PACE, short for the Medicare and Medicaid program known as Programs of All-Inclusive Care for the Elderly, provides qualifying seniors with an alternative to Medicaid nursing home facilities. For people who qualify and enroll in the program, PACE allows them to get the comprehensive care they need while staying in their own home, in the home of a relative or friend, or in an assisted living facility.
PACE becomes the provider for the participant’s Medicare and Medicaid benefits, and it provides extra benefits like vision, dental care, and other valuable hone and community-based services and support as well.
Today, there are over 130 PACE programs available in 31 states of the United States. Over 54,000 seniors are able to take advantage of these programs. Studies show that PACE programs are effective in reducing nursing home and hospital utilization, and in improving the health and quality of life for seniors taking part in PACE.
Who is eligible for PACE?
If there is a PACE program available in your area and you are interested in enrolling, or enrolling a loved one, here are the requirements for eligibility:
• You must be enrolled in either Medicare, Medicaid, or both as a dual-eligible.
• You must be 55 or older.
• You must reside in an area that is serviced by a PACE program.
• You must be certified by your state as needing a nursing home level of care.
• You must have the ability to live safely in the community with the help of the PACE program.
How much does PACE cost if you get Social Security benefits?
As a participating senior in a PACE program, any financial burden you may have is not directly dependent on your income from Social Security benefits or other sources. But it is dependent in an indirect way, because your eligibility for Medicaid depends on your income and resources.
If you are enrolled in Medicaid, you do not pay a monthly premium for long-term care in the PACE program. However, if you do not qualify for Medicaid and have Original Medicare coverage instead, you may be responsible for paying the following charges:
• A monthly premium for long-term care through the PACE program
• A monthly premium for a Medicare prescription drug (Part D) plan
Although you must pay a premium for the Part D plan, you do not have to pay a deductible or copayment for any prescription drugs, services, or care that your PACE health care team approves.
If you are younger than 65 and do not have Medicare or Medicaid and qualify for the PACE program, you have the opportunity to pay for PACE participation out-of-pocket.
If you are 65 years or older you may qualify for Medicaid if you are a United States citizen or lawful permanent resident, a resident of the state where you apply, and have an individual income of no more than $2,349.00 a month before taxes.
If you are a married couple and are both applying for Medicaid coverage for nursing care, the income limit is $4,698.00 a month before taxes. There are also limits on resources which vary from state to state. An example of these limits for individuals are no more than $2,000.00 in countable assets, and your home must not be worth more than $595,000.00.
What health care services does PACE cover?
As a participant in a PACE program, you are eligible for all care and services that both Medicare and Medicaid cover, but your health care team must first authorize the care. There are also extra services that PACE provides outside of Medicare and Medicaid coverage if they are deemed necessary for your health care needs.
PACE covers the following services:
• Adult day primary care which includes doctor and recreational therapy nursing services
• Dental care
• Emergency services
• Home care
• Hospital care
• Laboratory/x-ray services
• Medical specialty services
• Nursing home care
• Nutritional counseling
• Occupational and physical therapy
• Prescription drugs
• Preventive care
• Social services which include caregiver training, support groups, and Respite care
• Social work counseling
• Transportation to the PACE center for activities or medical appointments, if they are certified as medically necessary , and in some instances transportation to some medical appointments in the community can be arranged.
If you would like more information about eligibility and PACE programs in your area, contact your local Medicare or Medicaid office.