Frequently Asked Questions
AND PACE PROGRAM QUICK FACTS
Quick Facts about Programs of
All-inclusive Care for the Elderly (PACE)
What are Programs of All-inclusive Care for the Elderly (PACE)?
PACE is a Medicare program for older adults and people over age 55 living with disabilities. This program provides community-based care and services to people who otherwise need nursing home level of care. PACE was created as a way to provide you, your family, caregivers, and professional health care providers flexibility to meet your health care needs and to help you continue living in the community.
An interdisciplinary team of professionals will give you the coordinated care you need. These professionals are also experts in working with older people. They will work together with you and your family (if appropriate) to develop your most effective plan of care.
PACE provides all the care and services covered by Medicare and Medicaid, as authorized by the interdisciplinary team, as well as additional medically-necessary care and services not covered by Medicare and Medicaid. PACE provides coverage for prescription drugs, doctor care, transportation, home care, check ups, hospital visits, and even nursing home stays whenever necessary. With PACE, your ability to pay will never keep you from getting the care you need.
You should know this about PACE:
PACE Provides Comprehensive Care
PACE uses Medicare and Medicaid funds to cover all of your medically-necessary care and services. You can have either Medicare or Medicaid or both ; Or for a Flat Monthly fee you can also join PACE
The Focus is on You
You have a team of health care professionals to help you make health care decisions. Your team is experienced in caring for people like you. They usually care for a small number of people. That way, they get to know you, what kind of living situation you are in, and what your preferences are. You and your family participate as the team develops and updates your plan of care and your goals in the program.
PACE Covers Prescription Drugs
PACE organizations offer Medicare Part D prescription drug coverage. If you join a PACE program, you’ll get your Part D-covered drugs and all other necessary medication from the PACE program. Note: If you are in a PACE program, you don’t need to join a separate Medicare drug plan. If you do, you will lose your PACE health and prescription drug benefits.
PACE Supports Family Caregivers
PACE organizations support your family members and other caregivers with caregiving training, support groups, and respite care to help families keep their loved ones in the community.
PACE Provides Services in the Community
PACE organizations provide care and services in the home, the community, and the PACE center. They have contracts with many specialists and other providers in the community to make sure that you get the care you need. Many PACE participants get most of their care from staff employed by the PACE organization in the PACE center. PACE centers meet state and Federal safety requirements and include adult day programs, medical clinics, activities, and occupational and physical therapy facilities.
PACE is Sponsored by the Health Care Professionals Who Treat You
PACE programs are provider sponsored health plans. This means your PACE doctor and other care providers are also the people who work with you to make decisions about your care. No higher authorities will overrule what you, your doctor, and other care providers agree is best for you. If you disagree with the interdisciplinary team about your care plan, you have the right to file an appeal.
Preventive Care is Covered and Encouraged
The focus of every PACE organization is to help you live in the community for as long as possible. To meet this goal, PACE organizations focus on preventive care. Although all people enrolled in PACE are eligible for nursing home care, only 7% live in nursing homes.
PACE Provides Medical Transportation
PACE organizations provide all medically-necessary transportation to the PACE center for activities or medical appointments. You can also get transportation to appointments in the community.
What You Pay for PACE Depends on Your Financial Situation
If you qualify for Medicare, all Medicare-covered services are paid for by Medicare. If you also qualify for your State’s Medicaid program, you will either have a small monthly payment or pay nothing for the long-term care portion of the PACE benefit. If you don’t qualify for Medicaid you will be charged a monthly premium to cover the long-term care portion the PACE benefit and a premium for Medicare Part D drugs. However, in PACE there is never a deductible or copayment for any drug, service, or care approved by the PACE team.
PACE uses Medicare and Medicaid funds to cover all of your medically-necessary care and services. You can have either Medicare or Medicaid or both ; Or for a Flat Monthly fee you can also join PACE
The Focus is on You
You have a team of health care professionals to help you make health care decisions. Your team is experienced in caring for people like you. They usually care for a small number of people. That way, they get to know you, what kind of living situation you are in, and what your preferences are. You and your family participate as the team develops and updates your plan of care and your goals in the program.
PACE Covers Prescription Drugs
PACE organizations offer Medicare Part D prescription drug coverage. If you join a PACE program, you’ll get your Part D-covered drugs and all other necessary medication from the PACE program. Note: If you are in a PACE program, you don’t need to join a separate Medicare drug plan. If you do, you will lose your PACE health and prescription drug benefits.
PACE Supports Family Caregivers
PACE organizations support your family members and other caregivers with caregiving training, support groups, and respite care to help families keep their loved ones in the community.
PACE Provides Services in the Community
PACE organizations provide care and services in the home, the community, and the PACE center. They have contracts with many specialists and other providers in the community to make sure that you get the care you need. Many PACE participants get most of their care from staff employed by the PACE organization in the PACE center. PACE centers meet state and Federal safety requirements and include adult day programs, medical clinics, activities, and occupational and physical therapy facilities.
PACE is Sponsored by the Health Care Professionals Who Treat You
PACE programs are provider sponsored health plans. This means your PACE doctor and other care providers are also the people who work with you to make decisions about your care. No higher authorities will overrule what you, your doctor, and other care providers agree is best for you. If you disagree with the interdisciplinary team about your care plan, you have the right to file an appeal.
Preventive Care is Covered and Encouraged
The focus of every PACE organization is to help you live in the community for as long as possible. To meet this goal, PACE organizations focus on preventive care. Although all people enrolled in PACE are eligible for nursing home care, only 7% live in nursing homes.
PACE Provides Medical Transportation
PACE organizations provide all medically-necessary transportation to the PACE center for activities or medical appointments. You can also get transportation to appointments in the community.
What You Pay for PACE Depends on Your Financial Situation
If you qualify for Medicare, all Medicare-covered services are paid for by Medicare. If you also qualify for your State’s Medicaid program, you will either have a small monthly payment or pay nothing for the long-term care portion of the PACE benefit. If you don’t qualify for Medicaid you will be charged a monthly premium to cover the long-term care portion the PACE benefit and a premium for Medicare Part D drugs. However, in PACE there is never a deductible or copayment for any drug, service, or care approved by the PACE team.
PACE Your LIFE Frequently Asked Questions
The Program of All-Inclusive Care for the Elderly (PACE®) is a comprehensive, fully integrated, provider- based health plan for the frailest and costliest members of our society – those who require a nursing home level of care. The PACE philosophy is centered on the belief that it is better for frail individuals and their families
to be served in the community whenever possible. Although all PACE participants are eligible for nursing home care, 95 percent continue to live at home.
PACE serves over 51,000 participants in 31 states (see PACE in the States). PACE serves individuals who are age 55 or over and certified by their state as needing a nursing home level of care. The average participant is 76 years old and has multiple, complex medical conditions, cognitive and/or functional impairments, and significant health and long-term care needs. Approximately 90 percent are dually eligible for Medicare and Medicaid. PACE participants must live in a PACE service area
and be able to live safely in the community with PACE services at the time of enrollment.
PACE organizations provide the entire continuum of medical care and long-term services and supports required by frail older adults. These include primary and specialty medical care; in-home services; prescription drugs; specialty care such as audiology, dentistry, optometry, podiatry and speech therapy; respite care; transportation; adult day services, including nursing, meals, nutritional counseling, social work, personal care, and physical, occupational and recreational therapies; and hospital and nursing home care, when necessary. In short, PACE covers all Medicare Parts A, B and D benefits, all Medicaid-covered benefits, and any other services or supports that are medically necessary to maintain or improve the health status of PACE program participants.
» PACE Participants Are Served by a Comprehensive Team of Professionals: Upon enrollment in PACE, participants and their caregivers meet with an interdisciplinary team (IDT) that includes doctors, nurses, therapists, social workers, dietitians, personal care aides, transportation drivers and others. Their needs are assessed, and an individualized care plan is developed to respond to all of the participant’s needs – 24 hours a day, seven days a week, 365 days a year.
» PACE Participants Receive Regular, “High-Touch” Care: PACE participants receive comprehensive health and supportive services across a range of settings. At the PACE center they receive primary care, therapy, meals, recreation, socialization and personal care. In the home PACE offers skilled care, personal care supportive services, and supports such as ramps, grab bars, and other tools that facilitate participant safety. In the community PACE offers access to specialists and other providers.
» PACE Is Both a Health Provider and a Health Plan: PACE combines the intensity and personal touch
of a provider with the coordination and efficiency of a health plan. IDT members deliver much of the care directly, enabling them to personally monitor participants’ health and respond rapidly with any necessary changes. The PACE team also is responsible for managing and paying for services delivered by contracted providers such as hospitals, nursing homes and specialists.
PACE organizations receive fixed monthly payments from Medicare, Medicaid and private payers (for program participants who are not dually eligible). These funds are pooled, and care is provided following a comprehensive assessment of a participant’s needs. This bundled payment provides a strong incentive
to avoid duplicative or unnecessary services and encourages the use of appropriate community-based alternatives to hospital and nursing home care. For more information, see Medicare and Medicaid Payment to PACE Organizations.
PACE emphasizes the following processes, which are recognized as highly effective in the provision of primary care for community-based older adults with complex care needs:
- development of a comprehensive participant assessment that includes a complete review of all medical, functional, psychosocial, lifestyle and values issues;
- creation and implementation of a care plan that addresses all health and long-term care needs;
- communication and care coordination among all those who provide care for the participant; and
- promotion of participant and caregiver engagement in health care decision-making.
Furthermore, because PACE organizations are
fully responsible for the quality and cost of all care provided, they have a financial incentive to provide all necessary care. According to the “HHS Interim Report to Congress: The Quality and Cost of the Program of All-Inclusive Care for the Elderly,” Medicare costs for PACE and a comparable group were analyzed for a 60-month period and found to be similar, suggesting that Medicare capitation rates for PACE were set appropriately.
Similarly, the Medicaid statute requires that PACE rates be set below the upper payment level for a similar population. According to an analysis done by the National PACE Association, PACE rates are 13 percent less than the state costs of providing alternative services to a comparable population.
Congress authorized PACE as a permanent Medicare provider and Medicaid state option in the Balanced Budget Act of 1997 by establishing Sections 1894 (42 U.S.C. 1395eee) and 1934 (42 U.S.C. 1396u-4) of the Social Security Act. In the Deficit Reduction Act of 2005, Congress established a program to expand PACE to rural areas of the country. Regulatory authority for PACE can be found in 42 CFR Part 460. Operationally, the PACE program is unique and implemented through three-way program agreements among the Centers
for Medicare & Medicaid Services (CMS), states and PACE organizations. CMS and the state are responsible for monitoring the operations, cost, quality and effectiveness of PACE programs. For more information about PACE regulatory requirements, see 42 CFR Part 460 and the CMS PACE Manual.
PACE organizations often are part of larger health care systems or organizations, including hospital systems, medical groups, federally qualified health centers, area agencies on aging, hospice organizations, and collaborations among several different entities. Some PACE programs operate as stand-alone entities.
The National PACE Association advances the efforts of PACE programs across the country.