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Integrating Medicare and Medicaid Through PACE

Integrating Medicare and Medicaid Through PACE

When it comes to government programs, there are some individuals who qualify for both Medicare and Medicaid benefits. In an attempt to integrate such benefits, there are certain programs in place.

Programs of All-Inclusive Care for the Elderly, or PACE, works to integrate Medicare and Medicaid services, as well as to provide benefits at a low cost for those who qualify. However, this program is not available on a nationwide basis. At this time, PACE services approximately 20,000 individuals across 30 U.S. states.

The primary focus of PACE is to assist individuals who would otherwise require nursing home care to continue living in their homes or with their families in the community for as long as they possibly can. The program also offers comprehensive medical and social services, which include such items as home health care, day care, and physical therapy, as well as social work counseling, dentistry, meals, transportation, and many other additional services. If needed, PACE can also offer both hospital and nursing home care.

Those who are on a PACE plan are not allowed to choose their doctors. Rather, these participants are assigned to a primary care physician who is one of a team of health care professionals that work with both the patient and his or her family to help in maintaining the individual’s overall health.

The health care team will also offer support for the patient’s caregivers. An additional service that is offered through PACE is prescription drug coverage. Because of that, PACE participants may or may not need to purchase a Medicare Part D prescription drug plan.

How To Enroll In A PACE Program

In order to be eligible for PACE, an individual must meet the following criteria:

  • Age 55 or over
  • Certified by his or her state as being eligible for a nursing home level of care following an assessment by the PACE plan’s care team
  • Enrolled in Medicare, Medicaid, or both
  • Has the ability to live safely in the community with the assistance of PACE

In addition, the PACE program that serves the individual’s particular area must be accepting new enrollees.

How PACE Works Once a Person Is Accepted in the Program

Once a person has been accepted into the PACE program, they will be charged no deductibles or copayments for any of the services that they receive. Nor will they be required to pay for prescription drugs that are approved by their PACE care team. There may, however, be other costs that are incurred, depending on their particular situation.

For example, if the individual is qualified for Medicaid, he or she may pay a small monthly payment (although they will pay nothing for long-term care if they need it). The PACE plan will determine the amount of this payment.

If, however, the individual does not qualify for Medicaid, then they may be required to pay a monthly premium in order to cover the long-term care portion of the PACE benefit, as well as a monthly premium for Medicare Part D drugs. In each case, the individual will pay what the plan requires.

For those who qualify for PACE, they are allowed to join the program at any time. If a qualified individual is enrolled in Medicare, then he or she will get a Special Enrollment Period so that they can leave traditional Medicare or their Medicare Advantage plan in order to join the PACE program. (It is important to note that a person cannot be enrolled in both Medicare and PACE at the same time).

An individual is also allowed to leave a PACE program at any time and make a switch back over to either traditional Medicare (Medicare Part A and Medicare Part B) or to a Medicare Advantage plan.

Determining Whether You Qualify for PACE

In order to determine whether or not you qualify for a PACE program, as well as to find out if a PACE plan exists in your area, you can contact Medicare directly. Should there be a plan in your area, you can contact the plan and arrange to have a home visit with you or your caregiver, or you can alternatively arrange to make a visit to the PACE center.

The plan will typically set up a meeting with you and its care team for both a medical and a social assessment that will be able to determine your eligibility factors for the program going forward. Until that time, it will be important that you remain enrolled in your current Medicare plan of coverage.


MedicareWallet.com is an unbiased, online resource for individuals turning 65 or already on Medicare. Our utmost goal is to provide information in a way that is user-focused, informative and ethical. With a combined 40 years of experience in the Medicare market, we can answer any questions about Medicare and Medigap insurance. Feel free to reach out to us at 800.376.0824 or by email atinfo@medicarewallet.com.

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