CMS GUIDE Model
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The Alzheimer’s and Dementia Care Program provides ongoing care for patients with a dementia diagnosis. Call 310-319-3222 to learn more about dementia care at UCLA Health.
The Center for Medicare and Medicaid Services (CMS) introduced the Guiding an Improved Dementia Experience (GUIDE) Model, which is a voluntary nationwide Medicare model test that aims to support people with dementia and their unpaid caregivers. The model began on July 1, 2024, and will run for eight years.
In July 2024, the UCLA Alzheimer’s and Dementia Care Program (UCLA ADC) began providing comprehensive dementia care through the GUIDE model. This model provides Medicare coverage for comprehensive, coordinated dementia care. It aims to improve the quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities. It will achieve these goals through Medicare payments for a comprehensive care coordination and care management package, caregiver education and support, and respite services.
Persons living with dementia (PLWD) enrolled in the GUIDE model who have moderate or severe dementia will also have an in-home visit. They may be eligible for limited in-home or adult day care respite service benefits.
Eligibility
To be eligible for the CMS GUIDE Model, the patient must meeting the following:
- Has a confirmed diagnosis of Alzheimer’s or other types of dementia
- Has Medicare Part A&B as primary insurance
- Is not enrolled in a Special Needs Plan (SNP) or PACE (Program for All-Inclusive Care for the Elderly)
- Is not enrolled in Medicare hospice benefit
- Is not living in a long-term nursing home
- Lives within the UCLA ADC Program service area
- Is not residing in a memory care facility or residential care community
Enrollment Process
- A comprehensive appointment is scheduled by the ADC Program administrative team.
- The patient/caregiver completes a required pre-visit questionnaire prior to the assessment.
- The comprehensive assessment is conducted with a Dementia Care Specialist.
- We send information from the appointment to Medicare to determine benefits.
- The patient and caregiver receive continued coordinated care from the ADC program.
GUIDE Benefits
Home Visits
CMS requires GUIDE enrollees to have a in-home visit in cases of moderate or high complexity dementia and a telemedicine home visit for low complexity patients. A home visit is required for some patients within the program who meet criteria determined by Medicare. A home visit helps ensure that you and your caregiver get additional support and evaluate if any safety measures are recommended.
The UCLA ADC program partners with home care agencies to perform the one-time home visit. The home care agency will contact you directly to arrange a time.
During the home visit, we assess:
- The home environment
- How you function in your home, including performing your personal care tasks
- Other environmental, social and behavioral factors
The home agency visitor will talk with you and walk around your home to evaluate safety and fall risk.
We ask that the patient and caregiver be present for the home visit.
Respite Fund
Through GUIDE, Medicare offers a yearly amount for eligible GUIDE enrollees so caregivers can take a break when needed. Eligible UCLA ADC program GUIDE enrollees can receive respite services each year.
- Respite service support comes from local in-home respite providers and adult day centers. The UCLA ADC program partners with community-based organizations (CBOs) and home care agencies to provide these services.
- Patients enrolled in the GUIDE Model with moderate to high complexity dementia who have a caregiver are eligible for respite services. The respite services fund is available to eligible GUIDE enrollees after completing their initial visit and being aligned within the GUIDE Model.
- You can use respite service funds for in-home care or adult day services.
- Funds renew on July 1 yearly through the 8-year program. You cannot carry over unused funds to the following year.
- GUIDE respite covers up to the allowable amount each fiscal year. Any services above this amount are the responsibility of the patient.
- This benefit depends on insurance coverage, and changes to insurance plans could reduce or end this benefit. If a service is not covered by your insurance, the patient will be responsible for those costs.
GUIDE FAQs
How does the GUIDE Model differ from my current care with the UCLA Alzheimer’s and Dementia Care Program? What is changing?
The care you and your loved one currently receive with the UCLA Alzheimer’s and Dementia Care (ADC) program will remain the same. You’ll continue comprehensive visits, as-needed follow-ups, and communication with your dementia care specialist and ADC team. Enrolling in the GUIDE model can provide you with additional benefits if you are eligible. GUIDE Model enrollment is based on insurance type to qualify.
If you or your loved one is not eligible for the CMS GUIDE Model, you may still qualify for and receive services through the ADC Program.
What if I do not want to enroll in the ADC's GUIDE Model Program?
We understand that personal circumstances may vary, and we respect your right to decline participation in the GUIDE Model. However, if you are eligible for the GUIDE Model, you must enroll in GUIDE for you to continue receiving services through the UCLA ADC Program. In other words, patients who are eligible for GUIDE but choose not to participate cannot remain enrolled in the UCLA ADC Program. If you later decide that you would like to enroll in GUIDE and receive services through the UCLA ADC Program, a referral from your primary care provider (PCP) will be required to begin the enrollment process.
I don’t have straight Medicare Part A&B, but I have a Managed UCLA Medical Group Plan, commercial insurance, or another type of insurance that UCLA Health accepts. Will I be able to enroll in the UCLA ADC Program?
Patients with the UCLA Medical Group Medicare Advantage (Principal or Prestige plans) or UCLA Medical Group United Healthcare Sr. plan are also eligible for GUIDE benefits. GUIDE respite eligibility and services may vary depending on your plan.
The ADC Program enrolls patients of all insurance types. Patients with commercial plans are not eligible for GUIDE respite services or in-home visits.
Do I have to have a home visit?
If you meet the eligibility requirements for the GUIDE Model and have more complicated circumstances, you will be offered a home visit for participation. We understand that personal feelings about home visits may vary. We respect your right to privacy and your decision.
What if my loved one doesn’t qualify for a home visit? Can we still get one?
Home visits are available only for individuals who meet the eligibility criteria. Virtual home visits will be offered to those receiving GUIDE services whose circumstances are less complicated.
How can I use the respite fund?
Once we identify a need for respite services and confirm insurance eligibility, the ADC program will arrange for services to begin through a home care agency or refer you to an adult day care center. A representative from the selected provider will contact you directly to schedule services.
After services are delivered, the provider bills the UCLA ADC program, and we reimburse the provider using Medicare funds. You should not receive a bill from the home care agency for approved respite services.
Please note: Respite services depend on your insurance coverage. If your insurance changes, this benefit may be reduced or no longer available. If a respite service is not covered by your insurance, the patient will be responsible for paying those costs. In addition, if you use more respite services than the amount approved, the patient will be responsible for any extra costs.
Who has access to the respite services fund?
The UCLA Health ADC Program manages respite service funds for all eligible GUIDE enrollees. Funds are not given directly to the GUIDE enrollee. The UCLA ADC program manages available funds and payments to community partners.
Who can provide respite services?
Only community-based organizations (CBOs) and home care agencies that have established partnerships with the UCLA ADC program can provide GUIDE respite services.
GUIDE enrollees cannot use respite funds for their caregiver, In-Home Supportive Services (IHSS), or receive direct payments. The UCLA ADC program manages the respite funds and coordinates with the agencies to provide services.
When should respite services be used?
The respite fund is available to eligible GUIDE participants and may be used as needed. The fund has an annual maximum benefit amount, and any unused funds do not carry over to the next year.
For respite benefits, CMS defines the benefit year as July 1 through June 30, regardless of your enrollment date. For example, if you enroll on June 29, you may use the remaining respite funds available for that benefit year for two days, and your benefit amount will reset on July 1.
Unused respite funds cannot be carried over from one benefit year to the next.
I am not eligible for GUIDE benefits but have Medicare through a Managed Care Plan (such as UCLA Med Group), a commercial plan, or other insurance. Will I be provided with a respite fund?
Patients with the UCLA Medical Group Medicare Advantage (Principal or Prestige plans) or UCLA Medical Group United Healthcare Sr. plan are also eligible for GUIDE participation. GUIDE respite eligibility may vary depending on your plan. Respite services for patients with UCLA Medical Group- Medicare Advantage plans will be provided by Carelinx.
Patients with commercial plans or who are insured by Medicare Part A&B but are not eligible for GUIDE Model participation are not eligible for GUIDE respite services.
What if I run out of the respite fund before the end of the year? Will the UCLA ADC program cover additional respite costs?
No, if your respite funds run out before the end of the year, you are responsible for the costs of additional respite care. If appropriate, the UCLA ADC program team can provide recommendations on receiving these services, including qualifying for other benefits.
Respite services depend on your insurance coverage. If your insurance changes, this benefit may be reduced or no longer available. If a respite service is not covered by your insurance, the patient will be responsible for paying those costs. In addition, if you use more respite services than the amount approved, the patient will be responsible for any extra costs.
External Referring Providers
If you are a referring provider outside of UCLA Health, please find linked below additional information on eligibility requirements and required information to refer your patient to the ADC Program. Referral information can be faxed to 424-483-5850.