The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program for older adults. This program features a comprehensive service delivery system, and integrated Medicare and Medicaid financing.
Eligibility and Enrollment
To participate in PACE, an individual must:
- Be enrolled in Medicaid only
- Be enrolled in Medicare only
- Be enrolled in Medicare and Medicaid (dually eligible)
- Have the ability to privately pay
To receive PACE services, an individual must:
- Be 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
- Be able to live in a community setting when enrolled without jepoardizing health or safety
- Meet program-specific eligibility conditions imposed under the respective PACE agreement
- Enrollment in PACE is voluntary.
- The PACE organization’s Interdisciplinary Team (IDT) completes a comprehensive needs assessment.
- If an individual elects PACE, an Enrollment Agreement is signed that contains the participant’s:
- demographic data
- description of benefits
- effective date
- explanation of policy regarding premiums
- emergency care protocol
- rights and responsibilities
- PACE enrollment will continue until the participant's death regardless of changes in health status.
- PACE enrollment will end if the:
- Participant voluntarily disenrolls, or
- PACE organization involuntarily disenrolls the participants for strictly defined reasons.
Eight of 11 IDT members for each new participant must conduct initial and annual comprehensive health assessments. 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 PACE enrollment is effective the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement. Between 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 enrollment.
Client Success Stories
PACE Payment Methodology
- Organizations are paid monthly prospective payments for each eligible enrolled PACE beneficiary.
- Services are financed by combined Medicare and Medicaid prospective capitation payments and, in some instances, through private premiums.
- Organizations receive a monthly capitation payment for each eligible beneficiary, and combine these funds into a common pool from which providers pay health care expenses.
- Financing allows organizations to deliver services customers need without limiting them to services reimbursable under Medicare and Medicaid fee-for-service systems.
- Organizations assume full financial risk for all health care 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 not eligible for Medicaid pay monthly premiums equal to the Medicaid capitation amount and a premium for Medicare Part D drugs, but no deductibles, co-insurance, or other type of Medicare or Medicaid cost-sharing applies.
- For customers eligible for Medicaid, but not Medicare, the state pays the full cost to PACE organizations.
PACE Centers include 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.
A PACE organization can be a public or private entity primarily engaged in providing PACE services. A PACE organization 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
- Have a formal Participant Bill of Rights
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 quality care and services.
Each PACE organization must define its service area, which must be approved by NC Medicaid. The final approval is granted by CMS.
Managing PACE Services:
PACE uses an IDT to case manage services provided or arranged by the PACE organization for each participant. Consistent with federal regulations, the PACE organization’s IDT must have the following members:
- Primary care physician
- Registered nurse
- Masters level social worker
- Physical therapist
- Occupational therapist
- Recreational therapist or activity coordinator
- PACE center manager
- Home care coordinator
- Personal care attendant
- Transportation driver
NC PACE Organizations – Service Areas and Contacts
There are 11 PACE organizations operating in 12 locations in North Carolina.
National PACE Association
801 North Fairfax Street
Alexandria, VA 22314
North Carolina PACE Association
6805 Dwight Rowland Road #670
Willow Spring, NC 27592-9998
NC Medicaid Clinical Section
PACE Home Care Licensure FAQs
Q: 42CFR 460.62 outlines the personnel qualifications for PACE staff with direct participant contact. For home care licensure purposes, does the Division of Health Services Regulation (DHSR) require the PACE organization to have duplicate personnel files?
A: DHSR does not require PACE organizations to have duplicate personnel files. Agencies licensed to deliver home care services are required to establish and maintain a personnel record for each employee. For the PACE organization’s personnel files to comply with home care licensure requirements, the PACE organization should ensure that its personnel records include the following:
- An application or resume which lists education, training and previous employment that can be verified, to include job titles
- A description with record of acknowledgment by the employee
- Reference checks or verification of previous employment
- Documentation of a baseline skin test for TB or records of tuberculosis screening
- Documentation of Hepatitis B immunization or declination
- Airborne and bloodborne pathogen training including annual updates in compliance with 29CFR 1910
- Performance evaluations according to agency policy, at least annually
- Verification of employee’s credentials as applicable
- Records of the verification by agency supervisory personnel of all skills and competencies required of home care services personnel to carry out participant care tasks to which the employee is assigned
- Proof of consent for criminal background check and proof of appropriate criminal background check (in accordance with G.S. 131E-265)
- Health Care Personnel Registry check for unlicensed healthcare personnel
Q: 42CFR 460.71 requires the PACE organization to provide each employee and all contracted staff with an orientation that includes, at a minimum, the organization's mission, philosophy, policies on participant rights, emergency plan, ethics, the PACE benefit and any policies related to the job duties of specific staff. For home care licensure purposes, does DHSR have an annual orientation requirement?
A: According to 10A NCAC 13J .1003(d), DHSR requires home care agencies to establish and implement written policies regarding orientation. DHSR does not require an annual orientation. The frequency of orientation is determined by the PACE organization’s policy.
Q: 42CFR 460.104 outlines assessment requirements for a PACE participant. For home care licensure purposes, does DHSR require duplicate assessments and evaluation?
A: DHSR does not require duplicate assessments and evaluations. For the participant’s assessment to comply with home care licensure requirements, the PACE organization should ensure the participant’s assessment:
- Is conducted at the start of care and completed by the applicable health care practitioner.
- Includes an assessment of the participant’s functional status in the areas of social, mental, physical health, environmental, economic, ADLs and IADLs.
For agencies providing in-home aide services, the initial assessment shall be conducted in the participant's home by the health care practitioner, conducted prior to the development of the plan of care and signed and dated by the health care practitioner.
Q: 42CFR 460.106 outlines the PACE requirements related to the development, implementation and evaluation of the effectiveness of the participant’s plan of care. Is a duplicate care plan required to meet home care licensure requirements?
A: A duplicate care plan is not needed to meet home care licensure requirements. For the participant’s plan of care to comply with the home care licensure requirements, the PACE organization should ensure that the participant’s care plan is:
- Established in collaboration with the participant and incorporated in the service record
- Reviewed every 90 days and revised as needed based on the participant’s needs
- Based upon the findings of the participant assessment
The care plan should include:
- Type of service(s) and care to be delivered; frequency and duration of service; activity restrictions; safety measures; service objectives and goals
- Equipment required (when applicable); functional limitations of the participant, rehabilitation potential; diet and nutritional needs; medications and treatments; specific therapies and pertinent diagnosis and prognosis.
If an agency provides in-home aide services, the plan of care shall be signed and dated by the health care practitioner and the participant or the participant’s responsible party; the participant shall have access to a copy of the in-home aide plan of care in the home; the plan of care shall contain the level of assistance required by the participant for each ADL. If the participant’s plan of care requires the in-home aide to provide extensive assistance, the in-home aide shall be listed on the Nurse Aide Registry pursuant to G.S. 131E-255. However, if the participant’s plan of care requires the in-home aide to provide only limited assistance, the in-home aide is not required to be listed on the Nurse Aide Registry.
Q: When a participant discharges from a nursing home or hospital, the PACE organization is required to follow-up and coordinate the transition. Home care licensure requirements in the areas of lab work, wound care, therapy, end of life as well as screening and testing add significant non-value requirements that prohibit staff from easily and quickly making a face-to-face check-in with the participant.
A: DHSR requires the following data which should already be in the participant’s record:
- Admission and discharge dates from hospital or other institution when applicable
- Names of physician(s) responsible for the participant’s care
- Participant diagnoses
- Physician’s orders for pharmaceuticals and medical treatments. Care may commence in the interim with a verbal order
The PACE organization should ensure that treatment documentation specific to the home care service that was provided is included in the participant’s record.