What You Need to Know About Medicare: PACE Coverage

The PACE program was created to provide an alternative for those who prefer not to move into a nursing home but whose medical problems make it impossible to stay at home without medical help. 

PACE is provided by a not-for-profit or public entity for those who are frail enough to meet their state’s standards for nursing home care. PACE is a relatively small program (not available in all states) that is intended to allow patients to continue living at home while they receive service instead of being institutionalized. 

A PACE application can take nine months to be approved but enrollment in the program is effective on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement. However, any services provided are not considered PACE services until the effective date of enrollment after approval. Services provided by PACE before the effective date of enrollment will only be covered to the extent that the patient’s healthcare insurance covers them. 

Once enrolled, you will be charged a monthly premium to cover the long-term care portion of the PACE benefit and a premium for prescriptions. There is never a deductible or co-payment for any drug, service, or care approved by the PACE team. If a PACE enrollee joins a separate Medicare drug plan, they will lose their PACE health and prescription drug benefits.

You can join PACE if you fulfill the following criteria:

• You are 55 years old or older.
• You live in the service area of a PACE organization.
• You are certified by your state as meeting the need for nursing home-level care.
• You are able to live safely in the community with the help of PACE services when you join.

PACE services generally include but are not limited to the following:

• Support for family members and other caregivers with caregiver training, support groups, and respite care to help families keep their loved ones in the community.
• Primary care (including doctor, dentist, and nursing services).
• Hospital, home, nursing home, and adult daycare.
• Medical specialty, mental health, emergency, social, laboratory, and X-ray services.
• Physical, occupational, and recreational therapy.
• Nutritional and social work counseling.
• Prescription drugs.
• Meals.
• Transportation.

For a listing of PACE organizations visit: http://www.npaonline.org/pace-you/find-pace-program-your-neighborhood.

Sources: 

• “Enrollment Agreement.” www.cms.gov https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pace111c04.pdf.
• “Enrollment Agreement.” www.cms.gov https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pace111c04.pdf.
• “Enrollment Agreement.” www.cms.gov https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pace111c04.pdf.
•  “Who Can Get Pace?” www.medicare.gov, https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/pace.
• “What Does Pace Cover?” www.medicare.gov, https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/pace.