PACE Program Eligibility Starts at Age 55

You can qualify for PACE without Medi-Cal. Medi-Cal is California’s Medicaid program, and it affects how much you pay. Medicare’s PACE page states, “If you have Medicaid, you won’t pay a monthly premium for PACE.”

The PACE Premium Without Medicaid

If you have Medicare but not Medi-Cal, expect a different cost discussion. Your amount depends partly on whether you have Medicare Part A and Part B. Medicare lists “A monthly premium to cover the long-term care part of the PACE benefit” plus a premium for Part D prescription drugs.

You may also join without Medicare or Medicaid and pay the PACE premium yourself if you meet the other requirements. Medicare does not publish one universal monthly dollar amount for these situations. Ask the specific organization serving your address to provide a written quote based on your coverage.

What You Won’t Pay

PACE can make approved-care costs more predictable. Medicare says that “Regardless of your financial situation,” you will not owe deductibles, copayments or coinsurance for drugs, services or care approved by your PACE team. Monthly premiums, when applicable, are a separate expense.

That differs from paying separately for every hour of private home care. But it does not automatically make PACE less expensive for everyone. Compare the full monthly premium with your current costs and consider how comfortable you would feel changing medical providers.

Ask for the Numbers in Writing

Ask the PACE enrollment counselor for a written estimate before you sign anything. Have them explain the long-term care premium, drug premium and what happens if you later qualify for Medi-Cal. Also ask when enrollment and any changes in your current coverage would take effect.

PACE is not simply another benefit you add to your existing coverage. Medicaid.gov explains, “The PACE program becomes the sole source of Medicaid and Medicare benefits for PACE participants.” This is a major choice, especially if you value your current doctors.

In return, PACE coordinates many kinds of support. Medicare says it covers “all Medicare- and Medicaid-covered care and services,” as well as other services your PACE team determines are needed, including prescription medications.

What PACE Can Cover

Medicare’s list of services PACE may cover includes adult day primary care, home care, hospital care, personal care, prescription drugs and physical therapy. It also includes transportation to and from the PACE center and medical appointments, and nursing home care when medically necessary.

PACE is built around coordinated care rather than isolated appointments. Ask who would become your primary care provider, how urgent concerns are handled after hours and whether transportation is available for each appointment you expect to keep.

An interdisciplinary team of health professionals coordinates it all. DHCS describes a PACE Center that provides and coordinates preventive, primary, acute and long-term care.

The Trade You’re Making

The tradeoff is how care is arranged. Your PACE team helps decide what services you need and coordinates the providers. Our guide comparing PACE, ALW, IHSS and MSSP explains, “PACE is not a home care allowance that a family spends on whichever caregiver it chooses.”

Before you join, ask whether your current doctors work with the PACE organization.

If a long-standing specialist matters to you, ask about that relationship before enrolling. Find out whether the doctor participates in the program, whether an outside consultation might be approved and who makes the final decision about referrals.

You Can Leave

You can leave PACE. Medicaid.gov says “Individuals can leave the program at any time and for any reason.” Ask the PACE team to explain the disenrollment process and how to avoid a gap in medical or drug coverage during the transition.

One enrollment mistake can change your entire care arrangement. Medicare warns, “If you join a separate Medicare drug plan while you’re in the PACE program, you’ll be disenrolled from PACE.” This is more than a change in prescription coverage.

You don’t need a separate plan anyway. With Medicare, you get your Part D covered drugs and all other necessary medication from PACE.

PACE and Part D During Open Enrollment

During fall open enrollment, you may receive calls and mail offering Medicare drug plans. Someone helping with your coverage might think a separate Part D plan would save money. Tell them you receive prescription benefits through PACE and that joining a different drug plan can end PACE enrollment.

Before responding to any drug plan offer, contact your PACE enrollment coordinator. Ask them to review the offer and explain what it would do to your existing coverage. Checking first is much easier than dealing with an unexpected loss of PACE benefits.

PACE vs Home Care or Assisted Living

PACE is one option, not the answer for everyone. You may prefer to keep your current doctors while arranging private help at home. Our home care in Los Angeles page notes that “A family may begin with home care, then later compare it with assisted living” if daily needs keep growing.

We offer home care through our sister home care company. Our home care in Orange County works the same way. “This non-medical support focuses on safety, routine, companionship, and quality of life rather than skilled nursing treatment.” That’s the key difference from PACE, which coordinates your medical care too.

If living at home is getting harder, assisted living in Orange County is another option to compare. Whichever path you choose, ask what each one covers, what you pay and who makes the decisions.

Compare the full picture instead of looking only at the monthly price. Think about where you want to live, who will help each day, which doctors you can see and how quickly you can get support if your needs change.

• Medicare.gov. “PACE.” Centers for Medicare & Medicaid Services.
• Medicaid.gov. “Program of All-Inclusive Care for the Elderly.” Centers for Medicare & Medicaid Services.
• California Department of Health Care Services. “Program of All-Inclusive Care for the Elderly.” DHCS.

Disclaimer: This article provides general educational information about the Program of All-Inclusive Care for the Elderly (PACE), its eligibility requirements and how it differs from other senior care arrangements. It is not medical advice or an individualized determination of eligibility. PACE participation generally requires individuals to be at least 55 years old, reside within an approved service area, meet the applicable nursing home level-of-care criteria and be able to live safely in the community at enrollment. Eligibility assessments, service areas, participating providers and program requirements may change. Individuals should confirm current qualifications and enrollment procedures with their local PACE organization or the California Department of Health Care Services. Raya’s Paradise is not a PACE provider and offers residential assisted living and non-medical home care through its sister company, rather than PACE-coordinated medical services.