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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Program of All-Inclusive Care for the Elderly

DMA Clinical Policy and Programs
Phone Number 919-855-4340
Fax 919-715-2372

The Program of All-Inclusive Care for the Elderly (PACE) is a national model for a capitated managed care program for the frail elderly authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing.  PACE is an innovative model that provides a range of integrated preventive, acute care, and long-term services to manage the complex, medical, functional, and social needs of the frail elderly.  The PACE model is regulated by the Centers for Medicare and Medicaid.  PACE combines Medicaid and Medicare funding to serve persons who meet the State Medicaid plan for coverage of nursing facility services.  The overall goal of PACE is to manage all the health and medical needs of this frail population to keep them out of the hospital or a nursing facility for as long as possible.

To participant in PACE, an individual must be Medicaid only, Medicare/Medicaid, Medicare only or ability to privately pay.

SPECIAL BULLETIN: Cap Limits on PACE Enrollments for State Fiscal Year 2014

 

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PACE Contacts

Clinical Coverage Policies

For changes and updates to coverage criteria, billing information, and other program requirements refer to the N.C. Medicaid general and special bulletins.

What is the Purpose of PACE?

PACE is an innovative model that provides a range of integrated preventative, acute care, and long-term care services to manage the often complex medical, functional, and social needs of the frail elderly.  PACE was created as a way to provide Medicaid beneficiaries, family, caregivers and professional health care providers the flexibility to meet a person’s health care needs while continuing to live safely in the community.

The purpose of a PACE program is to provide pre-paid, capitated, comprehensive health care services that are designed to:

  • Enhance the quality of life and autonomy for frail, older adults;
  • Maximize dignity of and respect for older adults;
  • Enable frail, older adults to live in their homes and in the community as long as medically and socially feasible; and,
  • Preserve and support the older adult’s family unit.

Who is Eligible for PACE?

To receive PACE services, an individual must:

  • 55 years of age or older;
  • Be determined to need the level of care required under the State Medicaid plan for coverage of nursing facility services;
  • Reside in the PACE organization’s service area; and
  • Be able to live in a community setting at the time of enrollment without jeopardizing his/her health or safety based on criteria set forth in the program agreement.

In addition, must meet any additional program-specific eligibility conditions imposed under its respective PACE Program Agreement.

To be eligible for PACE under Medicaid or Medicare/Medicaid, an individual must be financially eligible to receive Long-term Care Medicaid Services.

How do you enroll in a PACE program?

Enrollment Process

  • Enrollment in the PACE program is voluntary. A comprehensive assessment of needs is completed by the PACE center through and Interdisciplinary Team (IDT) approach.  If an individual elects PACE, an Enrollment Agreement is signed.  This agreement contains participant’s demographic data, description of benefits, effective date, explanation of policy regarding premiums, emergency care protocol and participant’s rights and responsibilities.   Enrollment in the PACE program continues until the participant’s death regardless of changes in health status unless the participant voluntarily disenrolls or the PACE organization involuntarily disenrolls the participants for strictly defined reasons.

Comprehensive Assessment

  • The initial and annual comprehensive health assessment must be conducted by eight of the eleven IDT team members for each new participant.  Each IDT member uses a discipline-specific standardized health risk assessment form developed or adopted by the PACE organization.

Enrollment Effective Date

  • A participant’s enrollment in PACE is effective on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement.  Between the signing of the enrollment agreement and its effective date, the PACE organization may elect to provide services to the newly signed enrollee. However, any services provided are not considered “PACE” services until the effective date of the enrollment.

How are PACE services managed?

PACE uses an Interdisciplinary Team (IDT) to case manage all the services provided or arranged by the PACE Program for each participant.   Consistent with Federal regulations, the PACE program IDT must be comprised of the following members:

  • Primary Care Physician;
  • Registered Nurse;
  • Masters Level Social Worker;
  • Physical Therapist;
  • Occupational Therapist;
  • Dietitian;
  • Recreational Therapist or Activity Coordinator;
  • PACE Center Manager;
  • Home Care Coordinator;
  • Personal Care Attendant; and,
  • Transportation Driver

What is the PACE payment methodology?

PACE organizations are paid monthly prospective payments for each eligible enrolled PACE program participant.  PACE services are financed by combined Medicare and Medicaid prospective capitation payments, and, in some instances, through private premiums. PACE organizations receive a monthly capitation payment for each eligible enrollee, and combine these funds into a common pool from which providers pay health care expenses. This capitated financing allows PACE organizations to deliver all services participants need rather than be limited to those reimbursable under the Medicare and Medicaid fee-for-service systems. In exchange, PACE organizations assume full financial risk for all the health care services enrollees need, despite the amount, duration, or scope of services.

As a Medicare program and a Medicaid state plan option, PACE organizations receive two capitation payments per month for dually eligible participants.

Medicare eligible participants who are not eligible for Medicaid pay monthly premiums equal to the Medicaid capitation amount and a premium for Medicare Part D drugs, but no deductibles, coinsurance, or other type of Medicare or Medicaid cost-sharing applies. For those participants eligible for Medicaid, but not Medicare, the state will pay the full cost to the PACE organizations.

What services does PACE provide?

PACE Center.  The PACE Program provides a PACE Center that includes a primary care clinic, an adult day health program, areas for therapeutic recreation, restorative therapies, socialization, personal care, and dining that serves as the focal point for coordination and provision of most PACE services.

In-Home Care.  The PACE Program provides additional care to the individual in the home, such as In-Home Personal Care Services and home health care.

Acute, Emergency Care and Long Term Care Services.  The PACE Program arranges, manages, and pays for all care referred to community providers, including hospital services, nursing facility care, emergency room services, physician visits, and ancillary services.

Federal regulations require all PACE Programs to provide a comprehensive array of services that include the following:

  • All Medicaid-covered services, as specified in the State’s approved Medicaid plan;
  • Multidisciplinary assessment and treatment planning;
  • Primary care, including physician and nursing services;
  • Social work services;
  • Restorative therapies, including physical therapy, occupational therapy, and speech-language pathology services;
  • Personal care and supportive services;
  • Nutrition counseling;
  • Recreational therapy;
  • Transportation;
  • Meals;
  • Laboratory tests, x-rays, and other diagnostic procedures;
  • Drugs and biologicals,
  • Prosthetics, orthotics, durable medical equipment, corrective vision devices, such as eyeglasses and lenses, hearing aids, dentures, and repair and maintenance of these items;
  • Medical specialty services including, but not limited to the following:
    • Digestive Health
           Gastroenterology

    • Ear, Nose, Throat and Hearing Health      
         Otorhinolaryngology
         Audiology

    • Eye Health
          Ophthalmology

    • Foot Health
           Podiatry

    • Female Health
           Gynecology

    • Internal Medicine
           Cardiology
           Nephrology
           Oncology
           Pulmonary Disease
           Rheumatology

    • Mental Health
           Psychiatry

    • Oral Health
           Dentistry
           Oral Surgery

    • Pharmacy
           Pharmacy Consulting Services

    • Preventive Health
           Radiology

    • Skin Health
           Dermatology

    • Surgery Services
           Anesthesiology
           General Surgery
           Orthopedic Surgery
           Plastic Surgery
           Thoracic and Vascular Surgery

    • Urinary & Male Reproductive Health
           Urology
  • Acute inpatient care to include:
    • Ambulance,
    • Emergency room care and treatment room services;
    • Semi-private room and board,
    • General medical and nursing services,
    • Medical surgical, intensive care, and coronary care unit,
    • Laboratory tests, x-rays, and other diagnostic procedures,
    • Drugs and biologicals,
    • Blood and blood derivatives,
    • Surgical care and anesthesia,
    • Oxygen,
    • Physical, occupational, respiratory therapies, and speech language pathology services, and
    • Social services.
  • Nursing facility care to include:
    • Semi-private room and board;
    • Physician and skilled nursing services;
    • Custodial care;
    • Personal care and assistance;
    • Drugs and biologicals;
    • Physical, occupational, recreational therapies, and speech language pathology, if necessary;
    • Social services; and,
    • Medical supplies and appliances

Other services determined necessary by the Interdisciplinary Team to improve and maintain the participant’s overall health status.

What types of organizations can develop a PACE Program?

A PACE organization is a not-for-profit private or public entity that is primarily engaged in providing PACE services. The following characteristics also apply to a PACE organization. It must:

  • have a governing board that includes community representation;
  • be able to provide the complete service package regardless of frequency or duration of services;
  • have a physical site to provide adult day services;
  • have a defined service area;
  • have safeguards against conflict of interest;
  • have demonstrated fiscal soundness; and,
  • have a formal Participant Bill of Rights.

All PACE programs are approved by Centers for Medicare & Medicaid Services (CMS) and N.C. Medicaid.  Both federal and state agencies are required to monitor PACE programs on an ongoing basis and ensure that they comply with all state and federal regulations and provide quality care and services.

How are PACE service areas awarded?

Service Area.  Each PACE Program must define its service area and that service area must be initially approved by DMA and the final approval is granted from The Centers for Medicare and Medicaid Services (CMS).

There are ten organizations currently operating PACE programs in North Carolina.

There are two PACE programs in development in North Carolina.

 

Additional PACE Resources

National PACE Association
801 North Fairfax Street
Suite 309
Alexandria, Virginia  22314
(703) 535-1565
www.npaonline.org

North Carolina PACE Association
2401 Weston Parkway
Suite 101-B
Cary, NC  27513

 

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