Frequently Asked Questions
An FAQ List To Help You Understand How It Works.
A PACE program is a managed care benefit for the community-dwelling frail elderly, featuring medical and social services in an adult daycare setting. These services are supplemented by in-home and referral services depending on participant needs. Skilled healthcare professionals make that determination.
Enrollment is always voluntary. Once eligibility has been determined, an Enrollment Agreement is completed and signed. This agreement contains information such as demographics, a description of benefits, an effective date, an explanation of policy premiums, and care. Eligibility criteria will be discussed in future blogs.
If a major health event or change in medical status occurs between the enrollment date and the first of the following month, enrollment may be denied. If the potential participant is no longer able to live safely in the community, enrollment will be denied.
PACE centers provide participants with ongoing care needs along a broad continuum. These services include nursing and personal care, as well as physical, occupational, and recreational therapy. Meals and nutritional counseling, promote wellness and many forms of healing. Social services are provided to help participants and their family members. Other services include the following:
PACE organizations provide all medically necessary transportation to the PACE center for activities or medical appointments. You can also get transportation to appointments in the community.
TPACE participants may dis-enroll from the program at any time and for any reason. Those with Medicare or Medicaid will be assisted in returning to their former health care coverage. Enrollment continues for as long as the PACE participant desires, regardless of health status changes, until expiration or voluntary or involuntary dis-enrollment.
Oftentimes, understanding government-based websites can be difficult because of the jargon and technical language. It is helpful to boil down this information down to its simplest form. There are several ways PACE participation is paid for; Medicare and Medicaid are the largest contributors to the program, but there are other options:
These participants have only Medicaid coverage and no other.
Includes participants who have long-term care insurance (or other insurance) that pays, either in whole or in part, the long-term care premium.
Enrolling in a PACE program allows participants to enjoy the comforts of home and family while getting needed care and supervision during the day. This allows caregivers freedom to work and tend to their own needs. The program is built on the belief that seniors with chronic care needs are better served in the community when possible.
An initial comprehensive assessment is usually completed by the date of enrollment or within a few days after, so a care plan can be presented to the participant.
The goal is to help achieve and maintain the highest functional level for each participant, keeping in mind that each person has a different maximum potential. PACE programs seek to effectively manage chronic conditions and reduce the number of re-hospitalizations. The capitated pay structure offers an incentive for providers to manage the provision of care and to maintain a state of relative wellness for each participant. PACE organizations focus on helping the frail and elderly live in the community for as long as possible, and to meet this goal, PACE organizations focus on preventive care.
Each PACE program has a group of physicians on staff providing medical care as needed. This group is typically composed of a medical director that guides the program and oversees the other physicians. PACE physicians become familiar with the history, needs, and preferences of each participant. Medical specialties, such as audiology, dentistry, optometry, podiatry, and speech therapy, are usually present.
If a PACE enrollee needs nursing home care, the PACE program pays for itself and continues to coordinate the enrollee’s care. While all PACE participants must be certified as needing nursing home care, only about 7% of PACE participants nationwide live in nursing homes.
When enrolling, participants must be 55 years of age or older, require nursing home level of care, and be able to live safely in the community. Participants must live in the PACE service area as well.
The participant can have Medicare as the only source of insurance with either part A or part B separately or combined. There is an out-of-pocket cost due to a long term care premium that is not covered since those participants do not have Medicaid.
This includes participants who are covered by Medicare AND Medicaid.
This includes participants who pay both the Medicare and Medicaid capitation amounts privately out-of-pocket. The program also accepts participants who pay privately.
If you qualify for Medicare, all covered services are paid for by that payer source. If you also qualify for your state’s Medicaid program, you will either have a small monthly payment or pay nothing for the long-term care portion of the PACE benefit. If you do not qualify for Medicaid, participants will be charged a monthly premium to cover the long-term care portion of the PACE benefit, as well as a premium for Medicare Part D drugs. In PACE , there is never a deductible or copayment for any drug, service, or care approved by the PACE team. PACE agencies receive a set amount of Medicare and Medicaid funds each month to ensure participant care, regardless of the setting. There is an incentive to keep participants healthy.