Heartland PACE

Heartland PACE


An FAQ List to Help You Understand How the PACE Program Works

A PACE program is a managed care benefit for the community-dwelling frail elderly, featuring medical and social services in an adult daycare setting. These services are supplemented by in-home and referral services depending on participant needs. Skilled healthcare professionals make that determination.

Enrollment is always voluntary. Once eligibility has been determined, an Enrollment Agreement is completed and signed. This agreement contains information such as demographics, a description of benefits, an effective date, an explanation of policy premiums, and care. Eligibility criteria will be discussed in future blogs.

If a major health event or change in medical status occurs between the enrollment date and the first of the following month, enrollment may be delayed or denied. If the potential participant is no longer able to live safely in the community, enrollment will be denied.

PACE centers provide participants with ongoing care needs along a broad continuum. These services include nursing and personal care, as well as physical, occupational, and recreational therapy. Meals and nutritional counseling, promote wellness and many forms of healing. Social services are provided to help participants and their family members.

PACE programs provide comprehensive transportation to the PACE center for activities and healthcare services, as well as to all approved community-based medical services.

PACE participants may voluntarily disenroll from the program for any reason. Those with Medicare or Medicaid will be assisted in returning to their former health care coverage. A participant will never be disenrolled due to changes in health status.

Medicare and Medicaid are the largest contributors to the PACE program. If you have Medicaid and Medicare, there is no premium. If you have Medicaid only, there is no premium. If you have Medicare, but do not qualify for Medicaid, you pay the monthly Medicaid portion plus a Part D (prescriptions) premium. If you are not eligible for either Medicaid or Medicare, there is a self-pay rate available. Note, that if you live in or move into assisted living or a nursing home, you may have a copay.

Includes participants who have long-term care insurance (or other insurance) that pays the long-term care premiums completely or partially.

Participants may privately pay for PACE if they do not qualify for the full premium to be covered by Medicaid and/or Medicare. Medicare eligible individuals who do not qualify for Medicaid as well as individuals who neither qualify for Medicaid or Medicare may pay a private pay premium to participate in PACE.

Enrolling in a PACE program allows participants to enjoy the comforts of home and family while receiving required care and supervision during the day. This allows caregivers the freedom to work and tend to their own needs. The program is built on the belief that seniors with chronic care needs are better served in the community whenever possible.

Upon enrollment you will receive a PACE ID card showing that you are a participant in the PACE program. Your care team will work with you to implement your personal care plan that is designed just for you.

The goal is to help achieve and maintain the highest functional level for each individual participant. PACE programs seek to effectively manage chronic conditions and reduce the number of re-hospitalizations. The capitated pay structure offers an incentive for providers to manage the provision of care and to maintain a state of relative wellness for each participant. PACE organizations focus on helping the frail and elderly live in the community for as long as possible. To meet this goal, PACE organizations focus on preventive care.

Each PACE program has a group of medical providers on staff including medical doctors and nurse practitioners providing medical care as needed. This group typically includes a medical director who guides the program and oversees the other providers. PACE providers become familiar with the history, needs, and preferences of each participant. Medical specialties, such as audiology, dentistry, optometry, podiatry, and speech therapy, are typically provided as required.

If a PACE enrollee needs nursing home care, the PACE program continues to coordinate the enrollee’s care. While all PACE participants must be certified as needing nursing home care, only a small percentage of PACE participants nationwide live in nursing homes.

To qualify for PACE, an individual must be 55 years of age or older; able to live safely at home in your community with support; qualify for nursing facility level of care as determined by your state, and live in a PACE program service area.

The participant may have Medicare coverage as the only source of insurance with either part A or part B individually, or combined. There is an out-of-pocket cost, due to a long-term care premium not covered for those without Medicaid.

This includes participants who are covered by Medicare AND Medicaid.