Foley Hoag LLP

Key Takeaways:

  • On July 31, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary model – the Guiding an Improved Dementia Experience (GUIDE) Model – that the Center for Medicare and Medicaid Innovation (CMMI) will test to support people living with dementia and their caregivers.  
  • In its announcement, CMMI highlighted that the model aligns with President Biden’s Executive Order 14095 (“Increasing Access to High-Quality Care and Supporting Caregivers”) and the Office of the Assistant Secretary for Planning and Evaluation’s National Plan to Address Alzheimer’s Disease.
  • The Model is slated to run for eight years and will test whether an alternative payment for participants that deliver 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.

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:

  • Improve quality of life for people living with dementia by coordinating their care for dementia and co-occurring conditions, and improving transitions between their community and care settings.
  • Reduce the burden and strain on unpaid caregivers of people living with dementia by providing caregiver skills training, referrals to community-based social services and supports, 24/7 access to a support line, and respite services.
  • Prevent or delay long-term nursing home care by supporting caregivers and enabling dementia patients to remain in their homes.

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:

  • Established Community-Based DCPs: For applicants who have a community-based DCP as of July 31, 2023.  The DCPs must: (1) have an interdisciplinary care team that has (a) a care navigator who has received the required training in dementia, assessment, and care planning, and (b) a clinician with dementia proficiency;1  (2) use an electronic health record platform that meets the standards for Certified Electronic Health Record Technology, and (3) meet other care delivery requirements specified in the Request for Applications (RFA). The Established Community-Based DCPs track’s performance period begins July 1, 2024.  
  • New Community-Based DCPs: For applicants who do not have a community-based DCP as of July 31, 2023. These applicants are required to submit a detailed plan for establishing a DCP and then undergo a one-year pre-implementation period to establish their DCP.  The New Community-Based DCP track’s one-year pre-implementation will begin July 1, 2024, and the performance period will begin July 1, 2025.

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:

  • Respite Care Payment: All participants can bill for respite services for beneficiaries with a caregiver and moderate-to-severe dementia, up to an annual respite cap amount (unspecified in the announcement materials). 
  • Infrastructure Payment: Certain safety net providers participating in the New Community-Based DCP track are eligible for a one-time, lump sum infrastructure payment to support program development activities.

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.