Patient Eligibility for GUIDE

To qualify for GUIDE patients must:

1. Have a dementia diagnosis, defined as one of the ICD-10 code from the CMS approved list for this program;

2. Have Traditional Medicare (Part B) not Medicare Advantage as their primary payer;

   As of August, CMS dropped the FAST score threshold, and now any FAST score qualifies (prior to that, CMS was requiring a FAST score of 4 or higher).

Exclusions

Patients are excluded from GUIDE if they meet any of these criteria:

1. Enrolled in Medicare Advantage, including Special Needs Plans (SNPs);

2. Enrolled in the Program of All-Inclusive Care for the Elderly (PACE);

3. Has elected the Medicare hospice benefit;

4. Is a long-term nursing home resident (more details below)

Nursing Home Residents

For the purposes of GUIDE, CMS defines a nursing home resident as someone:

'having a nursing home stay 101 days or longer that is not covered under the Medicare skilled nursing facility benefit'.

GUIDE allows alignment of patients in a residential care community (RCC). They define this as:

'a residential facility staffed to provide comprehensive care services and supports, including assistance with activities of daily living, medication management, and supervision, to adults who cannot live independently but do not require intensive nursing care. Examples may include an assisted living facility or memory care program (excludes nursing home level of care) that create or maintain the individual’s ability to safely live in the community.'