Experiences, good or bad, with the PACE program, especially in Virginia?

Carol, something else re:PACE. Clearly find out how this PACE does their “living safely in the community” assessment and if this PACE really wants it so there is someone else in the home all nonPACE hours

PACE - in theory - is for those who would be in a NH/SNF if it was NOT for their being able to be in PACE. So the enrollee would be at the point that they have an assessment that clearly establishes they are “at need” for skilled nursing care. But instead of their need being provided for in a SNF with its 24/7 oversight, it’s going to be done at a PACE and they stay living in their home if they can live safely in their home.

((fwiw This also exists for those that do at home hospice. Hospice agency will have to have names of whomever is there the nonhospice staff time aka “a named designated adult primary caregiver”. Hospice agencies do enforce this due to Medicare rules.))

PACE does this differently….. it’s that the enrollee can “safely live in the community”. Often the enrollee lives in an inter-generational home, so there’s always an adult or two also living in the home. Or it’s a married couple with only 1 spouse is enrolled in PACE. If your friend lives alone, how this PACE does their assessment for “safely” will matter as to if PACE can work for her.

Igloo572,

How is PACE funded? Here’s the simple explanation.
 
There’s a lot of confusion online about whether PACE (Program of All‑Inclusive Care for the Elderly) is funded by Medicare or Medicaid. The truth is: it’s usually both.
 
PACE is federally authorized under Medicare, and Medicare provides a monthly payment to the PACE organization for each enrolled participant. That covers the Medicare portion of medical care.
 
In states that offer PACE as a Medicaid benefit, Medicaid also contributes a monthly payment. This helps cover long‑term services and supports like personal care, adult day health, transportation, and nursing home–level care delivered in the community.
 
For people who qualify for both Medicare and Medicaid (which is most PACE participants), the PACE program receives funding from both programs and combines those payments to provide all needed care with no separate bills or copays.
 
So:
• Medicare funds PACE everywhere it operates.
• Medicaid also funds PACE in participating states.
• Many participants are covered by both.
 
In short, PACE isn’t just Medicare or just Medicaid — it’s typically a partnership between the two to provide comprehensive, all‑inclusive care for older adults who want to stay at home instead of moving into a nursing facility.
 
https//www.cms.gov/medicare/medicaidcoordination/about/pace

I think it’s important to know that PACE is primarily a MediCARE program, not Medicaid but MediCARE. What Medicare is & how it pays becomes super important if enrolled at a PACE. So……

1. Medicare pays administrator of the program a per enrollee fixed rate every month. A “capitation”. What the rate is dependent on a # of factors but in the 5K range. For MediCARE, how it deals with paying PACE is somewhat similar to how MediCARE pays for hospice in that it too is paid a capitation rate. Issue often for capitation rate systems is programs make $ by having as many bodies as possible enrolled. So 300 elders at a PACE coming in 2 days a week is oh so much more $ than 150 elders coming in 4 days a week. This has led to some bad actors within PACE. Get my drift?
and…
2a. Medicare is health insurance. So pays only for things billed as to how Medicare runs. What has to happen for a PACE is that everyone enrolled has to - HAS TO- switch to only using the providers in their network. PACE becomes the nexus for all health care and all health care done at whatever health care system this PACE affiliated with. This is why that person said “it’s like a Medicare Advantage or like what Kaiser is“. A part of this is that the enrollee gets an entirely new M&M # for all insurance costs. All services are scheduled by PACE too. Enrollees only use that new #. If they need some weekend care, PACE does that. If their care needs goes beyond what the PACE can do, then it coordinates the move to a SNf/NH that is affiliated with the PACE.
However….
2b. As Medicare is health insurance, it needs a secondary/ gap/ supplemental health insurance. What is usually done is to have this be Medicaid. So btwn the 2 M&Ms all health care items billed & covered.
but…
2c. still some additional not-paid-by-health-insurance costs. This is where Medicaid HCBS comes in. Home and Community Based Services as it will cover those incidental costs, like meals, activities, transport. PACE really wants this to happen as they will get both $ from Medicare, Medicaid & HCBS. And HCBS - unlike Medicaid as health insurance- requires a Share of Cost of some of the enrollees monthly income (similar to the SOC paid to the NH for LTC Medicaid program). This too becomes an extra $ for the PACE. What the PACE SOC is varies wildly. & Some do no SOC at all.
2d. But as this is primarily Medicare, that means in theory the enrollee does NOT have to go onto on Medicaid as Medicare is “self-directed” program. There have been lawsuits on this. An enrollee only has to have Medicare to be at a PACE; they can keep their old nonMedicaid health insurance & not go onto HCBS at all. BUT! will have to - HAVE TO - pay a mo fee. It runs abt 3-7K mo. PACE absolutely do not want this as requires so much more staff time.

We have 2 PACE operated thru a division of Catholic Charities. That it’s CC as the administrator has mattered (both + & -) as have a pretty deep experience in having hospitals & orphanages, operating congregate living IL & AL facilities as well as NH/SNF. Have an existing population to draw enrollees from. The 2 PACE are very different as it’s representative of the demographic they are drawing from. One is very very low income w/lots of generational living situations & tend to have been on Medicaid most of their lives. Center built at an old rectory & convent using a $M+ gift from a uberCatholic donor in memory of his 1st wife. Site also has IL, also done by CC.

The other PACE, a former orphanage, is very different as draws from lots of old oil & gas retiree$ with very solid retirement$. They aren’t abt to go on Medicaid and go without their excellent supplemental health insurance policy as part of their retirement. They are not about to find themselves having a lien place for Estate Recovery due to being on HCBS Medicaid, if they can help it. They pay the mo. fee.

imho the operator of the PACE makes the difference as to quality,
& thank you for reading my Ted Talk (lol!).

Carrol,

Thoughts on PACE vs. Agency Home Care
Thanks for laying this out so clearly — it’s a real decision point.
Your understanding of PACE is accurate. It can be an excellent option for the right person, but it involves a meaningful trade-off.
PACE provides an all-inclusive model: medical care, specialists, medications, transportation, and some home care, all coordinated by one organization and paid for by Medicaid (and Medicare, if applicable). For elders with multiple conditions, this level of integration can reduce gaps and simplify care.
The trade-off is loss of choice. Once enrolled, the participant must use PACE’s doctors, specialists, pharmacies, and hospitals (except in emergencies). Quality depends entirely on the specific PACE program. Some are excellent; others are merely adequate. The structure does resemble Medicare Advantage, though with more intensive services.
Home care is an especially important point. PACE usually provides some in-home aide support, but it may not match the hours or consistency of agency-provided aides. The amount is determined by PACE’s care team and can change over time. If remaining at home with reliable aide coverage is her top priority, this needs to be discussed very explicitly.
Before enrolling, I’d want clear answers to a few questions:
• Typical number of in-home aide hours for someone with her needs
• Whether aides are PACE employees or contractors, and how continuity is handled
• Which cardiologists and nephrologists they use, and where they practice
• Which hospitals they use
• How easy it is to leave PACE later if it’s not a good fit
Bottom line: PACE doesn’t necessarily mean trading quality for convenience — but flexibility drops sharply once enrolled. Given that she is cognitively intact, values autonomy, and is currently managing with agency aides, it’s reasonable to proceed cautiously or defer PACE until her needs increase.

I hope this helps.

My answer duplicated so I'll just add here that, being on Medicaid myself, it's not always easy to find a specialist, but I've had many fine ones. But maybe that's a question to ask - if out-of-network specialists are allowed if unsatisfied with the one assigned, a second opinion is needed, or something.

Is the agency used by the PACE program? If so, that should give some continuity of care.

The program is designed to help older ones stay in their community for as long as possible so it sounds like worth checking into. And, unlike Kaiser, Medicaid isn't afraid to utilize specialists.

Being on Medicaid means you use their doctors too. Very few specialists take Medicaid. In my State, those specialists cannot have a Medicaid recipient pay out of pocket.

I’ve heard a mix, some folks find the PACE program in Virginia helpful for financing energy upgrades without upfront costs, while others run into confusion over long-term payments or contractor coordination. If you decide to go that route, read the contract carefully and check references so you know what to expect.