§1396u–4 Program of all-inclusive care for elderly (PACE)

Summary

States may let Medicaid pay for care through PACE programs. People who join a PACE program and are eligible for Medicaid get all their covered care through that program. The PACE provider is paid under a written agreement. Providers must give all Medicare and Medicaid covered items and other services required by rule, with no deductibles, copays, coinsurance, or limits on amount, duration, or scope. Care must be available 24 hours a day. Providers must use a team that integrates medical and long‑term care, arrange for services they do not provide directly, keep a quality plan, protect participant rights, and follow rules limiting extra billing. Definitions (one line each): PACE program — an all‑inclusive elderly care program meeting PACE rules; PACE provider — the nonprofit or public entity that runs a program under an agreement; PACE program agreement — the contract among the provider, the Secretary, and the State; PACE program eligible individual — someone age 55+, needing nursing‑facility level care, living in the program’s area; PACE protocol — the original On Lok program protocol; PACE demonstration waiver program — earlier demo authority programs; State administering agency — the State office that oversees PACE agreements; trial period — the first 3 contract years; regulations — rules the Secretary issues under this law. States and the Secretary must decide eligibility and collect uniform health data. Health status must match the PACE demo group. Eligibility is normally checked at least yearly, though the State can waive annual checks in some severe chronic cases. People may leave a PACE program any time. A program may only disenroll someone for timely nonpayment of premiums (if any) or for disruptive or threatening behavior, and proposed disenrollments get timely review by the Secretary or State. States pay PACE providers a prospective monthly capitation amount for each enrolled person. The amount must be less than what the State would otherwise pay under the State plan and must be adjusted for enrollees’ frailty and other factors. The Secretary and State make and monitor agreements. Early operations get extra oversight during the trial period, including annual onsite reviews of finances, capacity, and compliance. The Secretary can require corrective plans, withhold payments, or terminate agreements for cause. The Secretary will write regulations, may adapt the PACE protocol for flexibility but may not change core elements (focus on frail elderly needing nursing care; integrated acute and long‑term care; team care management; capitated integrated financing; provider assumes full financial risk). Up to 40 PACE providers were allowed as of August 5, 1997, with that capable of increasing by 20 each year; up to 10 for‑profit waivers may be granted and are not counted against that limit. States may treat post‑eligibility income for PACE the same as under certain Medicaid waivers. PACE providers may also contract with other payers for people not eligible for Medicare Part A or enrolled under Part B or for Medicaid.