We all have medical needs at some time in our lives. Certain groups, like senior citizens, are at greater risk for medical problems and complications related to accident, injury, and illness. It is for this reason that senior citizens are eligible for specialized health programs like Medicare and Medicaid.
Of course, even among the elderly, there are patients who need more care than the average group member. These are those who require long-term care. If you fall into this category and you are trying to avoid the prospect of placement in a nursing home or other round-the-clock care facility, there are options for health coverage and services to help you remain within your community, and near your family.
If you qualify for Medicare or Medicaid, you are eligible to participate in the PACE program for adults age 55 or older. What is PACE? How does it work? Who is it for?
Here are a few things you need to know.
What is PACE?
PACE, or the Program of All-inclusive Care for the Elderly, is a program that works in tandem with Medicare and Medicaid. It ensures that elderly patients are able to remain in their community and receive the health care they need, as opposed to being placed in a nursing home or similar facility for ongoing care. The ideology of the program revolves around the well-being of the patient, which is better served by remaining near family and friends in their community of residence.
Although PACE officially received waivers to operate from Medicare and Medicaid in 1990, the concept traces back to the Chinatown-North Beach Health Care Planning and Development Corporation (later On Lok).
This non-profit organization has the goal of providing a comprehensive system of care for needy patients. This includes such things as housing assistance, in-home care, home-delivered meals, medical services, social services, and trained medical professionals, all within a community.
In 1974, On Lok began to receive reimbursement from Medicaid, allowing the organization to expand. In 1979 the group was given a 4-year grant by the Department of Health and Human Services. In the 1980s, other organizations began to try the On Lok model, and with Medicare and Medicaid waivers to operate, PACE programs rapidly spread. As of 2015, 112 PACE programs were operating in 32 states, providing needed care to seniors with ongoing medical needs.
What Services are Offered?
Those who use PACE will receive all the services covered by Medicare and Medicaid, and potentially some that are not even covered by these programs, from PACE healthcare professionals and facilities. These services include hospital, home, emergency, and medical specialty care.
They also include nursing home and adult day primary care, occupational and physical therapy, dentistry, x-rays and laboratory testing. Additionally, they include prescription drugs, social services, and social work counseling, nutritional counseling, and home-delivered meals. They even provide for transportation to PACE facilities and medical appointments within the community.
In most cases, patients will have to use the doctors and facilities offered through PACE when participating in such programs. However, there are specialized teams of healthcare providers assigned to patients based on need. This ensures the best possible care, not to mention the advantages of working with a small group of healthcare providers for an extended period of time.
It is important to note that certain services offered through PACE preclude the use of alternatives. For example, PACE includes prescription drug coverage. If patients are simultaneously enrolled in Part D of Medicare (the prescription drug plan), benefits from PACE have been compromised as a result. At the very least, you will forfeit PACE prescription drug benefits, and possibly other health benefits, as well
Am I Eligible?
It is important to note that certain services offered through PACE preclude the use of alternatives. For example, PACE includes prescription drug coverage. If patients are simultaneously enrolled in Part D of Medicare (the prescription drug plan), benefits from PACE result in being compromised. At the very least, you will forfeit PACE prescription drug benefits, and possibly other health benefits, as well.
That said, both Medicare and Medicaid patients are eligible for PACE if their doctors deem it necessary, and they meet other requirements. In order to qualify for PACE, patients need be the age of 55 or older. They need to require a nursing home level of care, as certified by the state of residence and be able to live safely within the community that offers PACE care. Of course, a PACE organization needs to operate within the service area of the patient.
Patients have to be certified to require nursing home level care, as defined by their state of residence. They do not necessarily have to live in a nursing home to enroll in PACE. In fact, less than 10% of PACE users live in nursing homes. Either way, PACE coordinates patient care and services. In cases where participants require nursing homes care, PACE pays for the service.
What is the Cost?
Medicare requires users eligible for PACE to pay monthly premiums to cover long-term care and prescription drug benefits provided by PACE, in addition to regular costs for Medicare. Anyone on Medicaid, who is eligible for PACE, is not required to pay monthly premiums for long-term care.
With PACE, there are no co-pays or deductibles. Any healthcare services or prescription drugs approved by the PACE healthcare team have coverage with this program.
If you have neither Medicare nor Medicaid but you meet all other criteria, you may still be eligible to enroll in PACE. However, you will have to pay privately for the program.
How Can I Enroll?
Before you can enroll in PACE, first determine if such a program exists in your area and if you are eligible to participate. Your primary healthcare provider can help you make this determination based on your medical history and prognosis.
You can also find information on PACE through the Medicare website (Medicare.gov) or via your local Medicaid office. Medicare has a PACE plan search function on their website that allows you to see programs available in your state. Once you have found a suitable program in your area, you can contact the organization to enroll.