Program of All-Inclusive Care for the Elderly (PACE)
The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program for older adults. This program features a comprehensive service delivery system, and integrated Medicare and Medicaid financing.
To participate in PACE, an individual must:
- Be enrolled in Medicaid only
- Be enrolled in Medicare only
- Be enrolled in Medicare and Medicaid (dually eligible)
- Have the ability to privately pay
To receive PACE services, an individual must:
- Be 55 years of age or older
- Be determined to need the level of care required under the state Medicaid plan for coverage of nursing facility services
- Reside in the PACE organization's service area
- Be able to live in a community setting when enrolled without jepoardizing health or safety
- Meet program-specific eligibility conditions imposed under the respective PACE agreement
- Enrollment in PACE is voluntary.
- The PACE organization’s Interdisciplinary Team (IDT) completes a comprehensive needs assessment.
- If an individual elects PACE, an Enrollment Agreement is signed that contains the participant’s:
- demographic data
- description of benefits
- effective date
- explanation of policy regarding premiums
- emergency care protocol
- rights and responsibilities
- PACE enrollment will continue until the participant's death regardless of changes in health status.
- PACE enrollment will end if the:
- Participant voluntarily disenrolls, or
- PACE organization involuntarily disenrolls the participants for strictly defined reasons.
Eight of 11 Interdisciplinary Team (IDT) members for each new participant must conduct initial and annual comprehensive health assessments. Each IDT member uses a discipline-specific standardized health risk assessment form developed or adopted by the PACE organization.
Enrollment Effective Date
A participant’s PACE enrollment is effective the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement. Between signing of the enrollment agreement and its effective date, the PACE organization may elect to provide services to the newly signed enrollee. However, any services provided are not considered PACE services until the effective date of enrollment.
Managing PACE Services
PACE uses an IDT to case manage services provided or arranged by the PACE organization for each participant. Consistent with federal regulations, the PACE organization’s IDT must have the following members:
- Primary care physician
- Registered nurse
- Masters level social worker
- Physical therapist
- Occupational therapist
- Recreational therapist or activity coordinator
- PACE center manager
- Home care coordinator
- Personal care attendant
- Transportation driver
PACE Payment Methodology
- Organizations are paid monthly prospective payments for each eligible enrolled PACE beneficiary.
- Services are financed by combined Medicare and Medicaid prospective capitation payments and, in some instances, through private premiums.
- Organizations receive a monthly capitation payment for each eligible beneficiary, and combine these funds into a common pool from which providers pay health care expenses.
- Financing allows organizations to deliver services customers need without limiting them to services reimbursable under Medicare and Medicaid fee-for-service systems.
- Organizations assume full financial risk for all health care services.
As a Medicare program and a Medicaid state plan option, PACE organizations receive two capitation payments per month for dually eligible participants.
- Medicare-eligible participants not eligible for Medicaid pay monthly premiums equal to the Medicaid capitation amount and a premium for Medicare Part D drugs, but no deductibles, co-insurance, or other type of Medicare or Medicaid cost-sharing applies.
- For customers eligible for Medicaid, but not Medicare, the state pays the full cost to PACE organizations.
PACE Centers include a primary care clinic, an adult day health program, areas for therapeutic recreation, restorative therapies, socialization, personal care, and dining that serves as the focal point for coordination and provision of most PACE services.
Provide PACE Services
A PACE organization is a not-for-profit private or public entity primarily engaged in providing PACE services. A PACE organization must:
- Have a governing board that includes community representation
- Be able to provide the complete service package regardless of frequency or duration of services
- Have a physical site to provide adult day services
- Have a defined service area
- Have safeguards against conflict of interest
- Have demonstrated fiscal soundness
- Have a formal Participant Bill of Rights
All PACE organizations are approved by Centers for Medicare and Medicaid Services (CMS) and NC Medicaid. Federal and state agencies are required to consistently monitor PACE organizations and ensure that they comply with state and federal regulations, and provide quality care and services.
Each PACE organization must define its service area, which must be approved by DMA. The final approval is granted by CMS.
NC PACE Organizations – Service Areas and Contacts
There are 11 PACE organizations operating in 12 locations in North Carolina.
National PACE Association
801 North Fairfax Street
Alexandria VA 22314
North Carolina PACE Association
2401 Weston Parkway
Cary NC 27513
Medical Assistance Clinical Section