Most seniors want to stay at home as long as they can instead of moving into a nursing home. The Program for All-Inclusive Care of the Elderly (PACE), administered by Medicaid, provides care and services to some nursing home-eligible seniors and disabled individuals, enabling them to remain at home far longer than they might otherwise be able to do. The eligibility rules for PACE are less stringent than other Medicaid programs, but accessing specialists outside the PACE network can be extremely difficult.
What Is PACE?
PACE provides pre-paid, comprehensive health care designed to enhance quality of life and autonomy for frail older adults, enabling them to live in their homes as long as possible while preserving their existing family structure. Participants receive core services in their homes or adult day health centers.
To be eligible, participants must:
- be at least 55 years old
- qualify for Medicare or Medicaid (or both)
- live safely in a PACE service area
- meet their state’s criteria to qualify as a nursing home care candidate
- meet any additional program-specific conditions imposed by their local PACE
Similar to an HMO, if a person joins PACE, the program becomes the sole provider of Medicaid and Medicare services. Enrollees must agree to forgo their usual sources of care and receive all their services through PACE.
For example, participants may not enroll in any other Medicare Advantage, Medicare prescription drug or Medicaid prepayment plan or optional benefit. This includes the Medicaid Home and Community Based Services waiver benefit or the Medicare hospice benefit. PACE provides a team of doctors, nurses, social workers, personal care attendants and dietitians to assist each member. Participants can also receive therapeutic, ancillary and social support services.
Care is centralized in an adult health center and supplemented by in-home services and referrals to providers in the network. Other covered services include adult day care, dentistry and prescription drugs. Enrollees get Medicare Part D-covered drugs and all other necessary medications through the program. They don’t need to join a separate Medicare Part D prescription drug plan, and doing so would disenroll them from PACE.
In addition, PACE provides transportation to the health center or to doctor’s appointments at other locations. It also provides meals and social activities, along with other non-medical care. For example, sometimes PACE will fix a participant’s air conditioner during a heat wave. PACE can also provide food during a snowstorm.
Although the focus is on preventive care and avoiding hospitalization, in Massachusetts, PACE operates or has contracts with assisted living facilities and nursing homes, and will provide continued coverage for enrollees for whom home-based care is no longer safe or appropriate. Unlike other community-based Medicaid (MassHealth) programs, such as the Home and Community-Based Waiver, PACE members do not need to reapply for benefits if they require nursing home care.
PACE is organized by geographic areas. Providers, which are under contract with MassHealth, now operate throughout Massachusetts, including the western counties. Some areas have more than one PACE provider, so applicants can choose among programs. Once a person enrolls in PACE, it becomes their sole source of services. Participants can leave the program at any time. Enrollees must recertify annually, but requirements vary across states. A state may waive recertification requirements if it determines there is no reasonable expectation of improvement in a person’s condition because of the severity of their condition or functional impairment.
Program Costs
PACE is paid for by Medicare and Medicaid benefits, and private co-pay in some instances. Whether enrollees pay a premium depends on their financial situation. An individual’s resources must be under $2,000. A person who meets Medicaid’s resource limits will, depending on monthly income, generally have a small payment or have their entire premium covered. At enrollment, a PACE intake worker verifies income and assets, and then determines the amounts payable by the person, which likely won’t change over the course of their program participation.
PACE’s Success
Research shows that PACE reduces hospitalizations, emergency room visits and nursing home stays. Some states have documented that participants receive better preventive care with higher rates of community residence and caregiver satisfaction.
Currently, 155 PACE centers operate in 32 states. These numbers will likely increase as federal incentives for the program improve. Congress and the Centers for Medicare & Medicaid services are also exploring ways to improve PACE. Find a PACE program in Massachusetts.
If you have any questions, our elder law attorneys are available to provide guidance. Call us to schedule an appointment.