PACE: Eligibility, Services, and Cost

PACE eligibility starts with four local checks when a parent needs medical care, daytime support, and help at home under one plan. The parent has to be at least 55, live inside a PACE organization's service area, need a nursing-home level of care as the state certifies it, and be able to live safely in the community with help from PACE. Search for a PACE plan for that address, or call the state Medicaid office, and ask whether the address is covered before you sort doctors or bills.

Who should call a local PACE organization?

The Program of All-inclusive Care for the Elderly is a Medicare and Medicaid program for older adults who need nursing-home level care and are trying to stay in the community. Medicare's PACE page says you can join if you meet four conditions: you are at least 55, you live in the service area of a PACE organization, you need a nursing home-level of care as certified by your state, and you are able to live safely in the community with help from PACE. The eligibility rule states: "Eligibility to enroll in a PACE program is not restricted to an individual who is either a Medicare beneficiary or Medicaid beneficiary." A parent with both, with one of them, or with neither can still be screened. Any extra condition in a local program agreement cannot change the age rule, the state's care determination, or the requirement to live in that organization's service area.

Call when daily support is already at a nursing-home level and you want it coordinated in the community. Skilled home health is a different split, in Medicare home health vs non-medical home care. A Part B training visit tied to the treatment plan is on Does Medicare Pay for Caregiver Training?.

How do you confirm the service area and the care assessment?

The service area belongs to one PACE organization. Medicare tells families to search for PACE plans in the area or to call the state Medicaid office. Ask whether this street address is inside the area now.

The state administering agency decides the care level. 42 CFR 460.150 requires the person to "Be determined by the State administering agency to need the level of care required under the State Medicaid plan for coverage of nursing facility services, which indicates that the individual's health status is comparable to the health status of individuals who have participated in the PACE demonstration waiver programs." The CMS enrollment chapter says that agency assesses the potential participant, including a person who is not eligible for Medicaid. PACE staff also assess whether the parent can be cared for in a community setting. The state sets those safety criteria, and they go in the program agreement.

If the organization determines that living in the community would jeopardize the parent's health or safety, it has to deny enrollment, give the reason in writing, and refer the family to other services. Bring the address and any Medicaid caseworker so they can say who books the assessment.

How are medical care, adult day, home support, and transportation arranged?

One team coordinates the care. Medicare says PACE covers all Medicare- and Medicaid-covered care and services, plus anything else the team decides the person needs in order to improve and maintain health, including prescription drugs. The service rule states: "These services must be furnished in at least the PACE center, the home, and inpatient facilities."

On the Medicare list of services PACE may cover, adult day primary care includes meals and recreational therapy. The same list includes home care, personal care and support services, and transportation to and from the PACE center and medical appointments, along with primary care, hospital care, specialty care, dentistry, emergency services, and nursing home care when medically necessary. The team assigns what this person needs. Center days and home hours come from that plan.

Each center has to furnish primary care, social services, physical therapy, occupational therapy, personal care and supportive services, nutritional counseling, recreational therapy, and meals. How often someone attends is up to the interdisciplinary team, based on that participant's needs and preferences. Ask who arranges the ride on center days.

A few hours or a longer break so a caregiver can step away is a different task. How to filter that break by the hours you need is in respite care for an aging parent.

What should you ask about the cost?

Sort the question by the coverage the parent has today, and get the dollar amount from the organization. Medicare's PACE page, checked 2026-10-19, says: "If you have Medicaid, you won't pay a monthly premium for PACE." A participant who has Medicaid does not pay a monthly PACE premium.

If the parent does not qualify for Medicaid but has Medicare, the amount depends on Part A, Part B, or both. It also includes a monthly premium for the long-term care portion of the PACE benefit and a premium for Medicare Part D drugs. If the parent has neither Medicare nor Medicaid, they can pay the PACE premium themselves. That page does not print a national premium.

For a drug, service, or other care the team approves, you will not have a deductible, a copayment, or co-insurance. The CMS enrollment chapter still requires the agreement to notify a Medicaid participant, and a participant with both Medicare and Medicaid, that they are not liable for premiums but may be liable for a spenddown and for amounts due under the post-eligibility treatment of income. Ask the local organization whether either amount applies.

What happens to the current doctor, medicines, and other coverage?

During intake, the CMS enrollment chapter says staff must explain "The requirement that the PACE organization would be the participant's sole service provider and clarification that the PACE organization guarantees access to services, but not to a specific provider." Ask whether the current doctor and the specialists can keep seeing your parent, or who in the network would take that place.

If the parent has Medicare and joins PACE, Part D drugs and the other necessary medication come through PACE. Joining a separate Medicare drug plan while the parent is in PACE disenrolls them from PACE. Ask how current prescriptions would be filled, and do not start a new drug plan while you are waiting.

A PACE participant may not be enrolled at the same time in another Medicare Advantage plan, a Medicare prescription drug plan, a Medicaid prepayment plan, or an optional benefit such as a 1915(c) home and community-based services waiver or the Medicare hospice benefit. Choosing one of those after joining is treated as leaving PACE. Ask the organization what enrollment would do to the plan the parent already has. Do not drop Medicare Advantage, a separate drug plan, a waiver, or hospice on your own before that conversation.

End-of-life care and the Medicare hospice benefit are different steps. Participants who need end-of-life care will receive the appropriate medical, pharmaceutical, and psychosocial services through the PACE organization. If the parent specifically wants the hospice benefit from a certified hospice organization, the participant must voluntarily disenroll from PACE, and the organization coordinates the transition with the state and that hospice.

Original Medicare dementia coordination sits on What Is the Medicare GUIDE Model?. A family that does not fit GUIDE can still ask a PACE organization to run the four checks. One answer does not decide the other. Medicare Advantage belongs in the PACE call, because the two cannot run together.

What should you ask on the next call?

Make one call, to the PACE organization or to the Medicaid office that can point you to it. Ask:

1. Does the service area cover this address right now?
2. How do we schedule the state's nursing-home level-of-care assessment, and the check on living safely in the community?
3. Can the current doctor and specialists keep seeing my parent, or who in the network would take that role?
4. How will current medicines be filled, and what happens to a separate Part D plan?
5. What would my parent pay: a monthly premium, and any Medicaid spenddown or post-eligibility income amount?
6. If my parent qualifies and signs, when do services start?

The enrollment chapter says: "If the prospective PACE enrollee meets the eligibility requirements and signs the PACE enrollment agreement, the effective date of enrollment in the PACE program is on the first day of the calendar month following the date the PACE organization receives the participant's signed enrollment agreement."

Frequently asked questions

Who can get PACE?

Someone who is at least 55, lives in a PACE organization's service area, needs a nursing-home level of care certified by the state, and can live safely in the community with help from PACE. Call the state Medicaid office or a local PACE organization and ask whether the address is in a service area.

What does PACE cost?

Ask the organization for this parent's amount. A participant who has Medicaid does not pay a monthly PACE premium. A participant with Medicare but not Medicaid should ask about the Part A or Part B amount, the long-term care premium, and the Part D premium, and a participant with neither can pay the PACE premium privately. Medicare prints no national premium on its PACE page, and a Medicaid participant may still have a spenddown or a post-eligibility income amount for the organization to explain.

How do I apply for PACE?

Search for PACE plans near the address, or call the state Medicaid office. Intake includes a home visit and can include a center visit, plus the state care assessment. If the parent qualifies and signs, enrollment starts on the first day of the next calendar month after the organization receives the signed agreement.

What happens if you join a separate Medicare drug plan while in PACE?

Joining a separate Medicare drug plan while the parent is in PACE disenrolls them from PACE. Ask the organization how it will fill current prescriptions before anyone enrolls in another drug plan.

Sources

• Medicare.gov, PACE. Four enrollment conditions, the services PACE may cover, the three premium situations, team-approved care without a deductible, copayment, or co-insurance, and disenrollment from a separate Medicare drug plan. Checked 2026-10-19.
• Cornell Law School, 42 CFR 460.150. Age, state nursing-facility level of care, service area, and the rule that eligibility is not limited to Medicare or Medicaid beneficiaries. Checked 2026-10-19.
• Cornell Law School, 42 CFR 460.98. Care in the PACE center, the home, and inpatient facilities, and the center's minimum services. Checked 2026-10-19.
• CMS, PACE Chapter 4, Enrollment and Disenrollment, Rev. 3, 12-05-23. State assessment, sole provider and no guarantee of a specific provider, spenddown and post-eligibility income, end-of-life care through PACE, hospice disenrollment, and the enrollment effective date. Checked 2026-10-19.