Medicare and Medicaid PACE Plans

By Patricia Barry

Copyright © 2018 by AARP. All rights reserved.

Programs of All-Inclusive Care for the Elderly (PACE) integrate Medicare and Medicaid services and provide valuable benefits at low cost for people who qualify. But they’re not available everywhere. Currently, PACE has more than 38,000 people enrolled in 121 programs nationwide in 31 states.

PACE plans help people who’d otherwise need nursing home care to continue to live in their own homes or with their families in the community for as long as possible. They provide comprehensive medical and social services — including home care, day care, physical therapy, dentistry, meals, social work counseling, transportation, and many other services. They also provide hospital and nursing home care if you need it.

You can’t choose your own doctors in a PACE plan. Instead, you’re assigned a primary-care physician who is one of a team of health-care professionals working with you and your family to help maintain your overall health. The team also provides support for your caregivers. PACE services include drug coverage, so you don’t have to join a separate Part D prescription drug plan.

You can join a PACE plan if the following are true:

  • You’re 55 or older.
  • You’re certified by your state as being eligible for a nursing home level of care, after an assessment by the PACE plan’s care team.
  • A program serves the area where you live and is accepting new enrollees.
  • You’re enrolled in Medicare, Medicaid, or both.
  • You’re able to live safely in the community with the help of PACE.

PACE charges no deductibles or co-payments for any service, care, or prescription drug approved by your care team. Other costs depend on your situation:

  • If you qualify for Medicaid, you pay a small monthly payment — and nothing for long-term care if you need it. The PACE plan determines the amount of the payment.
  • If you don’t qualify for Medicaid, you pay a monthly premium to cover the long-term-care part of the PACE benefit and also a monthly premium for Medicare Part D drugs, in each case paying what the plan requires.

If you qualify for an available PACE, you can join it at any time. If you’re enrolled in Medicare, you get a special enrollment period to leave traditional Medicare or a Medicare Advantage private health plan to join the program. (You can’t be in either of these programs at the same time as being enrolled in a PACE.) Also, you can leave a PACE any time you want to switch to traditional Medicare or to a Medicare Advantage plan.

To find out whether a PACE exists in your area, call Medicare at 800-633-4227 (TTY 877-486-2048), or go to this website and enter your zip code or state. If a program is available and you’re interested in joining it, contact the plan to arrange a home visit with you or your caregiver or a visit to the PACE center. The plan will schedule a meeting between you and its care team for a medical and social assessment that determines your eligibility for the program. For more on how PACE plans work, go to the National PACE Association’s website.