GUIDE, PACE and Medicare Advantage are three different ways a person with dementia can get coordinated care through Medicare. GUIDE is a payment model built for people with dementia who have Original Medicare and live in the community. PACE is a comprehensive program for people 55 and older who need a nursing home level of care but can live safely at home. Medicare Advantage is a private health plan that replaces Original Medicare.
They are not interchangeable, and in most cases a person can't be in more than one. This guide compares how each works, who is eligible and who pays, then sets out the questions that help match a patient to a model. It is written for provider teams, referrers and program leads. Coverage decisions for an individual belong to that person, their family and the program or plan involved.
The Three Models at a Glance
GUIDE (Guiding an Improved Dementia Experience). A CMS Innovation Center model that runs for eight years, from July 2024. Participating providers offer care coordination, care navigation, caregiver education and support, and respite for eligible patients. It sits on top of Original Medicare.
PACE (Program of All-inclusive Care for the Elderly). A Medicare and Medicaid program that gives eligible older adults comprehensive medical and social services through an interdisciplinary team, so they can stay in the community instead of moving to a nursing home.
Medicare Advantage (Part C). According to Medicare.gov, a Medicare-approved plan from a private company that offers an alternative to Original Medicare. These bundled plans include Part A, Part B and usually Part D, and they may offer extra benefits Original Medicare doesn't.
Who Is Eligible?
GUIDE. A patient must have a dementia diagnosis, live in the community, and be enrolled in Original Medicare Parts A and B, including people who also have Medicaid. People in Medicare Advantage or PACE, people in a long-term nursing home stay and people receiving the Medicare hospice benefit are not eligible. Community includes a personal home, assisted living and other community settings.
PACE. According to Medicare.gov, a person must be at least 55, live in the service area of a PACE organization, need a nursing home level of care as certified by the state, and be able to live safely in the community with help from PACE. PACE is not dementia-specific. It serves frail older adults who meet those criteria.
Medicare Advantage. Members must have Medicare Parts A and B and live in the plan's service area. Dementia is not a criterion.
How Care Is Delivered
GUIDE. The participant's interdisciplinary care team includes a care navigator and a clinician with dementia proficiency. Participants must offer 24/7 access to a care team member or help line, caregiver training and support, and connections to community resources. Aligned patients keep their freedom of choice about who provides their clinical services.
PACE. A coordinated interdisciplinary team plans and delivers care, and the team meets regularly with each participant and their representative. Medicaid.gov says PACE becomes the sole source of services for enrolled participants, and it covers all Medicare- and Medicaid-covered care plus anything else the team decides the person needs, including prescription drugs. A care plan usually combines home care with visits to a PACE center.
Medicare Advantage. The plan arranges care through its network of doctors, hospitals and other providers. According to Medicare.gov, in many cases people can use only providers in the plan's network and service area, and some services need the plan's approval first. Care management and extra benefits vary by plan.
How Each Model Is Paid
GUIDE. Participants receive a monthly, per-patient Dementia Care Management Payment on top of fee-for-service Medicare, plus a separate payment for respite. CMS adjusts the monthly payment up or down based on performance on five measures. Participants may not charge aligned patients for GUIDE services.
PACE. Financing is capped, according to Medicaid.gov, which allows PACE providers to deliver all the services a participant needs rather than only those reimbursable under fee-for-service Medicare and Medicaid.
Medicare Advantage. Medicare pays the plan a fixed amount each month for a member's coverage, according to CMS's guide to Medicare Advantage. Payment is risk-adjusted, so it reflects the expected costs of each enrollee.
What the Patient Pays
GUIDE. Nothing for GUIDE services. Regular Original Medicare cost-sharing still applies to other covered care.
PACE. Medicare.gov says people with Medicaid pay no monthly premium. People with Medicare but not Medicaid pay a monthly premium for the long-term care part of the benefit and a premium for Part D drugs. There is no deductible, copayment or coinsurance for any drug, service or care the PACE team approves.
Medicare Advantage. Premiums, deductibles, copays and coinsurance vary by plan, and plans have an annual out-of-pocket maximum.
Which Model Fits Which Patient? Five Questions
These questions help sort a case. They don't replace advice from a benefits counselor or the program itself.
1. How does the person get Medicare today? If they have Original Medicare, GUIDE is a possibility. If they are in a Medicare Advantage plan, they can't be aligned to a GUIDE participant, and they need to look at what the plan offers.
2. Does the person need a nursing home level of care but still live safely at home? If a state certifies the need and a PACE organization serves their area, PACE may fit. Because PACE becomes the sole source of a participant's Medicare and Medicaid services, joining changes how they get all their care.
3. Is the person in the community with a caregiver and an existing doctor they want to keep? GUIDE is designed for that situation. The person keeps their choice of providers, and the caregiver receives training, support and, for patients in the moderate and high complexity tiers, respite.
4. Does the person have both Medicare and Medicaid? Dually eligible people can be aligned to GUIDE if they have Original Medicare. Medicaid.gov notes that most PACE participants are dually eligible, so PACE is worth exploring too.
5. Where does the person live? Someone in a long-term nursing home stay can't be aligned to GUIDE. PACE requires the ability to live safely in the community when enrolling, and it is only available in the service area of a PACE organization.
Four Illustrative Situations
These are hypothetical examples, not real patients or advice.
A 74-year-old with Original Medicare, early dementia, living at home with a spouse, who wants to keep their doctor. GUIDE fits if a participating provider is nearby. The spouse would gain a care navigator, caregiver training and possibly respite as needs grow.
An 82-year-old who needs help with most daily activities, has Medicare and Medicaid, and has a PACE center in their county. If the state certifies nursing home level of care and they can live safely at home with support, PACE is worth a serious look.
A 70-year-old with dementia enrolled in a Medicare Advantage plan. GUIDE isn't available while they remain in the plan. The family should ask the plan what care management and caregiver support it offers, and whether their doctors are in the network.
A 79-year-old in a long-term nursing home stay. GUIDE isn't an option, and PACE requires living safely in the community at enrollment, so the family would need to look at other supports.
Questions to Ask Before Choosing
The North Dakota Insurance Department suggests several questions for anyone considering Medicare Advantage. They apply well to dementia:
Do my doctors and hospitals accept the plan's terms?
Do I need a referral to see a specialist?
What costs are involved?
Can I afford the annual out-of-pocket limit?
For PACE, ask whether a PACE organization serves the person's address and whether a PACE center is realistic to reach. For GUIDE, ask whether a participating provider is available nearby. CMS's GUIDE page is the place to start.
Where Elli Cares Fits
Whichever model a patient is in, the care team faces the same challenge between visits: knowing who needs attention now. Elli Cares gives care teams a clinician dashboard, AI-generated summaries, daily wellbeing check-ins and family observations so they can see who may need earlier outreach. Elli doesn't determine eligibility, enroll anyone in a program or plan, or replace the care a program provides. You can read more on our Value-Based Care page and our GUIDE page.
Frequently Asked Questions
What is the difference between GUIDE and PACE?
GUIDE is a payment model for people with dementia who have Original Medicare and live in the community, and it adds care coordination and caregiver support to their existing care. PACE is a program for people 55 and older who need a nursing home level of care but can live safely at home, and it becomes the sole source of their Medicare and Medicaid services.
Can someone in Medicare Advantage join GUIDE?
No. CMS excludes Medicare Advantage enrollees, and PACE enrollees, from alignment to a GUIDE participant.
Does PACE serve people with dementia?
PACE serves eligible older adults who need a nursing home level of care, and it is not limited to dementia. A person with dementia can qualify if they meet the age, service area, state certification and safety criteria.
Does GUIDE change a patient's Medicare coverage?
No. GUIDE is a payment model within Original Medicare. Aligned patients keep their freedom of choice about who provides their clinical services, and they aren't charged for GUIDE services.
Who decides which model is right?
The person and their family decide, with the relevant program or plan. Medicare.gov and State Health Insurance Assistance Programs can help with individual coverage questions.
