GUIDE adds or subtracts a small fixed dollar amount from each aligned patient's monthly payment based on a Population and Income Adjustment, known as the PIA. Patients whose scores fall in the top 20 percent add $15 a month, patients in the middle range add nothing, and patients in the bottom 50 percent subtract $6. The score combines how deprived a patient's community is with whether the patient receives the Medicare Part D Low-Income Subsidy or is dually eligible for Medicare and Medicaid. CMS designed it to be budget neutral.
CMS's early materials called this the health equity adjustment. This guide explains how the current adjustment works, why CMS built it, and what it means for a dementia program. It is written for GUIDE program leads and finance teams, and for anyone comparing how value-based models handle equity.
Why Add an Equity Adjustment?
Payment models that reward cost and quality outcomes can penalize organizations that serve patients with fewer resources. CMS's request for applications documents why this matters in dementia care. It notes that Black and Hispanic populations have a higher prevalence of dementia, are less likely to receive a timely diagnosis, have more unmet needs, are more likely to face high caregiving demands, and spend a larger share of family assets on dementia care.
The request for applications says the adjustment is meant to give participants an incentive to deliver care to beneficiaries from underserved communities. In its original design, it would raise the monthly payment for low-income patients from underserved communities and lower it for higher-income patients from more advantaged ones.
What Is the Population and Income Adjustment?
According to CMS's Payment Methodology Paper, version 3.0, effective June 1, 2026, the PIA is an adjustment to each aligned patient's base Dementia Care Management Payment. Three features define it:
It is a fixed dollar amount. It isn't a percentage of the payment.
It applies at the patient level. Two patients in the same practice can have different adjustments, so adjusted payments vary by patient.
It is based on the patient's PIA score percentile. CMS ranks aligned patients by score.
CMS notes that the design gives participants a material incentive to care for particular patients and is budget neutral, while limiting the size of any downward adjustments.
How the Score Is Calculated
The PIA combines one community-level measure and two patient-level measures. CMS calculates the score for every aligned patient with this formula from the Payment Methodology Paper:
PIA score = (0.1 × CDI percentile) + (10 × LIS or dual eligibility)
CDI is the Community Deprivation Index percentile, from 1 to 100, for the census block group where the patient lived on their first day of eligibility. CMS says the index correlates strongly with several health outcome and utilization measures, uses statistical shrinkage to account for imprecise measurement, and reweights its factors using recent data.
LIS or DE equals 1 if the patient is enrolled in the Medicare Part D Low-Income Subsidy program or is dually eligible for Medicare and Medicaid, and 0 otherwise. CMS counts either one, and the request for applications explains that the aim is to increase access whether a patient has full or partial dual status.
Scores range from 0 to 20. At the maximum, CDI contributes half and low-income status contributes the other half.
As an illustration, using only the formula: a dually eligible patient living in a block group at the 90th percentile of deprivation would score 19, while a patient with neither LIS nor dual status living in a block group at the 30th percentile would score 3. Where each falls in the ranking depends on everyone else in the aligned population.
CMS's earlier materials used a different community measure. A footnote in the Payment Methodology Paper says the previously published methodology used the Area Deprivation Index instead of the CDI, and that CMS may keep updating the measures.
How the Score Becomes Dollars
CMS ranks aligned patients by score and assigns an adjustment based on percentile:
80th percentile or higher: +$15 per month
51st to 79th percentile: $0
0 to 50th percentile: -$6 per month
The numbers roughly balance. The top 20 percent of patients receiving $15 comes to an average of $3 per patient, and the bottom 50 percent losing $6 also comes to $3 per patient, which is consistent with CMS's budget-neutral design. Budget neutral means the adjustment nets to about zero across the model. It doesn't mean it nets to zero for every participant.
For scale, PY 2026 base rates in the Payment Methodology Paper run from $68 to $409 a month, depending on tier and time since alignment. A $15 adjustment on a $126 established-patient rate is roughly 12 percent, and a $6 reduction on the same rate is about 5 percent. The PIA is applied alongside other adjustments to the base rate, including geography and, at the participant level, the performance-based adjustment.
When It Applies
Established Program Track: CMS began applying the PIA on July 1, 2025.
New Program Track: CMS begins applying it on July 1, 2026.
Both tracks from July 2026: percentiles are based on all aligned patients in both tracks in the prior year.
CMS recalculates scores and percentiles each year before the performance year starts, and it applies a patient's adjustment for the whole year. It also applies the adjustment when a patient aligns to an established track participant during the year.
What the PIA Isn't
It isn't a performance adjustment. The performance-based adjustment depends on how you do on five measures and applies at the participant level. The PIA depends on who your patients are and applies at the patient level.
It isn't your whole equity strategy. GUIDE also requires participants to develop and implement a Health Equity Plan that identifies disparities in outcomes in their patient populations and strategies to reduce them. Participants also have to collect and report sociodemographic and health-related social needs data, though patients can opt out of sharing.
It isn't fixed. CMS has already replaced one community measure with another, and it says it may add other measures to the PIA in future years.
What This Means for Dementia Programs
Expect variation by patient. Your payment mix will reflect your panel's income and community profile, so forecast with the distribution in mind and not a single number.
Use the plan, not just the payment. An adjustment of $15 a month doesn't pay for an outreach worker or a translator. Use your Health Equity Plan to decide where to invest, and track outcomes by group.
Watch the patient-level payment report. CMS provides a monthly payment report, so compare actual and expected payments and check that adjustments look right.
Track changes. CMS updates its methodology paper and can change the measures behind the score.
Be careful with claims. Don't describe the PIA as reimbursement for a specific service or as proof of equity outcomes. It is a payment adjustment.
Where Elli Cares Fits
Equity work depends on hearing from the families a program serves, including those who are hardest to reach. Elli Cares gives care teams a clinician dashboard, AI-generated summaries, daily wellbeing check-ins and family observations, so a care navigator can see who may need earlier outreach. Elli doesn't calculate or influence the PIA, doesn't replace a Health Equity Plan and doesn't guarantee equity outcomes. You can read more on our GUIDE page.
Frequently Asked Questions
What is the GUIDE Population and Income Adjustment?
A fixed dollar adjustment to each aligned patient's monthly Dementia Care Management Payment. It is based on the patient's percentile rank on a score combining community deprivation with Part D Low-Income Subsidy or dual eligibility status.
How much is the adjustment?
According to CMS's Payment Methodology Paper, patients at or above the 80th percentile add $15 a month, patients at the 51st to 79th percentile add $0, and patients in the bottom 50 percent subtract $6.
Is the PIA the same as the health equity adjustment?
It replaces the earlier name. CMS's original materials described a health equity adjustment with the same dollar amounts, based on the Area Deprivation Index. The current methodology uses the Community Deprivation Index.
Does the PIA apply to every patient?
Yes, CMS calculates a score and applies an adjustment for every aligned patient, though the amount is $0 for patients in the middle range.
Is the adjustment budget neutral?
That is CMS's design. The amounts roughly offset across the aligned population, but an individual participant can come out ahead or behind depending on its patient mix.
