Every GUIDE participant must maintain an interdisciplinary care team that includes, at a minimum, a care navigator and a clinician with dementia proficiency who can bill Medicare Part B evaluation and management services. Participants must also make sure every aligned patient has 24/7 access to a care team member or a help line, and that the help line can take one-on-one support calls from caregivers. CMS treats these as core care delivery requirements, and the payment rules make it clear that having the structure isn't enough. The team has to deliver the service.
This guide sets out who has to be on the team, how the care navigator training works, the contact frequencies CMS sets, what the 24/7 requirement means in practice, and how partners fit in. It is written for GUIDE program leads and clinical directors. The requirements below come from CMS's request for applications and its June 2026 payment paper, and the Participation Agreement that participants sign sets the binding terms.
The Minimum Care Team
According to CMS's request for applications, the interdisciplinary care team must include two roles at a minimum:
A care navigator.
A clinician with dementia proficiency who is eligible to bill Medicare Part B evaluation and management services, such as a physician, nurse practitioner, physician assistant or clinical nurse specialist.
Participants may add other members, such as a pharmacist or a behavioral health specialist. CMS's payment methodology paper adds that the dementia-proficient clinician must be listed on the participant's GUIDE Practitioner Roster and approved by CMS. Only rostered practitioners can bill GUIDE codes, and that applies to partner organizations that have been approved as well.
What Counts as Dementia Proficiency?
A clinician qualifies if they meet at least one of these criteria, according to the request for applications:
They attest that at some time in the past five years, at least 25 percent of their patient panel, regardless of payer, was adults with any cognitive impairment, including dementia.
They attest that at least 25 percent of their panel in the past five years was adults age 65 or older.
They hold a specialty designation in neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology or geriatric neurology.
If the dementia-proficient clinician isn't a physician, the request for applications says the participant must also have a part-time medical director who is a physician to oversee the quality of the dementia care program.
The Care Navigator Role
The care navigator is the primary point of contact for the patient and caregiver, according to the request for applications. CMS doesn't require a particular professional background or certification, though it says registered nurses, licensed clinical social workers and community health workers would all be well suited. It does require that the care navigator be an individual and not artificial intelligence.
Care Navigator Training
CMS requires participants to deliver a one-time training when a care navigator joins the team, regardless of their background. The request for applications sets these minimums:
20 hours in total, with at least 10 hours of didactic instruction, live or web-based, and at least 10 hours of experiential training that must be live, such as job shadowing, supervised interactions with patients, case studies or on-the-job training
A comprehension assessment that the participant develops for navigators to take after the training
2 additional hours every year, which the participant can develop or buy from a third party as continuing education
The curriculum must cover 13 topics: background on dementia; overview of assessments; care plan; person-centered planning; challenging behaviors; functional needs; advance care planning; decision-making capacity; safety; communication; coordination of medical care and community services; supporting a caregiver; and diversity in dementia.
Participants may combine existing training programs to meet the requirement, and staff who took training on a required topic in the past five years and stayed with the program don't have to retake it.
CMS supports participants with webinars, affinity groups and written materials, according to the request for applications.
How Often the Team Must Be in Touch
The request for applications sets minimum contact frequencies by model tier. CMS's payment paper repeats them and adds a tier for residential care communities:
Low complexity dyad tier (patient with a caregiver): at least quarterly
Moderate and high complexity dyad tiers: at least once a month
Low complexity individual tier (no caregiver): at least once a month
Moderate to high complexity individual tier: at least twice a month
Residential care community tier: at least bimonthly
The payment paper says these contacts need not be clinical encounters. They can be ongoing contact and support, transitional care management and medication management, and they are always billable each month under the monthly payment. Participants that miss a required touchpoint can't bill the payment for any care delivery service for that patient until the touchpoint is done.
The 24/7 Access Requirement
The request for applications states the requirement plainly: the patient has 24/7 access to an interdisciplinary care team member or a help line. Three details matter:
Outside vendors are allowed after hours. The help line may be a third-party vendor during off-duty hours.
Caregivers must be able to call. The help line must be available to receive ad hoc one-on-one support calls from the caregiver.
It is part of the caregiver package. CMS's model overview lists ongoing monitoring and 24/7 access to a support line as caregiver services.
CMS's performance measurement manual explains why the requirement matters. In its appendix linking care delivery to performance measures, CMS says 24/7 access supports timely identification of potential crises, which can reduce avoidable acute care use, and that it strengthens support for patients and caregivers. It says participants should routinely assess whether access is sufficient and responsive to caregiver needs. CMS lists it as a driver of both the caregiver-reported measure and the total per-capita cost measure, and describes the appendix as a supportive reference and not a formal protocol.
The Billing Rule Behind It
The payment paper spells out that infrastructure alone doesn't earn payment. Participants may not bill the monthly payment for an aligned patient if they only maintained the infrastructure to deliver a service, such as providing access to a 24/7 helpline or developing caregiver trainings. A participant must not bill for any month in which no GUIDE care delivery service was provided to that patient.
Using Partner Organizations
Participants can contract with other organizations to meet the requirements. The request for applications calls them partner organizations, and they can be Medicare-enrolled or not, including community-based organizations. The payment paper adds that:
CMS must review and approve partner organizations, including program integrity screening, before they provide services under GUIDE.
Participants must have contracts in place to pay partners and to make sure services meet model requirements.
CMS doesn't pay partner organizations directly.
CMS's partnership fact sheet gives an example of a family geriatrics practice that provides six of the nine care delivery requirements itself and contracts with a local health system for 24/7 access. Other examples show a national organization providing caregiver education and support.
Other Care Team Requirements
A few other requirements apply to the team, according to the request for applications:
Medication management. A clinician with prescribing authority must review each patient's medications, and any changes must be shared and confirmed with the patient's primary care provider and relevant specialists.
Primary care coordination. If the participant isn't a primary care practice, it must coordinate with the patient's primary care provider and make sure that provider can see the care plan.
Certified health record technology. Participants must use an electronic health record platform that meets CMS and ONC standards for certified technology.
A Practical Checklist
Keep the practitioner roster current. Confirm the dementia-proficient clinician is listed and approved.
Document navigator training. Record hours, topics, the live experiential component and the comprehension assessment for every navigator.
Schedule the annual 2 hours. Put them on the calendar for each navigator.
Track contact by tier. Know each patient's minimum contact frequency and log every touchpoint.
Test the 24/7 line. Place test calls at night and on weekends, and check who answers, how the call is handled and how it reaches a clinician when needed.
Brief any after-hours vendor. Give the vendor your care plan format, escalation rules and a way to see recent contacts.
Tell caregivers how to use it. A line nobody knows about isn't access.
Check partner approvals. Don't let a partner deliver services until CMS has approved them.
Bill only for delivered services. Don't bill for a month in which no care delivery service took place.
Where Elli Cares Fits
CMS requires the care navigator to be a person, and Elli Cares isn't one. It doesn't replace a navigator, a clinician or your 24/7 line, and it doesn't provide emergency monitoring. What it gives care teams is a clinician dashboard, AI-generated summaries, daily wellbeing check-ins, medication reminders and family observations, so a navigator can see who may need earlier outreach between required contacts. You can read more on our GUIDE page.
Frequently Asked Questions
Who must be on a GUIDE care team?
At a minimum, a care navigator and a clinician with dementia proficiency who is eligible to bill Medicare Part B evaluation and management services. The clinician must be on the practitioner roster and approved by CMS.
What is dementia proficiency in GUIDE?
A clinician meets it by attesting that at least 25 percent of their panel in the past five years was adults with cognitive impairment or adults 65 and older, or by holding a specialty designation such as neurology, psychiatry or geriatrics.
How much training does a GUIDE care navigator need?
A one-time training of at least 20 hours, with at least 10 hours of didactic instruction and 10 hours of live experiential training, plus 2 hours of additional training each year, according to CMS's request for applications.
Can a vendor provide the 24/7 line?
Yes, during off-duty hours. The help line must be able to take ad hoc one-on-one support calls from caregivers.
Can AI serve as a care navigator?
No. CMS says the care navigator must be an individual and not artificial intelligence.
