PACE-Affordable, Accountable, and All-inclusive
A Benefit Plan Focused on Your Health Long-Term
A recent poll released by The AP-NORC Center for Public Affairs Research reported, “two out of every three people over the age of 40, have made no plans regarding paying for long term care. The irony is that seven out of ten people will need long term care services once they pass the age of 65.” The poll also showed a continued lack of understanding about how long term care is funded, with over 50% of seniors unaware that their current insurance, like Medicare, does not cover services such as continuous rehab and the homecare support needed for long term care success.
Fortunately, there is a long-term benefit plan that is affordable and available for all seniors, regardless of when they decide to plan for their future. PACE (Program of All-inclusive Care for the Elderly) is designed to meet the needs of seniors 55 and older requiring home and community based support, so they can continue to thrive and take ownership of their healthcare and quality of life. As a Medicare not for profit, Medicaid state plan option, PACE meets the needs of many seniors who otherwise would not be able to afford services necessary for their overall health and wellness while aging at home. Enrollment is voluntary, and those who are eligible for enrollment do not have to wait until open enrollment to take advantage of all PACE has to offer.
As a health plan, PACE organizations become the all-inclusive payer for services. Private monthly premiums, if any, for the PACE benefit plan, are calculated utilizing sliding scale guidelines set by the State. Regardless if a participant has a monthly premium or not, once they are enrolled in PACE, they are no longer required to pay co-payments or deductibles for authorized services, including but not limited to prescription drug coverage benefits and traditional services covered under Medicare Part B. This model of pricing ensures PACE is an affordable long term care option for everyone.
So what makes PACE uniquely different than similar health plans? PACE organizations also provide healthcare directly through a comprehensive service delivery system. With an Interdisciplinary Team (IDT) approach to care, healthcare professionals, such as Primary Care Physicians (PCP), Social Workers, Nurses, Dieticians, and Therapists, work with participants and their caregivers to assess needs, and develop care plans. Being fully responsible for the quality of both the cost for and care of services provided directly by PACE staff and contracted providers, PACE organizations provide both accountable and patient centered care across preventive, primary, acute, and long-term-care services.
The program is open to both Medicare and Medicaid beneficiaries and provides comprehensive medical and social services at home, specialty care as needed, and adult day health as an alternative for those who would otherwise require nursing home care. PACE programs are a very good option for families and working caregivers that are able to provide some level of care but need additional support with services such as transportation for appointments, preventing social isolation, and services involving activities of daily living like bathing, dressing, or cooking (all of which are covered under the PACE benefit plan).
The majority of the services are coordinated and provided at the PACE Day Health Center. This once stop shop model for participants enrolled includes a PACE Medical Clinic for both Primary Care and Urgent Care needs, an Adult Day Health Program promoting socialization and engagement, areas for therapeutic recreation, restorative therapies, personal care, transportation and nutrition. Other benefits of PACE include capped financing for the program, which means that providers can deliver virtually all the health services that participants need like home based support and additional services currently not reimbursable under the fee-for-service plans offered by Medicare and Medicaid.
PACE participants may be fully and personally liable for the costs of out-of-PACE program agreement services or out of network providers if prior authorization is not obtained. Any additional services recommended by a PACE provider, including referrals to other providers, diagnostic tests and treatments must be specifically authorized by PACE. In most cases, the PCP and/or IDT will authorize additional services, tests, and treatments based on the PACE authorization criteria of medical necessity, and/or ability for the services to improve the participant’s quality of life significantly.
All PACE organizations are approved by Centers for Medicare and Medicaid Services (CMS) and NC Medicaid. Federal and state agencies are required to consistently monitor PACE organizations and ensure that they comply with state and federal regulations, and provide both quality care and services. For more information on PACE or how to enroll call 704-887-3840 or visit www.pacesp.com
