What is the PACE Program?
The Program of All-Inclusive Care for the Elderly (PACE) is a unique health plan that offers all-inclusive medical and social services to older adults who need a nursing home level of care but wish to remain living in the community. It operates as both a Medicare and Medicaid program option. PACE is centered around a comprehensive interdisciplinary team (IDT) that coordinates and provides all necessary care, including primary care, specialist services, therapies, and more. By managing all aspects of a participant's care, the program aims to improve their quality of life and help them live as independently as possible.
PACE Eligibility: The Role (and Non-Role) of Income
The most important distinction to understand is that the core eligibility for the national PACE program is not directly determined by a person's income. The primary criteria for enrollment are based on age, location, and health needs, not your financial bracket. To qualify for PACE, you must meet the following general requirements:
- Age: Be 55 years of age or older.
- Location: Live in the service area of a PACE organization.
- Health Status: Be certified by your state as meeting the need for a nursing home level of care.
- Safety: Be able to live safely in the community with the help of PACE services.
While income is not a barrier to enrollment itself, it does heavily influence the cost of participation. Your income determines whether you qualify for Medicaid, which acts as the primary payer for the long-term care services provided by PACE.
How Income Determines Your PACE Costs
The cost structure for PACE is tiered and directly tied to your eligibility for Medicare, Medicaid, or both.
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Dual Eligibles (Medicare and Medicaid): For individuals who qualify for both Medicare and their state's Medicaid program, the long-term care portion of the PACE benefit is covered by Medicaid. This means these individuals typically pay nothing for their PACE care, which includes all services, medications, and equipment approved by their IDT.
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Medicare Only: If you have Medicare but do not qualify for Medicaid, you will be responsible for a monthly premium to cover the long-term care portion of the PACE benefit. You will also pay a premium for Medicare Part D prescription drugs. However, for all approved services, you will not have any deductibles or copayments.
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Private Pay: For those without Medicare or Medicaid, private payment is an option. This is the most expensive route and requires you to pay the full monthly premium for all services.
Because Medicaid eligibility is based on income and asset limits, your financial situation is the central factor in determining whether you pay premiums or receive PACE services at little to no cost.
The Crucial Link: State-Specific Medicaid Rules
It is important to remember that Medicaid is a joint federal and state program, meaning eligibility rules, including income and asset limits, can vary significantly by state. For example, a person with a particular income level in one state might qualify for Medicaid and therefore receive free PACE services, while a person with the same income in another state might not qualify for Medicaid and have to pay a monthly premium. Most states set the Medicaid income limit for long-term care at 300% of the Federal Benefit Rate (FBR), but some states have their own specific rules.
The Pennsylvania Exception: PACE vs. PACENET
When researching PACE, it's crucial to be aware of certain state-specific programs that use the same acronym but serve a different purpose. For example, in Pennsylvania, there is a program called PACE (Pharmaceutical Assistance Contract for the Elderly) that is exclusively a prescription assistance program with its own distinct income limits. The national PACE (Program of All-Inclusive Care for the Elderly) is a completely different, much broader program.
Comparing PACE Payment Tiers
To make the payment structure clearer, here is a comparison of how different financial situations affect your costs in the PACE program.
| Enrollment Status | Monthly Cost | Copayments & Deductibles |
|---|---|---|
| Dual Eligible (Medicare + Medicaid) | Free for long-term care portion. | No copayments or deductibles for approved services. |
| Medicare Only | Monthly premium for long-term care and Medicare Part D. | No copayments or deductibles for approved services. |
| Private Pay (No Medicare or Medicaid) | Full monthly premium, potentially thousands of dollars. | No copayments or deductibles for approved services. |
What to Do Next
If you are considering PACE for yourself or a loved one, here are the steps you should take:
- Assess Clinical Need: Determine if the individual requires a nursing home level of care, as certified by your state's assessment agency. This is a non-negotiable step.
- Verify Location: Confirm that the individual lives within a PACE organization's specific service area. Find a provider using the National PACE Association's website.
- Check Financial Status: Evaluate income and assets relative to your state's Medicaid limits. This will indicate whether you'll pay a premium or receive services for free.
- Consult with a PACE Counselor: A local PACE organization can provide definitive answers regarding eligibility and costs specific to your situation. They can also help navigate the enrollment process.
Conclusion
In short, while the national Program of All-Inclusive Care for the Elderly (PACE) program does not use income as a direct factor for eligibility, your income is critically important because it determines your eligibility for Medicaid. If you qualify for Medicaid, you receive the full PACE benefits at no cost, which is the case for approximately 90% of PACE participants. If you only have Medicare, you will pay premiums for the long-term care portion, and if you have neither, you can enroll privately at a much higher cost. The key takeaway is that income affects your financial obligation, not your ability to enroll, as long as you meet the age, location, and nursing-home-level-of-care requirements. For more information on the federal program, consult official sources like the Centers for Medicare & Medicaid Services.
