MEDICAID 15-2d

Chapter 15: Medicaid

15-2d Programs of All-Inclusive Care for the Elderly (PACE)

• Book Title: Understanding Health Insurance: A Guide to Billing and Reimbursement: 2023

• Printed By: Kristin Eubanks (eubankskristin@aol.com)

• © 2024 Cengage Learning, Inc.

• © 2025 Cengage Learning Inc. All rights reserved.

Overview of PACE

• Programs of All-Inclusive Care for the Elderly (PACE): Designed for community-dwelling older adults who are most often dually eligible for Medicare and Medicaid.

• Target Group: Older adults, particularly those eligible for both Medicare and Medicaid benefits.

• Service Delivery:

  • An interdisciplinary team of health professionals delivers coordinated care.

  • Services enable individuals to remain in their communities instead of receiving care in nursing facilities.

• Financing Structure:

  • Capitated Financing: Allows providers to offer all necessary services rather than being restricted to only those covered under traditional Medicare and Medicaid fee-for-service plans.

• Cost Management:

  • PACE limits out-of-pocket costs for participants by eliminating deductibles, copayments, and other forms of cost-sharing.

  • When a participant needs to use a noncontract provider, there are limits on charges made by these noncontract entities to the PACE program.

• Status of the Program:

  • PACE functions as a Medicare program that states can opt to implement for Medicaid beneficiaries as an added benefit.

  • Upon implementation, PACE serves as the sole source of Medicaid and Medicare benefits for its participants.

• Establishment: PACE is recognized as a distinct provider within the Medicare program, ensuring complete integration of care for participants.