A patient can be aligned to a GUIDE participant if they have a dementia diagnosis, live in the community and are covered by Original Medicare. People enrolled in Medicare Advantage or PACE, people in a long-term nursing home stay and people receiving the Medicare hospice benefit are not eligible.
This guide covers the details that program leads and care navigators ask about most: what "community" includes, how dual-eligible patients are treated, how alignment works in practice, and why eligibility affects your performance results.
The Short Version: Who Is Eligible?
According to CMS's GUIDE Performance Measurement Manual and the LeadingAge summary of the model design, an aligned patient:
Has been diagnosed with dementia, confirmed by a clinician practicing with a participating GUIDE dementia program
Lives in the community
Is enrolled in Original Medicare Parts A and B, including people covered by both Original Medicare and Medicaid
Is not enrolled in Medicare Advantage or PACE
Is not receiving the Medicare hospice benefit
The manual's own eligibility screen, which CMS uses to build the comparison group for its claims-based measures, adds two conditions that follow the same logic. Medicare must be the primary payer, and the patient must not be in a long-term nursing home stay, which the manual defines as 101 days or more. CMS applies that screen month by month, so a change in coverage or setting can change whether someone counts.
What Counts as "Community-Dwelling"?
CMS defines community-dwelling broadly. A patient lives in the community if they are in a personal home, an assisted living facility, a group home or another community setting. LeadingAge adds that affordable housing and independent living residences count too.
A hospital admission doesn't change the picture. According to CMS's request for applications, a patient is still considered community-dwelling if they are admitted to an acute care hospital or receive post-acute care in a facility.
The distinction that matters is the nursing home. A person who lives in a nursing home long term can't be aligned.
Why Medicare Advantage and PACE Patients Are Excluded
GUIDE is a model within Original Medicare. The manual states that patients enrolled in Medicare Advantage are not eligible for alignment, and the manual's eligibility screen excludes PACE enrollees as well. LeadingAge notes that this includes Medicare Advantage special needs plans.
This has a practical consequence for referral workflows. Before you spend time on an assessment, confirm how the patient gets their Medicare coverage. A patient who looks like a strong fit clinically, with a clear dementia diagnosis and an engaged caregiver, still can't be aligned if they are in a Medicare Advantage plan.
Patients who have both Original Medicare and Medicaid are eligible. CMS specifically includes them.
How Alignment Works
Alignment is voluntary. The manual describes a process in which patients are told about the GUIDE Model and then complete an initial comprehensive assessment.
That assessment is a required, multi-domain clinical evaluation. CMS uses it to assign the patient to a model tier based on dementia complexity, caregiver status and residence type. It also informs the care plan and the performance measures.
Some points worth knowing:
Patients keep their choice of doctors. CMS says aligned patients maintain freedom of choice about who provides their clinical services.
Patients pay nothing for GUIDE services. According to CMS's FAQ, participants aren't permitted to charge aligned patients for GUIDE services, including respite.
Caregivers are named. The Patient Assessment and Alignment Form (PAAF) lists the caregiver by name, and CMS defines a caregiver as a relative or unpaid nonrelative who helps with daily activities.
Assessments repeat. Follow-up comprehensive assessments happen annually. A reassessment is also required when something changes that could affect the tier, such as the dementia stage, the caregiver's status or burden, or where the patient lives.
CMS also sends each participant a monthly beneficiary alignment file listing every aligned patient, their tier assignment and how long they've been aligned. That file is the reference to check when you aren't sure who counts.
Why Eligibility Affects Your Performance Results
Eligibility isn't only an enrollment question. It decides which patients feed your performance measures.
CMS only scores a measure if you meet a minimum case count, which is 20 eligible patients for most measures. Some measures also require patients to have been aligned for a minimum period, such as 90 days for the medication and nursing home measures. A patient who doesn't qualify, or who leaves the model early, may not count toward those totals.
For programs still building a panel, that makes accurate eligibility checks worth the effort. The measures, and how they translate into payment, are covered in our guide to the GUIDE performance-based adjustment.
Where Elli Cares Fits
Eligibility is set by CMS's criteria and your clinicians, and technology doesn't change it. Once patients are aligned, the work is staying in touch between assessments. Elli Cares gives care teams a clinician dashboard, daily wellbeing check-ins, medication reminders and family observations, so a care navigator can see who may need outreach before the next scheduled contact. Elli doesn't determine eligibility or submit any CMS reporting. You can read more on our GUIDE page.
Frequently Asked Questions
Can someone with Medicare Advantage be aligned to a GUIDE participant?
No. According to CMS, patients enrolled in Medicare Advantage are not eligible for alignment. PACE enrollees are excluded as well.
Can a person in assisted living be aligned?
Yes, if they meet the other criteria. CMS defines community-dwelling to include personal homes, assisted living facilities, group homes and other community settings.
Are people who have both Medicare and Medicaid eligible?
Yes. CMS includes patients covered by both Original Medicare and Medicaid.
Do patients pay for GUIDE services?
No. CMS's FAQ states that participants may not charge aligned patients for GUIDE services, including respite.
Does an aligned patient have to switch doctors?
No. CMS says aligned patients maintain freedom of choice about who provides their clinical services.
Are people receiving hospice eligible?
No. Patients receiving the Medicare hospice benefit are not eligible for alignment.
