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Insurance NewsEligibility, outreach, rules, and support | #insurance | #seniors | #elderly

Eligibility, outreach, rules, and support | #insurance | #seniors | #elderly

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Programs of All-Inclusive Care for the Elderly (PACE) is a joint Medicare and Medicaid program. It allows a person requiring nursing care to live at home by receiving care from the community.

PACE provides coverage of a broad array of services. A team of professionals and paraprofessionals delivers the care an individual needs.

The costs of PACE depend on someone’s financial situation, and eligibility requirements involve several factors, such as a person’s age and health conditions.

This article provides an overview of PACE and how it fits within Medicare. It also explores its eligibility requirements, costs, and coverage, and looks at state availability and the healthcare teams involved.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:

  • Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
  • Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
  • Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

Some people who need nursing home care can live safely at home if they have access to enough services.

PACE Medicare makes this possible for eligible individuals by providing a health team that coordinates and delivers care.

PACE works with a person and their family to develop a customized care plan. These plans include all the services that Medicare and Medicaid cover, with some additional help.

Each PACE team usually has a small caseload to pay close attention to a person’s preferences and needs.

Because PACE offers comprehensive care, it replaces original Medicare, which comprises Part A’s inpatient hospital insurance and Part B’s outpatient medical insurance. PACE also takes the place of Medicare Advantage plans, the alternative to original Medicare.

A person with PACE is not eligible for Medigap, Medicare supplement insurance.

Because PACE includes prescribed medications, there is no need to buy a Part D prescription drug plan. If a person joins a Part D plan, this could lead to disenrollment from PACE.

PACE covers the services that the care team authorizes to improve and maintain a person’s health.

These include, but are not limited to:

  • dentistry
  • lab tests
  • meals and nutritional counseling
  • social services such as support groups
  • transportation to the PACE center and some medical appointments
  • social work counseling
  • emergency services
  • physical, recreational, and occupational therapy
  • primary care including doctor and nurse services
  • medical specialty services such as podiatry or optometry
  • hospital care
  • nursing home care
  • home care
  • preventive care
  • prescription drugs

Once a person enrolls, they may stay on a PACE plan as long as they wish, regardless of their health condition.

After enrollment, if someone’s health deteriorates to the point where they need to live in a nursing home, the plan pays for this and continues to coordinate care.

PACE costs involve a monthly long-term care premium and Part D premium. However, the amount a person pays depends on their financial situation.

When a person is eligible for Medicaid, they do not pay the long-term care premium.

An individual not eligible for Medicaid with a Medicare plan pays the long-term care premium, the Part D premium, and the Part B monthly premium, which is $148.50 for 2021.

Unlike other Medicare programs, PACE costs do not include copayments and deductibles, which is why a person cannot have a Medigap plan with PACE.

If someone does not have Medicare or Medicaid, they may pay PACE costs from their personal funds.

An individual may have Medicare, Medicaid, or both to sign up for PACE.

To be eligible, a person must:

  • live within a PACE center’s service area
  • be aged 55 years or older
  • be able to live at their home with PACE care safely
  • have received state certification that they need nursing home level care

PACE is currently available in 31 states.

As of 2019, the below states provide at least one PACE center.

People may use this search tool to find PACE plans in their area.

The PACE healthcare team, sometimes called the interdisciplinary team, comprises professional and paraprofessional staff members.

They include:

  • PACE center supervisors
  • primary care doctors
  • nurses
  • physical, occupational, and recreational therapists
  • dietitians
  • home care liaisons
  • social workers
  • personal care attendants
  • drivers

According to the National PACE Association (NPC), the typical person enrolled with PACE is 80 years old and female, with limitations in three activities of daily living, such as dressing or bathing.

The NPC also advise that typically, a person with PACE also has eight medical conditions, while nearly half of the participants are living with a dementia diagnosis.

The NPC state that approximately 90% can continue to live in their homes after enrolling in PACE, despite their health challenges.

PACE Medicare believes older adults with chronic health conditions should live at home whenever possible.

To make this a reality, PACE covers a broad range of services an eligible person needs. The program offers coverage on all assistance required, including meals, doctor visits, and therapy.

If an individual has Medicare but not Medicaid, they pay two monthly premiums: one for long-term care and one for prescription drug coverage.

If someone has Medicaid, they do not pay the monthly long-term care premium.

The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.

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