August 23, 2023
On July 31, 2023, the Centers for Medicare & Medicaid Services (CMS) announced its new Guiding an Improved Dementia Experience (GUIDE) Model, which aims to support Americans living with dementia and reduce the burdens placed upon their unpaid caregivers. Select Medicare Part B enrolled providers may be eligible to participate in this nation-wide, eight-year program. Under GUIDE, participating providers assign dementia patients and their caregivers to an interdisciplinary care team, arrange for caregiver respite services, and offer caregivers access to dementia training materials and a support hotline. The new GUIDE compensation model will allow providers to receive monthly per-beneficiary, per-month payments, bill for respite care services offered to caregivers, and collect a single, lump-sum payment to support program development.
BACKGROUND
The GUIDE Model was promulgated in response to Executive Order 14095, a directive issued by the Biden Administration on April 18, 2023, to increase access to high-quality care and support caregivers. GUIDE aligns with key goals of the bipartisan National Alzheimer’s Project Act and is the result of extensive collaboration between CMS and external stakeholders.
PROVIDER & BENEFICIARY ELIGIBILITY
Eligible participants under the GUIDE Model include Medicare Part B enrolled providers and suppliers, with the exception of durable medical equipment and laboratory suppliers, which are eligible to bill for Medicare Physician Fee Schedule services and satisfy care delivery requirements.
CMS has developed two participant tracks: i) one for established programs which already provide comprehensive dementia care and are equipped for immediate implementation of the GUIDE Model; and 2) one for new programs which are interested in scaling dementia support. Participants in the latter track must submit a detailed plan for GUIDE implementation and will be subject to a one-year pre-implementation period for program development and technical support.
The GUIDE Model is intended to serve community-dwelling Medicare fee-for-service beneficiaries, including beneficiaries dually eligible for Medicaid and Medicare, who are diagnosed with dementia and not enrolled in the Medicare hospice benefit or residing in a long-term nursing home.
PROGRAM REQUIREMENTS
Participating providers must maintain an interdisciplinary care team which includes: 1) a care navigator trained in dementia assessment and care planning; and 2) a clinician with dementia proficiency, as recognized by experience caring for adults with cognitive impairment; experience caring for patients 65 years or older; or a specialty designation in neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology. At the discretion of the participating provider, an interdisciplinary care team may also include pharmacists, behavioral health professionals, or other members.
Under GUIDE, the interdisciplinary care team is tasked with offering beneficiaries a standardized set of services, to include medical and non-medical care coordination and the development of a person-centered care plan. With respect to a beneficiary’s unpaid caregiver(s), participating providers must also furnish periodic monitoring services, dementia education and training, and 24/7 support hotline access.
COMPENSATION MODEL
Participating providers may be eligible to receive the following payments:
- Infrastructure Payment: Certain providers in CMS’s new program track will be eligible to receive a one-time, lump-sum infrastructure payment for program development.
- Per-Beneficiary, Per-Month Payment: CMS will furnish a monthly payment per beneficiary receiving care management and coordination services, caregiver education, and additional support.
- Respite Care Payment: Participating providers may bill for respite services for beneficiaries with a caregiver and moderate to severe dementia, up to an annual respite cap amount.
CONCLUSIONS
The GUIDE Model recently introduced by CMS poses an exciting opportunity for health care providers furnishing dementia care. Prospective participants may submit a letter of interest through September 15, 2023. CMS is anticipated to release a request for applications in the coming months, in advance of the program’s official launch on July 1, 2024.
If you have questions or need assistance regarding the GUIDE Model, please contact a member of Hancock Daniel’s Compliance or Long-Term Care & Post-Acute Care teams.
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The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson, P.C., is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel & Johnson, P.C. be liable for any direct, indirect, or consequential damages resulting from the use of this material.
