Page 1

North Carolina Department of Health and Human Services North Carolina Medicaid Division of Health Benefits AGED, BLIND AND DISABLED MEDICAID MANUAL MA-2275

PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

REVISED 05/18/2021 - CHANGE NO. 07-21

I. BACKGROUND & INTRODUCTION

Program of All-Inclusive Care for the Elderly (PACE) is a federal program administered by the Centers for Medicare and Medicaid Services (CMS).

PACE is a managed care program that enables individuals who are 55 years or older and are certified to need nursing facility care to live as independently as possible.

PACE participants receive a comprehensive service package which permits them to live at home while receiving services. This prevents institutionalization. The PACE organization must provide all Medicaid covered services, in addition to other services determined necessary by PACE for the beneficiary. The PACE program becomes the sole source of services for Medicaid and/or Medicaid/Medicare eligible enrollees.

The PACE organization receives a capitated payment for each beneficiary and assumes full financial risk for participants’ care without limits on amount, duration, or scope of services. CMS establishes and pays the Medicare capitation and each State establishes and pays the Medicaid capitation. When the enrollee receives Medicaid and Medicare, the PACE organization receives a Medicaid capitation payment and a Medicare capitation payment.

A. PACE Organization

1. The PACE program is regulated through a three-party agreement among Centers for Medicare and Medicaid Services (CMS), North Carolina Department of Health and Human Services (DHHS) through the Division of Health Benefits (DHB), and the PACE organization.

2. The PACE organization administers and is responsible for enrolling individuals into the PACE program.

3. The PACE program allows North Carolina to use Medicaid funds to provide home and community-based services to Medicaid beneficiaries who require institutional care (placement in a skilled nursing facility [SNF]), but for whom care can be provided cost-effectively and safely in the community. Institutional care for PACE is defined as SNF level.

4. A PACE organization is required to provide a specified set of services that includes:

• Interdisciplinary team case management • Adult day health program • Skilled nursing care • Primary care physician services