Is PACE a Type of Medicare Advantage Plan?

Medicare and Medicaid offer various programs to help individuals manage their healthcare needs as they age. The Program of All-Inclusive Care for the Elderly (PACE) and Medicare Advantage plans are two distinct options. Understanding the distinctions between these programs is important for individuals seeking comprehensive care options. This article clarifies the relationship between PACE and Medicare Advantage, detailing what each program entails and how they function.

Understanding PACE Programs

The Program of All-Inclusive Care for the Elderly (PACE) is a comprehensive system designed to allow frail older adults to remain living in their communities rather than relocating to a nursing home. This model emphasizes an “all-inclusive” approach, coordinating all necessary medical and social services under one umbrella. A central philosophy of PACE is to provide integrated care that meets the specific health and personal needs of each participant. A multidisciplinary team, including primary care physicians, registered nurses, social workers, and various therapists, collaborates to deliver and manage care.

Services typically provided by a PACE program are extensive, encompassing:

• Adult day primary care
• Dentistry
• Emergency services
• Home care
• Hospital care
• Laboratory services
• Meals
• Nutritional counseling
• Occupational and physical therapy
• Preventive care
• Prescription drugs
• Social work counseling
• Transportation to the PACE center or medical appointments

The program also covers any other medically necessary care determined by the healthcare team, ensuring comprehensive support without deductibles or copayments for approved services.

Understanding Medicare Advantage Plans

Medicare Advantage plans, often referred to as Medicare Part C, represent an alternative way for individuals to receive their Medicare Part A (hospital insurance) and Part B (medical insurance) benefits. These plans are offered by private companies that have been approved by Medicare. They must cover all the services that Original Medicare covers, except for hospice care.

Many Medicare Advantage plans also include additional benefits that Original Medicare does not, such as prescription drug coverage (Part D), and sometimes dental, vision, and hearing services. Common types of Medicare Advantage plans include Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans, which structure how participants access their healthcare providers. These plans often have their own premiums, deductibles, and copayments, which vary by plan.

PACE and Medicare: Clarifying the Relationship

It is important to understand that PACE is not a type of Medicare Advantage plan. While both programs are part of the broader Medicare framework, they operate under fundamentally different structures and provide care in distinct ways. PACE is a unique, comprehensive care model that integrates all Medicare and, if applicable, Medicaid benefits for its participants.

When an individual enrolls in PACE, the PACE program becomes the sole provider and manager of all healthcare services covered by Medicare and Medicaid. This means that once enrolled, a participant’s existing Original Medicare or Medicare Advantage plan is effectively replaced, and they will be disenrolled from any previous plans, including separate Medicare Part D prescription drug plans. PACE organizations receive a fixed monthly payment for each enrollee from Medicare and Medicaid, allowing them to provide all necessary services without deductibles or copayments for approved care. This capitated payment model distinguishes PACE from the fee-for-service structure of Original Medicare or the network-based models of Medicare Advantage, as PACE is designed to deliver a holistic, coordinated care approach.

PACE Eligibility Requirements

To be eligible for a Program of All-Inclusive Care for the Elderly (PACE), individuals must meet specific criteria designed to ensure the program serves those most in need of comprehensive support.

• The individual must be 55 years of age or older. This age criterion ensures that the program is tailored to the needs of older adults who often face complex health challenges.
• Individuals must reside within the defined service area of a PACE organization. This geographical requirement ensures that participants can readily access the integrated services provided by the PACE center and its network of care providers.
• A state-level certification is required, confirming that the individual needs a nursing home level of care.
• Despite this need for extensive care, participants must be able to live safely in a community setting at the time of enrollment with the support of PACE services.

The PACE Enrollment Process

The process for enrolling in a Program of All-Inclusive Care for the Elderly (PACE) involves several structured steps to ensure the program is appropriate for a prospective participant’s needs.

• Initially, individuals or their caregivers contact a local PACE program to begin the intake process. During this initial contact, an enrollment specialist provides information about the program and gathers basic details to determine preliminary eligibility.
• Following this, a comprehensive assessment is conducted by the PACE team. This assessment typically involves medical, functional, social, and financial evaluations, often including a home visit.
• The purpose of these assessments is to fully understand the individual’s health status, living situation, and support needs.
• Once the assessments are complete and eligibility is confirmed, the PACE team develops a personalized care plan, and the individual signs an enrollment agreement, with coverage typically beginning on the first day of the subsequent month.