The Dementia Care Management Payment, or DCMP, is GUIDE's monthly, per-patient payment. It replaces fee-for-service billing for a set of care management services, and it is paid at one of six tiers, each with its own billing code. For performance year 2026, base rates run from $68 to $409 a month, and they are higher during a patient's first six months of alignment. CMS then adjusts the base rate for geography and cost growth, and for performance and patient community and income. Participants bill with GUIDE-specific G-codes on a standalone claim.
This guide walks through what the payment covers, how tiers and rates work, how the adjustments apply and how to bill without avoidable denials. Everything below comes from CMS's GUIDE Payment Methodology Paper, version 3.0, effective June 1, 2026. Rates change each performance year, so confirm the current figures at CMS before you budget.
What Does the DCMP Cover?
According to the payment paper, the DCMP is the primary payment in GUIDE. It pays per patient per month, in place of billing traditional codes for covered services. Those include annual wellness visits, chronic and principal care management, transitional care management, advance care planning and technology-based check-ins. CMS lists the full set of replaced codes in the paper, and it may change the list as the Physician Fee Schedule changes.
Two rules follow from that:
You can't bill replaced services separately for aligned patients. CMS treats those claims as duplicative and rejects them. If a duplicate is paid, CMS may recoup it from a future Medicare payment.
You can still bill other services. Services not on the list, and not part of the required care delivery elements, remain billable under fee-for-service.
The DCMP covers all comprehensive assessments, including the initial, annual and any necessary reassessments. Respite is paid separately.
The Six Tiers
CMS assigns each aligned patient to one of six tiers based on disease stage, residence type, and whether the patient has a caregiver and how much strain that caregiver reports. The tier sets the base rate and decides whether the patient can use GUIDE respite. As of July 1, 2026, the tiers are:
Low complexity dyad tier: mild dementia, with a caregiver.
Moderate complexity dyad tier: moderate or severe dementia, with a caregiver reporting low to moderate strain (ZBI-22 score of 0 to 60).
High complexity dyad tier: moderate or severe dementia, with a caregiver reporting high strain (ZBI-22 score of 61 to 88).
Low complexity individual tier: mild dementia, no caregiver.
Moderate to high complexity individual tier: moderate or severe dementia, no caregiver.
Residential care community (RCC) tier: any stage of dementia, in an approved residential care community, whatever the caregiver status.
Only the moderate and high complexity dyad tiers are eligible for GUIDE respite. Patients in the RCC tier aren't. CMS uses the Clinical Dementia Rating or the Functional Assessment Staging Tool for dementia stage, and the Zarit Burden Interview for caregiver strain.
PY 2026 Base Rates
The payment paper's base rates for performance year 2026, which runs from July 2026 to June 2027, are below. Each rate has its own G-code.
First six months of alignment (new patient rate):
Low complexity dyad: $157 (G0519)
Moderate complexity dyad: $288 (G0520)
High complexity dyad: $377 (G0521)
Low complexity individual: $241 (G0522)
Moderate to high complexity individual: $409 (G0523)
RCC tier: $180 (G0574)
After the first six months (established patient rate):
Low complexity dyad: $68 (G0524)
Moderate complexity dyad: $126 (G0525)
High complexity dyad: $231 (G0526)
Low complexity individual: $126 (G0527)
Moderate to high complexity individual: $225 (G0528)
RCC tier: $70 (G0575)
CMS applied the Medicare Economic Index to the PY 2025 base amounts, a 2.2 percent increase, to set these PY 2026 rates. Notice that patients without a caregiver generally carry higher rates than patients with one at a similar stage, though not in every comparison. CMS's earlier request for applications explained that patients without a caregiver are expected to have more intensive needs, and that tiers without a caregiver don't include payment for caregiver education and support.
New Patient vs Established Patient Rates
Each patient's six-month clock starts in the first month of alignment, even if that month is partial, and it ends on the last day of the sixth month. CMS's example: if a patient in the low complexity dyad tier aligns on July 15, the participant bills G0519 from July through December and G0524 beginning January 1.
The higher rate reflects the workload at the start, including the comprehensive assessment, the home visit and setting up the care plan.
How Adjustments Work
The base rate isn't the final payment. According to the payment paper, CMS adjusts each DCMP in several ways:
Cost growth. CMS updates base rates using the Medicare Economic Index at the start of each performance year. The change applies for the whole year.
Geography. CMS applies the Medicare Physician Fee Schedule Geographic Adjustment Factor, based on the service facility zip code on the claim. When a service takes place at the patient's home, the location is the patient's home, so one participant can face different adjustments across localities.
Performance. The performance-based adjustment applies at the participant level, so the same percentage applies to every aligned patient. CMS applies it each January for 12 months. The total ranges from -3.5 percent to +10 percent once all five measures are in place.
Population and income. The Population and Income Adjustment is a fixed dollar amount, from -$6 to +$15, applied at the patient level. Our guide to health equity in value-based dementia care explains how it works.
Sequestration and other policies. Unless CMS says otherwise, DCMP claims are subject to other adjustments that apply to Medicare fee-for-service claims, such as sequestration.
CMS says that, after all adjustments, a DCMP base rate could receive at most a +75 percent adjustment, or 1.75 times the base rate. It advises participants to build potential adjustments into their charge amounts, since CMS pays the lesser of the participant's charge and the allowed amount.
The Performance Adjustment Payment Quirk
Medicare's fee-for-service system currently processes only whole-number percentage adjustments on claims. If a participant's performance-based adjustment includes a decimal, such as 2.5 percent, the claim carries the whole-number portion, and CMS pays the decimal portion through the Innovation Payment Contractor portal. Participants should verify their banking information in that portal.
What Patients Pay
Nothing extra. GUIDE waives the usual 20 percent coinsurance for the DCMP, and Medicare pays 100 percent of the DCMP amount. The payment paper says participants shall not subject aligned patients to additional cost sharing for the DCMP or GUIDE respite services.
How to Bill the DCMP
Wait for confirmation. Don't bill the first month until the patient appears as aligned in the Beneficiary Alignment Report. A preliminary determination is useful for care planning but isn't a signal to bill.
Find the right code. The Beneficiary Alignment Report shows each patient's tier and matching G-code. CMS updates it twice a month.
Bill each month you provide a service. Bill the code for each month in which the participant provides a GUIDE care delivery service.
Use a standalone claim. Bill GUIDE G-codes on their own claim with no other HCPCS codes, using the CMS-1500 form. You can bill more than one GUIDE code, and more than one month, on the same claim.
Include the required details. The claim needs the G-code, the date of service, your GUIDE TIN and rendering NPI, the patient's Medicare number, at least one eligible dementia ICD-10 code and the servicing location.
CMS explains the date of service: it is the earliest day of the calendar month in which the participant or partner provided a care delivery service. For the first month, it is the alignment date, which is the date of the initial comprehensive assessment. The rendering NPI must be on the practitioner roster, and the date of service must fall within the practitioner's and the patient's effective dates. Claims that fail these checks may be denied or returned, which delays payment. Billing the wrong G-code for a patient's tier is one example CMS gives.
When You Can't Bill
No service that month. Don't bill for any month in which no GUIDE care delivery service was provided to that patient.
Only infrastructure. Don't bill if all you did was maintain the capacity to deliver a service, such as running a 24/7 helpline or developing caregiver trainings.
A missed touchpoint. CMS's contact minimums vary by tier, from quarterly for the low complexity dyad tier to twice a month for the moderate to high complexity individual tier. If you miss one, you can't bill the DCMP for that patient until you complete it.
After unalignment. Claims with dates of service on or after the alignment end date are rejected.
For replaced codes. See above.
Touchpoints don't have to be clinical encounters. CMS says they can include ongoing contact and support, transitional care management and medication management, and they are always billable each month.
Tier Changes, Reassessments and Unalignment
Reassessments. A reassessment is needed when residence type, dementia stage, or caregiver status or burden changes. CMS accepts reassessment data every 30 days for a change in residence type and every 180 days for a change in dementia severity or caregiver status or burden. When CMS assigns a new tier, you use the new code beginning the month after the assignment.
Annual assessments. They must be completed between 306 and 425 days after the previous comprehensive assessment.
Unalignment. In general, the alignment end date is the last day of the calendar month in which unalignment occurred. CMS doesn't prorate the DCMP for partial months. If a patient joins Medicare Advantage or PACE, or dies, the end date is the day before coverage begins or the date of death. CMS also unaligns patients for whom no DCMP or respite claim is filed for eight consecutive months.
A CMS Billing Example
CMS's own example follows a patient in the low complexity dyad tier who aligns on July 15, 2026. The participant provides care in July, August, September, November and December, and doesn't bill in October because no service was provided. In January 2027 the patient moves to the established rate. The base amounts total $853: five months at $157 and one month at $68. CMS notes these are base rates and that actual payments include the adjustments above.
A Practical Checklist
Reconcile against the Beneficiary Alignment Report every month. Confirm tier, G-code and alignment dates.
Track touchpoints by tier. Log each one so you can show compliance.
Check the roster. Make sure every rendering NPI is listed and current.
Include a dementia ICD-10 code on every claim. Use the codes CMS lists.
Review the monthly payment report. Compare actual and expected payments, including the respite cap balance.
Set charge amounts with adjustments in mind.
Watch for updates. CMS updates rates each performance year.
Where Elli Cares Fits
Billing depends on documenting that a real service happened each month. Elli Cares gives care teams a clinician dashboard, AI-generated summaries, daily wellbeing check-ins and family observations, which can help a navigator see who is due for contact. Elli doesn't bill, submit claims or replace your billing and compliance processes, and it doesn't guarantee that any contact meets CMS's requirements. You can read more on our GUIDE page.
Frequently Asked Questions
What is the GUIDE Dementia Care Management Payment?
A per-patient, per-month payment that replaces fee-for-service billing for services such as chronic care management, transitional care management and advance care planning. Participants bill it with GUIDE-specific G-codes.
How much does GUIDE pay per month?
For performance year 2026, base rates run from $68 to $409 a month depending on tier and how long the patient has been aligned. CMS then adjusts them for cost growth, geography, performance and patient community and income.
Why are the first six months paid at a higher rate?
CMS says the higher rate reflects the intensity of early activities such as the comprehensive assessment, home visit and care plan set-up.
Can I bill fee-for-service codes for aligned patients?
Not for services the DCMP replaces. CMS rejects duplicate claims and can recoup payments. Services not on the list stay billable under fee-for-service.
Do patients pay coinsurance on the DCMP?
No. GUIDE waives the 20 percent coinsurance, and participants can't add other cost sharing.
