PACE Program Helps Seniors Remain at Home

Most seniors want to stay at home as long as they can instead of moving into a nursing home. The little-known Program for All-Inclusive Care of the Elderly (PACE) provides care and services to some nursing home-eligible seniors and disabled individuals, enabling them to remain in their home far longer than they might otherwise be able to do.

Program History

PACE’s inception dates to the 1970s when the federal and state governments were developing community-based services for some of their most in-need constituents. As part of this effort, states explored fee-based services for the elderly and disability communities. PACE was among the programs developed during this time.

Today’s PACE model comprises managed care services serving a population of very frail community-dwelling elderly or disabled individuals. These people are usually dually eligible for Medicare and Medicaid and also qualify for nursing home placement.

Participants receive core services not in nursing homes, but in their home or an adult day health center.

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.

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

Participants must meet any additional program-specific conditions imposed by their local PACE program.

If a senior joins PACE, the program becomes the sole provider of Medicaid and Medicare services. The enrollee must agree to forgo their usual sources of care and receive all their services through PACE. For example, participants may not also enroll in any other Medicare Advantage, Medicare prescription drug, or Medicaid prepayment plan, or optional benefit. This includes a 1915c Home and Community Based Services waiver or the Medicare hospice benefit.

PACE provides a team of doctors, nurses, social workers, personal care attendants, and dietitians to assist each senior. Participants can also receive therapeutic, ancillary, and social support services.

All care is centralized in an adult health center and supplemented by in-home and referral services. 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; doing so disenrolls 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, PACE in New York City will fix an air conditioner during a heat wave. It can also provide food during a snowstorm. The focus is on preventative care and avoiding hospitalization.

Once a person enrolls in PACE, it becomes their sole source of services. Participants can, however, leave the program at any time.

Enrollees must recertify annually, which varies 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 pay in some instances. Whether enrollees pay a premium depends on their financial situation. If a senior meets Medicaid’s income and resource limits, they’ll generally have a small payment, or their entire premium will be covered.

At enrollment, PACE verifies whether an individual is dually eligible for Medicare and Medicaid and whether they have Medicare Part A and/or Part B. Unless a person is dually eligible, and to the extent they would normally be required to pay, they will need to continue to pay their Medicare Part A, Part B, and/or Part D premiums. PACE 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.

PACE will operate in five regions throughout Illinois. These regions include: