring and support

. Care coordination and transitional care management

. Referral and coordination of services and supports

. Medication management and reconciliation

. Caregiver education and support

. Respite services (including in-home respite, adult day centers, and respite in a 24-hour

facility)

. None of the above

2. For each of the nine GUIDE Care Delivery Service domains, describe in detail:

• Whether and how the applicant organization currently provides these services,

• If the applicant organization currently provides some form of these services,

whether and how their service provision will need to evolve to meet Model

requirements,

• If the applicant organization does not currently provide these services, how it plans

to meet these requirements by the start of the Model performance period.

Responses should enable application reviewers to understand which services will be

provided by the GUIDE Participant versus a Partner Organization. Responses should also

describe the care setting and modality (e.g., in-office, in-home, virtual) that will be used to

deliver the activities under each care delivery domain. Review and address the detailed care

delivery requirements in Appendix B of the Request for Applications in your responses.

• Comprehensive assessment [Text Box, 3000 character limit]

• Care planning [Text Box, 3000 character limit]

• 24/7 access [Text Box, 3000 character limit]

• Ongoing monitoring and support [Text Box, 3000 character limit]

• Care coordination and transitional care management [Text Box, 3000 character

limit]

• Referral and coordination of services and supports [Text Box, 3000 character limit]

• Medication management and reconciliation [Text Box, 3000 character limit]

• Caregiver education and support [Text Box, 3000 character limit]Respite services

(including in-home respite, adult day centers, and respite in a 24-hour facility) [Text

Box, 3000 character limit]

3. Describe how you will affect outcomes for your target beneficiary population through

participation in the GUIDE Model. How will you ensure ongoing quality improvement

throughout the GUIDE Model’s performance period and address the Model’s goals? [Text

Box, 3000 character limit]

Alignment (Tab 3)

1. Describe the population of people with dementia that the applicant organization

currently serves. This should include geographic service area, sociodemographic

characteristics, type and/or stage of dementia, number of people currently served, and

referral source, i.e., how the applicant organization identifies people to receive

services. [Text box, 3000 character limit]

2. Estimate the number of Medicare Fee-for-Service beneficiaries with dementia that the

applicant organization intends to serve per year under the GUIDE Model. [Text Box,

numeric values only]

3. Describe how the applicant plans to identify and recruit beneficiaries and caregivers

through voluntary alignment over the course of the Model. [[Note: Please include

experience of the applicant in engaging caregivers and people living with dementia in

their care as well as an overview of marketing and communication plans that the

applicant has for recruitment. Also, include the safeguards the applicant has

implemented or will implement to ensure that, in conducting voluntary alignment

activities, the applicant does not coerce a beneficiary into voluntary alignment or

involuntary exclusion, and to otherwise ensure that beneficiary freedom of choice is

honored.]] [Text Box, 5000 character limit]

Health Equity (Tab 4)

1. Describe your organization’s role in improving health equity among your beneficiary

population. [Text Box, 3000 character limit]

2. Describe your organization's historical or planned processes in engaging underserved

populations. Note: Applicant should include engagement processes through

community outreach, program materials such as translated materials, partnerships

with community-based organizations, or other materials, and results on engagement

where relevant. [Text Box 3000 character limit]

Health Information Technology (Tab 5)

Please select one of the following:

. I certify that my organization will be able to adopt and maintain the health IT needed to

meet the CEHRT definition at 42 CFR 414.1305 by the first performance year as referenced

under the Participation Requirements section of the RFA.

. I am unsure if my organization will be able to adopt and maintain the health IT needed to

meet the CEHRT definition at 42 CFR 414.1305 by the first performance year as referenced

under the Participation Requirements section of the RFA.

. My organization will not be able to adopt and maintain the health IT needed to meet the

CEHRT definition at 42 CFR 414.1305 by the first performance year as referenced under the

Participation Requirements section of the RFA.

Applicant Service Area (Tab 6)

Please complete and submit the Excel template to identify, by 5-digit zip-code, the service area from

which your organization will accept patients. If you are selected to participate in the GUIDE Model, CMS

will use this service area data to identify beneficiaries who will receive outreach letters that list your

organization as an available dementia care provider in their area (see the Beneficiary Outreach and

Engagement section of the RFA for more information). [Require attachment]

Appendix B: Care Delivery Requirements

Comprehensive

Assessment

1.1 Comprehensive Assessment:

1.1.1 GUIDE Participant shall deliver a comprehensive assessment of, and care

planning for, the beneficiary with dementia in accordance with the requirements

below.

1.1.2 Frequency:

1.1.2.1 GUIDE Participant shall perform a comprehensive assessment of the

beneficiary. The comprehensive assessment will initiate the model intervention

and serve as the initial model visit.

1.1.2.2 GUIDE Participant shall complete a new comprehensive assessment

under the terms of Section 1.1 for any beneficiaries that the GUIDE Participant

may have previously assessed as a patient prior to the beneficiary voluntarily

aligning with the GUIDE Participant for purposes of this Model.

1.1.2.3 After the initial comprehensive assessment, GUIDE Participant shall

perform a comprehensive assessment of the beneficiary at least once every

twelve months.

1.1.2.4 The GUIDE Participant has the discretion to re-assess the beneficiary

more frequently; however, the GUIDE Model will only accept data from

reassessments once every one hundred and eighty days.

1.1.3 Modality:

1.1.3.1 An assessment may be performed via telehealth or in-person in the care

team’s office or other outpatient home or domiciliary based on the preference of

the beneficiary and/or caregiver.

1.1.3.2 The assessment shall be administered by appropriate members of the

interdisciplinary care team according to their license and scope of practice.

1.1.4 Required Domains:

1.1.4.1 Clinical:

1.1.4.1.1 Cognition-focused evaluation including a pertinent history and

examination;

1.1.4.1.2 Evaluation of medical decision-making of moderate or high

complexity;

1.1.4.1.3 Functional assessment (e.g., Basic and Instrumental Activities of

Daily Living);

1.1.4.1.4 Screening, or referral to screening, for hearing loss;

1.1.4.1.5 Use of standardized instruments for staging of dementia;

1.1.4.1.6 Medication reconciliation and review.

1.1.4.2 Behavioral Health and Psychosocial Needs:

1.1.4.2.1 Evaluation of beneficiary with dementia for behavioral health

needs, including screening for depression, anxiety, substance use, and suicidal

ideation;

1.1.4.2.2 Evaluation of safety, including, but not limited to, environmental,

driving, wandering, fall risk, and abuse, neglect and exploitation.

1.1.4.3 Health-Related Social Needs:

1.1.4.3.1 Screening of beneficiary’s health-related social needs in

accordance with the requirements detailed in the “Health Equity Strategy”

section of this RFA.

1.1.4.4 Advance Care Planning:

1.1.4.4.1 Development, revision, and/or review of an Advance Care Plan

and a Physician Order for Life-Sustaining Treatment (POLST) if available and

beneficiary wishes to complete.

1.1.4.5 Coordination:

1.1.4.5.1 Identification of beneficiary’s primary care provider, behavioral

health provider, and specialty provider(s), if any, and coordination services to

manage the beneficiary’s dementia and any co-occurring conditions.

1.1.4.5.2 Identification of any community-based services and supports, and

home and community-based services that the beneficiary is receiving.

1.2 Caregiver Assessment: GUIDE Participant shall deliver an assessment of the

beneficiary’s caregiver in accordance with the requirements hereinbelow.

1.2.1 GUIDE Participant shall identify the beneficiary’s caregiver(s) and their ability

and willingness to assume, or to continue to furnish, assistance.

1.2.2 GUIDE Participant shall assess the caregiver’s knowledge, needs, and social

supports, and assess the caregiver’s well-being, stress level, and other challenges.

1.2.3 If the beneficiary does not have a caregiver, the GUIDE Participant shall make a

reasonable effort to help identify a caregiver for the beneficiary.

1.2.3.1 If the GUIDE Participant and the beneficiary are not able to locate a

caregiver for the beneficiary, then Section 1.2: Caregiver Assessment and Section

8: 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.

1.3 Home Visit Assessment:

1.3.1 For beneficiaries in the low complexity dyad tier or low complexity individual

tier: GUIDE Participant may, but is not required to, visit the beneficiary and, if

applicable, his or her caregiver in person at the current residence of the beneficiary.

If the GUIDE Participant does not visit the beneficiary in person, the visit may be

performed remotely through electronic means. For beneficiaries in moderate or high

complexity dyad tiers, or moderate to high complexity individual tier: GUIDE

Participant shall visit the beneficiary and, if available, his or her caregiver at the

current residence of the beneficiary. If the caregiver or other members of the care

team are not present, the GUIDE Participant may facilitate participation of the

caregiver and other members of the care team by enabling such individuals to

participate in the visit remotely through electronic means.

1.3.2 The home visit with the beneficiary should occur within two months after the

initial assessment and can be performed by any member of the interdisciplinary care

team.

1.3.3 During the home visit, the GUIDE Participant shall assess the following: i) safety

of the home environment and the beneficiary’s ability to navigate and manage the

home environment, ii) beneficiary’s function in activities of daily living, and iii) other

environmental, social, and behavioral factors that might impact the function and

needs of the beneficiary and their caregiver.

Care Plan

2.1 Based on findings from the comprehensive initial assessment, including the HRSN

screening, home visit, and guidance from the beneficiary and the caregiver, the

GUIDE Participant shall develop elements of the person-centered care plan with

recommendations for i) addressing the beneficiary’s goals, strengths, preferences and

needs, ii) the required domains of the comprehensive assessment, iii) the

coordination of community-based services and supports, including respite services if

applicable, and a listing of recommended service providers and which individual or

program is responsible for payment of each service provider, and iv) the caregiver’s

education and support services.

2.2 The initial care plan and future revisions shall be led by the beneficiary. At the

discretion of the beneficiary and as appropriate to the individual, the GUIDE

Participant may also incorporate input from the beneficiary’s caregiver. The GUIDE

Participant shall share the initial care plan and future revisions with the beneficiary

and their caregiver along with any relevant education, supports, and other resources,

to carry out the goals of the plan.

2.3 The GUIDE Participant shall modify the written care plan as needed, or requested, to

reflect the beneficiary’s changing circumstances, goals, preferences, and needs.

2.4 The person-centered care plan shall be incorporated into the beneficiary’s electronic

health record and shared with the beneficiary’s primary care provider (if the

beneficiary’s primary care provider is not a member of the GUIDE Participant’s care

team) and any specialist or other provider in accordance with Section 5, Care

Coordination and Transitional Care Management.

24/7 Access

3.1 GUIDE Participant shall provide either (i) 24/7 access to an interdisciplinary care team

member or (ii) 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.

3.2 If the GUIDE Participant uses a 24/7 helpline, the 24/7 helpline shall be available to

receive ad hoc one-on-one support calls from the caregiver (see Section 8.2.4).

Ongoing

Monitoring and

Support

4.1 The care navigator shall be the primary point of contact for the beneficiary and their

caregiver.

4.2 The care navigator shall provide ongoing contact with the beneficiary and/or

caregiver in order to revise and maintain the person-centered care plan as needed

(see Section 2), identify unmet needs and coordinate clinical and community-based

services and supports (see Section 6), monitor medication management and

adherence (see Section 7), and provide caregiver education and support (see Section

8) as may be needed to support the beneficiary and their caregiver.

4.2.1 If the care navigator is a non-clinical professional, the care navigator should

consult with the care team’s clinical team members for any medical or other issues

that present with complexity.

4.3 Frequency: GUIDE Participant shall maintain a minimum contact frequency with the

beneficiary and/or their caregiver. Minimum contact requirements vary by model tier,

as follows:

4.3.1 Beneficiaries 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

4.3.2 Beneficiaries without a caregiver

Low complexity individual tier: at least once a month

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

4.4 Modality: GUIDE Participant may provide ongoing contact 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, as applicable. Short Messaging Service

(SMS) may not be used to contact the beneficiary or caregiver to meet the minimum

contact frequency, but can be used, with the beneficiary’s and caregiver’s consent, in

other communications.

Care

Coordination

and Transitional

Care

Management

5.1 If the beneficiary’s primary care provider is not a member of the GUIDE Participant’s

care team, GUIDE Participant shall coordinate with the beneficiary’s primary care

provider and notify the beneficiary’s primary care provider that the beneficiary is

participating in a dementia care management program and ensure that the primary

care provider has access to the beneficiary’s care plan and any updated/revised care

plans.

5.2 GUIDE Participant may refer the beneficiary to a specialist or other provider to

address any physical or behavioral health (such as, mental health or substance use)

co-occurring conditions of the beneficiary. GUIDE Participant may notify the specialist

or other provider that the beneficiary is participating in a dementia care management

program and send the specialist or other provider the beneficiary’s person-centered

care plan, and any updated/revised care plans, by electronic health record, fax, or

mail. The GUIDE Participant shall also notify the beneficiary’s primary care provider of

the referral to a specialist and/or other provider. If the primary care provider is

actively co-managing the beneficiary, the GUIDE Participant should make this referral

in consultation with the primary care provider. The dementia care team must close

the referral loop with the specialist by ensuring they receive documentation from the

beneficiary’s visit and any changes to their care plan.

5.3 If the GUIDE Participant refers the beneficiary to a specialist or other provider, a

member of the care team shall introduce the beneficiary to the new provider if

requested by the beneficiary and/or their caregiver so that the new provider is aware

of the patient history and can share recommendations with the care team for

incorporation into the care plan.

5.4 GUIDE Participant shall provide care coordination services, medication

management/reconciliation, and support to the beneficiary in transitions between

their personal residence and care settings, such as a hospital, emergency department,

nursing facility, and/or hospice.

5.5 GUIDE Participant shall provide additional care coordination services needed to help

manage the beneficiary’s dementia and co-occurring conditions, if any, across the

care-continuum.

Referral and

Coordination of

Services and

Supports

6.1 GUIDE Participant shall i) refer and connect beneficiaries and their caregivers to

community-based services and supports that address the common needs of persons

with dementia and their caregivers (e.g., home-delivered meals, adult day centers,

personal care, environmental modifications, contractors, food banks), and/or ii) enter

into a written agreement with a local Area Agency on Aging or a Tribal Aging Program

(funded through Title VI of the Older Americans Act) requiring that the local Area

Agency on Aging or Tribal Aging Program assists beneficiaries and their caregivers

with coordinating community-based services and supports.

6.2 If the beneficiary is eligible for and receiving home- and community-based services

(HCBS) through a state Medicaid program, the GUIDE Participant shall contact and

attempt to coordinate the delivery of community-based services and supports and

HCBS with the beneficiary’s waiver/HCBS program case manager. Coordination

between the GUIDE Participant and the beneficiary’s waiver/HCBS program case

manager shall include sharing information about the GUIDE Model and reviewing the

services that the beneficiary receives through both the GUIDE Model and Medicaid

for the purpose of understanding gaps or duplication in the beneficiary’s care.

6.3 GUIDE Participant shall join or maintain a community referral inventory system that

includes resources for the health-related social needs screened as part of the

comprehensive assessment (see Section 1.1.4.3), and the care navigator shall refer

and connect the beneficiary and their caregiver to resources relevant to their needs.

6.4 GUIDE Participant shall maintain, or have access to, an inventory of community-based

resources for services and supports that address the common needs of persons with

dementia and their caregivers (e.g., home-delivered meals, adult day centers,

personal care, environmental modification, contractors, food banks) and as

appropriate, share these resources with the beneficiary and their caregiver.

Medication

Management

and

Reconciliation

7.1 A clinician with prescribing authority shall review and reconcile the medications that

beneficiary is taking at the time of the comprehensive initial assessment, at any

additional future assessments, and then periodically as requested by other members

of the care team, the beneficiary or the caregiver, as appropriate. Medication review

would customarily include, as part of this element, a review of prescription drugs,

over-the-counter medications, supplements, natural treatments, and/or any other

substances the beneficiary might be using for any purpose.

7.2 If clinically advisable for the beneficiary, GUIDE Participant’s advanced practice nurse,

physician assistant, or physician shall consider prescribing medications that are

beneficial for the beneficiary.

7.3 If clinically advisable for the beneficiary, GUIDE Participant’s advanced practice nurse,

physician assistant, or physician shall de-prescribe any medications that are

inappropriate for the beneficiary to continue taking.

7.4 GUIDE Participant shall share recommended changes to the beneficiary’s medications

with the beneficiary’s primary care provider and other medical specialists, as

applicable, and confirm that the relevant medical provider, either the primary care

provider or the medical specialist, agrees to the proposed change to the beneficiary’s

medications prior to the beneficiary changing their medications.

7.5 GUIDE Participant’s care navigator shall provide information on supports to help the

beneficiary maintain the correct medication schedule, such as pill reminders, pill

boxes, and/or software applications.

8.1 In order to provide education and support to the caregiver of a beneficiary, GUIDE

Participant shall administer a caregiver support program, which is based on the

caregiver assessment referred to in Section 1.2 and is responsive to ongoing

caregiver needs.

8.2 The caregiver support program shall offer the following services:

Caregiver

Education and

Support

8.2.1 Caregiver skills training: GUIDE Participant shall provide the caregiver with the

option to receive training to help the beneficiary continue to live as safely and

comfortably as possible in the community. The training shall include the following

topics: emergency services, safety in the home, assistance with activities of daily

living (ADL) and instrumental ADLs, responding to and managing the beneficiary’s

behavioral and psychosocial symptoms, identifying and obtaining help across the

care continuum, working with health care and other community-based providers,

recreation, social and leisure activities, making plans for the future, and caregiver

self-care and stress management.

8.2.2 Dementia diagnosis information: If beneficiary and/or caregiver wish to

receive further information regarding the beneficiary’s dementia diagnosis, GUIDE

Participant shall speak with and provide written educational materials to the

caregiver regarding the beneficiary’s dementia diagnosis. These materials may

include, but are not limited to, information on dementia, common behavioral

changes, functional status, and resources available publicly and through the GUIDE

Participant. These materials should be comprehensible to a lay person and in the

primary language spoken by the beneficiary and the caregiver.

8.2.3 Support group services: GUIDE Participant shall provide the caregiver with the

option to participate in a group setting where a facilitator trained in dementia and

caregiving shall work with caregivers on self-care, home safety, caregiver skills,

personal care, and managing challenging behaviors.

8.2.4 Ad hoc one-on-one support calls: GUIDE Participant shall be available for one-

on-one support calls with the caregiver to address issues in furnishing care and

support to the beneficiary as the issues arise. For example, these calls may focus on

the caregiver’s needs and goals by coaching caregivers on stress management, self-

care and well-being behaviors, and how to identify and address behavioral

challenges and functional status of the beneficiary with dementia, and support safety

of the caregiver, and the beneficiary. The calls may be initiated by the beneficiary,

the caregiver, or the GUIDE Participant. The GUIDE Participant’s requirement to

maintain minimum contact with the beneficiary in accordance with Section 4.3 may

be used to satisfy this requirement for one-on-one support calls.

8.3 Modality: All services may be provided virtually or in-person. In addition, GUIDE

Participant shall deliver the services listed under Section 8.2 as follows:

8.3.1 Caregiver skills training: Must be provided by either a member of the care

team or through a contracted vendor or community organization that is reimbursed

by the GUIDE Participant; may be provided in a one-on-one setting or group format.

8.3.2 Dementia diagnosis information at program entry: Must be provided directly by

a member of the care team in a one-on-one setting.

8.3.3 Support group services: May be provided directly by a member of the care

team, through a contracted vendor or community organization that is reimbursed by

the GUIDE Participant, or through referral to a community organization that offers

support group services to the community free of charge. Beneficiaries with dementia

and caregivers may decline to participate in support groups or change their mind

about participation at any time.

8.3.4 Ad hoc one-on-one support calls: Must be provided directly by a member of

the care team.

8.4 In addition to the required services listed above, the GUIDE Participant should

consider whether to provide the following optional services:

8.4.1 Peer-to-peer support: Experienced caregivers, whose caregiving experience

has come to an end, would provide practical information, and support and mentoring

to the caregiver participating in the Model.

8.4.2 Resources or referrals for self-care and well-being instruction (e.g., group

walks, meditation classes): Specialized services centered around caregiver stress and

health management. Services could include, but are not limited to, mindfulness and

relaxation techniques, cognitive behavioral therapy, musical and arts classes, and

exercise classes.

8.4.3 Assist with education on the role of the caregiver: Information on the

traditional responsibilities of a caregiver for a person living with dementia and the

resources available to them through the GUIDE Participant.

8.4.4 Accessing community-based resources: Coaching the caregiver on how to

access community-based resources relevant to their caregiving role, such as

transportation, nutrition support, homemaker/yard services. This service is in

addition to the referral support provided under Section 6 Referral and Coordination

of Services and Supports.

8.5 Psychological counseling referral: The caregiver may work with a specialist on

developing new behaviors or strategies to help address caregiving demands,

identifying areas for improvement for the beneficiary-caregiver dyad, or assistance in

addressing depression, anxiety, and suicidal ideation in the caregiver and/or the

beneficiary.

Respite

9.1 GUIDE Participant shall provide GUIDE Respite Services to beneficiaries who qualify

for respite under the Model and choose to receive respite. GUIDE Respite Services are

furnished based on the beneficiary’s qualifying status. GUIDE Participants and eligible

beneficiaries shall decide how much GUIDE Respite Services the beneficiary will

receive taking into consideration the beneficiary’s need for GUIDE Respite Services

and the capped amount of GUIDE Respite Services covered under the Model.

9.2 GUIDE Participant shall provide in-home GUIDE Respite Services directly or contract

with at least one provider of in-home respite services. The contract must specify how

the GUIDE Participant will reimburse the respite provider for Respite Services

rendered to eligible beneficiaries.

9.3 GUIDE Participant may also contract with adult day centers or facilities that can

provide 24-hour care to deliver GUIDE Respite Services in these settings to eligible

beneficiaries.

Appendix C: Example Patient Assessment and Alignment Form

Example GUIDE Patient Assessment and Alignment Form

Results from (check one):

. Initial Assessment . Re-assessment . Re-assessment due to new primary caregiver

Date of assessment: ____________

Patient first name: ________ Patient middle name:(if applicable) ______ Patient last name: _________

Patient Address: _______________ Email: _______________ Phone Number: _______________

Patient resides in: . home . assisted living facility . memory care program (excludes nursing home

level of care)

Patient Date of Birth: ___/___/_____

Patient Medicare Beneficiary Identifier: __________

Patient Medicaid ID number: _____________ (as applicable)

Patient dementia stage: (Drop-down menu: CDR, FAST): ___ (enter numerical score)

Does patient have a caregiver, defined as a relative, or an unpaid nonrelative, who assists the

beneficiary with activities of daily living and/or instrumental activities of daily living? (Drop-down menu:

yes-multiple, yes-one, no, undetermined)

If yes:

Caregiver first name: __________ Caregiver last name: ___________

Caregiver Address: _______________ Email: _______________ Phone Number: _______________

What is primary caregiver’s relationship to patient? (Drop-down menu: spouse, child, non-immediate

family member, friend, other)

Does primary caregiver live with patient? (Drop-down menu: yes, no)

Is primary caregiver a Medicare beneficiary? (Drop-down menu: yes, no)

If yes, what is the primary caregiver’s Medicare Beneficiary Identifier: __________

Primary caregiver Zarit Burden Interview score: ___ (enter numerical score as a whole number)

In my clinical judgment, the assessed beneficiary meets the National Institute on Aging-Alzheimer’s

Association diagnostic guidelines for dementia and/or the DSM-5 diagnostic guidelines for major

neurocognitive disorder, or I have received a written report (electronic or hard-copy) of a documented

dementia diagnosis from another Medicare qualified health professional.

Yes

Attesting clinician:

First name: ____________ Middle Name:_____________ Last name: ____________

National Provider Identification (NPI): ____________

Patient referral source:

. Referred by a healthcare provider . Referred by a community-based organization . Self-referral