PACE Programs as an Alternative to Nursing Homes for Medicaid Beneficiaries

Last updated: December 23, 2021

 

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. In some areas of the country, notably the mid-Atlantic states, PACE Programs are also called LIFE Programs (Living Independence for the Elderly). These programs are particularly relevant to persons applying for Medicaid, as the vast majority of PACE recipients are “dual eligible”. Dual eligible refers to a person who is eligible for both Medicare and Medicaid.

For program participants, PACE becomes the sole provider of all Medicare and Medicaid benefits, as well as some additional benefits, such as dentistry and ophthalmology. While nursing home care is covered, only a very small percentage of participants (approximately 7% according to the National PACE Association) reside in nursing homes. Since one of the major goals of this program is to prevent and / or delay unnecessary nursing home admissions, a variety of home and community-based services and supports are available to seniors, including those with Alzheimer’s disease or a related dementia. These benefits include in-home personal care assistance, homemaker services, adult day care, and other non-medical types of care. Program participants commonly receive these benefits in a variety of settings. These include one’s home, the home of a close friend or relative, PACE centers, rehabilitation centers, and assisted living / memory care residences.

PACE is a voluntary program, which means there is no mandatory enrollment. Due to the comprehensive level of assistance provided, PACE Programs are highly desirable for those who qualify. This is especially true for persons with conditions that require high levels of non-medical care assistance, such as Alzheimer’s or Parkinson’s disease.

Unfortunately, PACE Programs are not available nationwide. As of December 2021, this program is available in 30 states. Within these states, there are 142 PACE Programs. To see if there is a program in the area in which you or a loved one lives, click here. 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 are the requirements that must be met for an individual to eligible for a PACE Program. While dual enrollment in Medicaid and Medicare is not a requirement, the vast majority of program participants are dually enrolled. Therefore, Medicare requirements are included below.

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. 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

Applicants must live in a state, and geographic region within the state, that has a PACE Program. As of Dec. 2021, PACE is available in the following 30 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, and Wisconsin. To see geographic regions within each state that have PACE Programs, click here.

Medicare Eligibility

Medicare requires participants to be a United States citizen OR legal resident of the states for 5 years prior to application. They must 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 – $2,523 / month in 2022
• Have assets valued at $2,000 or less (not including the primary 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.

Persons who are not Medicaid-eligible may pay the monthly private pay portion for the long-term care Medicaid benefit of PACE, as well as the 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. There are no co-payments or deductibles to receive program benefits.

 

Additional PACE Program Benefits

All benefits available via Medicaid and Medicare, and some benefits not covered by either program, are made available via PACE Programs. 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. The following list of benefits may not be exclusive of all available services and supports. All benefits may not be offered by every PACE Program.

• Adult Day Care / Adult Day Health
• Caregiving Training / Support Groups
• Durable Medical Equipment
• Emergency Services
• End-of-Life Care
• Home Health Care
• Homemaker Services
• Hospital Care
• Lab Work / X-Rays / Radiology
• 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 (Cardiology, Dental, Hearing, Vision, Women’s, 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 need to be certain 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 one is confident that they meet the program’s eligibility criteria, one’s local PACE program should be contacted directly for specific application information. Persons should also ask if a program wait list exists.

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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