The GUIDE Model
Overview: The GUIDE Model is an eight-year model that will test an alternative payment for participants that delivers key supportive services to people with dementia, including comprehensive, person-centered assessments and care plans, care coordination, and 24/7 access to a support line. As a part of the Model, participants will assign dementia patients and their caregivers to a care navigator who will help them access services and supports, including clinical and non-clinical services such as meals and transportation through community-based organizations (referred to as a dementia care program (DCP)).
CMMI intends the GUIDE Model will:
Participants: The Model will involve voluntary participation by Medicare Part B-enrolled providers and suppliers, except for durable medical equipment (DME) and laboratory suppliers, who have expertise or capabilities to provide ongoing, longitudinal care and support to people living with dementia.
The GUIDE Model provides two tracks for participants. They are as follows:
Interested participants unable to meet the GUIDE care delivery requirements for either track on their own may collaborate with another eligible applicant (referred to as “Partner Organizations”).
Payments: Under the Model, participants will receive a per-beneficiary per month payment referred to as a dementia care management payment (DCMP) for offering care management, coordination, caregiver education, and support services to beneficiaries and caregivers. The DCMP rates may be adjusted by a Health Equity Adjustment (HEA) and a Performance Based Adjustment (PBA). The HEA is designed to increase model payments for disadvantaged beneficiaries and collect beneficiary demographic data to identify and address disparities. The PBA is intended to incentivize high-quality care and presumably will include both upward and downward adjustments to DCMPs payable to participants.
In addition to the DCMP, the GUIDE Model provides for up to two other types of payments for participants:
Populations: The Model will include Medicare FFS enrollees, including beneficiaries dually eligible for Medicare and Medicaid, who have dementia, as confirmed by attestation from a clinician associated with a GUIDE DCP. However, these individuals may not be receiving the Medicare hospice benefit or residing in a nursing home.
CMS has excluded Medicaid-only beneficiaries, as well as individuals who are enrolled in a Medicare Advantage plan, Special Needs Plan, or a PACE program from the Model.
Federal Expenditures: CMMI noted in its FAQ for the GUIDE Model that it projects that the Model is expected to reduce Federal expenditures (collectively referring to both Medicare and Medicaid expenditures), but is not likely to save money for the Medicare Trust Fund. Rather, CMMI expects that most savings will come from reduced Federal Medical Assistance Percentage (FMAP) spending as the result of lower expenditures on “long-term nursing home placement” for Medicaid beneficiaries.
While it is uncommon for CMMI to initiate a model for which savings are not expected in Medicare, the authorizing statute for CMMI in Section 1115A(a)(1) of the Social Security Act states that the agency’s purpose is “to test innovative payment models and service delivery models to reduce program expenditures under the applicable title.” Here, the GUIDE Model includes Medicare FFS beneficiaries and dual-eligible individuals (i.e., those enrolled in Medicare and Medicaid). Thus, it is possible that this Model could collectively reduce Federal expenditures under both the Medicare and Medicaid titles (i.e., Title XVIII for Medicare and Title XIX for Medicaid), even if the Model increases Medicare expenditures.
Implementation and Timeline: CMS will host a webinar on August 10, 2023 to provide more information on the GUIDE Model. Registration is available here. The RFA will be made available in Fall 2023, but CMS encourages interested participants to submit letters of interest by September 15, 2023.
1 Additional members may be included at the participant’s discretion, such as pharmacists or behavioral health specialists.