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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:
The DCMP is designed to offer GUIDE Participants more flexibility to deliver personalized dementia care than 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 monthly 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 intensity 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 Participant 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 month, 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.40 In order to support accurate billing, CMS will provide each GUIDE Participant with a monthly beneficiary alignment file that lists all the beneficiaries aligned to that GUIDE Participant, their model tier assignment, and the length of their alignment to the GUIDE Participant.
| | 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.