Long-term care planning is a significant part of most elder law practices. While the ideal clients seek counsel long before there is a crisis, the usual clients do not. It is in these crisis situations that clients benefit most from the elder law attorney's knowledge of the resources available in their communities and our understanding of the medical and financial criteria for eligibility.
PACE, the Program for All-Inclusive Care for the Elderly, is a national comprehensive health program created to help elders remain at home as long as possible. While PACE is a valuable resource for many elders, it remains a fuzzy concept for many attorneys and is, thereby, under utilized. Following is a brief overview of the criteria and coverage areas of PACE.
WHERE IS PACE?
Unfortunately, PACE is not available in all cities and towns. There are presently six PACE programs in Massachusetts, each covering a different geographic area as follows:
Elder Service Plan of Harbor Health
Contact: Lisa Yorra at 617-533-2400
Avon, Brookline, Hyde Park, Norwood, Sharon,
S. Boston, Canton, Kenmore, Quincy, Soughton, Braintree, Dedham, Mattapan, Randolph, West Roxbury, Brighton, Dorchester, Milton, Roslindale, Weymouth
Uphams Elder Service Plan
Boston (area codes 02108, 02109, 02110, 02111, 02114, 02115, 02116, 02210), S. Boston, Brookline, Dorchester (area codes 02121, 02122, 02124, 02125), Hyde Park, Jamaica Plain, Mattapan, Roslindale, Roxbury
Elder Service Plan at Fallon (Summit Elder Care)
See also www.summiteldercare.org
All towns in Worcester County, Hudson, Marlboro
Elder Service Plan of the Cambridge Health Alliance
Allston, Chelsea, Arlington, Everett, Brighton, Malden, Cambridge, Medford, Charlestown, Somerville
Elder Service Plan of the East Boston Neighborhood Health Center
East Boston, Revere, Winthrop
Elder Service Plan of the North Shore, Inc.
Beverly, Ipswich, Marblehead, Salem, Wakefield, Danvers, Lynn, Middleton, Saugus, Wenham, Essex, Lynnfield, Nahant, South Hamilton, Gloucester, Magnolia, Peabody, Swampscott, Hamilton, Manchester, Rockport, Topsfield
You will note that some areas are listed in more than one PACE program. The contact person for any of the programs will appropriately direct you based on the specific address of your client in such a case. Additional information can be found on the PACE website at www.npaonline.org. Be advised, however, that while the substantive information on this site is helpful, the contact names and numbers do not seem to be updated frequently.
WHO IS ELIGIBLE FOR PACE?
In order to be eligible for PACE, applicants must be 55 years of age or older, live in a PACE service area as outlined above, and must be certified by the state as eligible for nursing home care but able to safely remain in the community with the additional supports PACE offers. Members must also agree to receive all health services exclusively through the Elder Service Plan. While many elders are initially hesitant to give up their primary care physicians or other medical professionals, it is the interdisciplinary team model of PACE that allows each member to maximize his or her potential to remain in the community and ensures that nobody falls through the cracks.
HOW IS PACE FUNDED AND WHAT SERVICES DOES PACE COVER?
PACE is jointly funded by Medicaid (2/3) and Medicare (1/3) in a capitated system. In other words, Medicaid and Medicare each pay a set rate per member per month. Medicaid presently pays $3,497 per member per month, with the Medicare rate dependent on the diagnosis codes of each member. Each PACE program must offer a number of Core Services, and may offer elective services based on the various needs of their members. This flexibility allows each program to customize individualized care plans designed to help each member maximize his or her potential.
Interdisciplinary teams of doctors, nurses, social workers, therapists, nutritionists, and other medical staff work together to provide primary medical care, home health, adult day health (recreation), rehabilitation services, transportation, medications, podiatry, optometry, dental, social services, and more. While the majority of PACE services are provided at an adult day center to encourage socialization and activity, services are provided in the home when appropriate. Some PACE programs, such as Harbor Health, offer residence in certain Assisted Living Facilities. In these cases, the member pays the rent (usually $1,000) and PACE pays the service fee. PACE members never pay more than their income to live in assisted living. If nursing home care becomes necessary, it is paid for by PACE and PACE continues to coordinate the member’s care, so long as the member resides in a PACE facility.
WHAT IS THE FINANCIAL CRITERIA FOR MEMBERSHIP
PACE accepts Medicare, Medicaid, and private payment. For married couples, only the income and assets of the applicant are countable. For members with monthly income of $2,022 or less per month, there is no monthly spenddown and they can keep the entire $2,022. For members who have income over $2,022, there is a monthly spenddown to $542. Members with monthly income over $4,039 (which represents the MassHealth amount of $3,497 plus the deductible of $542) would pay privately, while members with income below $4,039 would apply for MassHealth in order to keep the $542 monthly. Private pay members pay only the portion that Medicaid would pay, or $3,497 per month.
WHY SHOULD SENIORS CONSIDER JOINING PACE?
The most significant reason that PACE is appealing is that its primary goal is to provide each member with the individual supports needed to remain in the community as long as possible. Another benefit to consider when advising clients of their options is that PACE is covered by Community MassHealth, under which transfers of assets are presently not penalized. Therefore, for clients who have not done prior planning who are suddenly faced with the need for long-term care services, the option of joining PACE should be explored for 1) quality of life issues and 2) additional planning options. In addition, the application process for Community MassHealth/PACE is far less burdensome than the long-term care MassHealth application, requiring only the previous two months of financial statements to verify assets. Members are free to disenroll from PACE at any time. Although a transition from Community MassHealth to long-term care benefits would be required in some cases, the DMA usually does not request additional verifications at that time.
Admittedly PACE is not for every body and there are many reasons why it may not be the perfect option for you. If you are fortunate enough to live in a PACE service area, however, this is an option that warrants consideration.