PACE Programs as an Alternative to Nursing Homes for Medicaid Beneficiaries

Last updated: July 31, 2019

 

Medicare PACE Program Overview

 PACE Programs help seniors, who would otherwise be required to live in a Medicaid nursing home, to continue living at home in or in assisted living residences.

 

PACE, which stands for Program of All-Inclusive Care for the Elderly, is a comprehensive Medicare and Medicaid program. For PACE Program participants, PACE becomes the sole provider of all Medicare and Medicaid benefits, as well as some additional benefits, such as dentistry and ophthalmology. With PACE, home and community-based services and supports, such as adult day care, in-home personal care assistance, homemaker services and other non-medical types of care are made available to seniors, including those with Alzheimer’s disease or a related dementia.

In some areas of the country, notably the mid-Atlantic states, PACE Programs are also referred to as LIFE Programs (Living Independence for the Elderly).

Benefits may be provided in the senior’s home, the home of a close friend or relative, at a PACE center, in rehabilitation centers, in assisted living / memory care residences, and in nursing homes. While a “nursing home level of care” is required to be eligible, one of the major goals of this program is to prevent and / or delay unnecessary nursing home admissions. While PACE does cover nursing home care, only a very small percentage of PACE participants (approximately 7% according to the National PACE Association) reside in nursing homes.

PACE / LIFE Programs are relevant to those seeking Medicaid because the vast majority of program recipients are “dual eligibles” (persons who are eligible for both Medicare and Medicaid). PACE is a voluntary program, meaning there is no mandatory enrollment of those dually eligible for Medicare and Medicaid, and program participants can disenroll from the program at any time. However, due to the comprehensive level of assistance provided, PACE Programs are desirable for those persons who live in geographic areas where PACE is offered. This is especially true for persons with conditions that require high levels of non-medical care assistance such as Alzheimer’s or Parkinson’s diseases.

Unfortunately, PACE is not available in all states. However, at the time of this writing (July 2019), it is available in 31 states, and within these 31 states, there are 129 PACE / LIFE programs. To see if there is a program in the area in which you or a loved one lives, click here. Note that for persons with dire need, relocation to an area that offers PACE is an option.

 

 Did You Know? PACE has proven especially beneficial for persons with Alzheimer’s disease and related dementias. According to the National PACE Association, almost 50% of program participants have a diagnosis of dementia.

 

PACE Program Eligibility Requirements

Follows the are requirements that must be met for an individual to eligible for a PACE or LIFE Program. Note, dual enrollment in Medicaid and Medicare is not a requirement, but the vast majority of program participants are dually enrolled and therefore those requirements are also included here.

Age

Applicants must be a minimum of 55 years old.

Functional Need

Applicants must require a level of care consistent to that which is provided in a nursing home facility. While each state has its own requirements that must be met in order for an individual to be determined to require a “nursing home level of care”, requiring extensive assistance with activities of daily living (bathing, grooming, toileting, walking, transferring, and eating) may warrant the designation of this level of care. Furthermore, with assistance / support from the PACE program, the individual must be able to safely live in the community at the time of enrollment.

Geographic Region

PACE is not available nationwide. Applicants must live in a state, and geographic region within the state, that has a PACE program. As of July 2019, PACE is available in the following 31 states: Alabama, Arkansas, California, Colorado, Delaware, Florida, Iowa, Indiana, Kansas, Louisiana, Massachusetts, Maryland, Michigan, North Carolina, North Dakota, Nebraska, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia, Washington, Wisconsin, and Wyoming. To find out which areas of the states above have PACE programs, click here.

Medicare Eligibility

Medicare requires participant to be a United States citizen OR legal resident of the states for 5 years prior to application and they ust be at least 65 years of age OR disabled OR diagnosed with Lou Gehrig’s disease OR have end-stage renal disease.

Medicaid Eligibility

Medicaid eligibility is not straightforward, as each state runs its Medicaid program as it sees fit within federally set parameters. However, for most states, seniors and disabled persons are eligible for long-term care Medicaid if they meet the criteria below. See state specific Medicaid eligibility requirements.

  • Have income under 300% of the Federal Benefit Rate, which as of 2019, is $2,313 / month.
  • Have assets valued at $2,000 or less (not including their home).
  • Require a nursing home level of care

 

  Important: Not meeting the above financial criteria does not mean someone cannot become eligible for Medicaid and therefore a PACE Program. Medicaid offers multiple pathways to eligibility and Medicaid planning professionals can assist persons in meeting Medicaid’s requirements. Learn more.

 

For persons who do not have Medicaid, there is the monthly private pay portion for the long-term care Medicaid benefit of PACE, as well as a monthly premium for prescription drugs (Medicare Part D). While the fees vary based on the PACE program, on average, the private pay cost is generally $4,000 – $5,000 / month. That said, there are no co-payments or deductibles to receive program benefits.

 

Additional PACE Program Benefits

All benefits available via Medicaid and Medicare are made available via PACE programs. In addition, some benefits not covered by either program are available. All PACE participants have a team of health care professionals, including primary care doctors, nurses, social workers, dieticians, PACE center supervisors, personal care aides, and drivers, that work together with them and their families to develop a care plan to enable them to continue to live safely at home and in their communities. Please note that this list of benefits may not be exclusive of all available services and supports, and all benefits may not be offered by every PACE program.

  • Adult Day Care / Adult Day Health
  • Caregiving Training / Support Groups
  • Emergency Services
  • End-of-Life Care
  • Home Health Care
  • Homemaker Services
  • Hospital Care
  • Lab Work / X-Rays
  • Meals / Nutritional Counseling
  • Medication Management
  • Nursing Home Care
  • Personal Care Assistance
  • Physician Visits
  • Prescription Medications (Medicare Part D)
  • Preventative Care
  • Respite Care
  • Social Services
  • Social Work Counseling
  • Specialty Medical Services (Dental, Hearing, Vision, Feet / Ankles / Lower Limbs)
  • Therapies (Occupational, Physical, Recreational, Speech)
  • Transportation (To & From Medical Appointments / Adult Day Care)

 

How to Apply / Find a PACE Program

Prior to applying for a PACE or LIFE Program, candidates will want to make sure they meet the program’s eligibility requirements. While nearly all seniors are eligible for Medicare, Medicaid eligibility is more complicated; our organization offers a Medicaid eligibility pre-screen here.

Once an interested party is confident that they meet the program’s eligibility criteria, they should contact a local PACE program directly for specific application information and to determine if there is a waiting list for that program.

Persons can also contact their local Medicaid office to inquire about PACE programs in their area or call Medicare at 800-633-4227. As part of the application process, one should expect an in-person assessment, either in one’s home or at one’s local PACE center.

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