Program of All-Inclusive Care for the Elderly (PACE)

The Program of All-inclusive Care for the Elderly (PACE), offers a benefit that combines medical care, long-term care and prescription drugs to help frail and disabled individuals age 55 and older live independently within the community.

Eligibility

To be eligible for PACE, individuals must be: 

• Age 55 or over
• Live in the counties served by a PACE center
• Meet Iowa's criteria for nursing facility level of care
• Be able to live safely in the community with help from the PACE center

PACE Cards

A PACE card takes the place of the Medicaid and Medicare cards. You will be provided with a card once you are approved for PACE. This card helps you get medical care and services. 

Medicare/Medicaid Coordination & Fees

• Individuals may have to pay the PACE centers monthly rate using private funds.
• The monthly rate will be consistent with the PACE rates paid by Medicaid or Medicare.
• You can have either Medicare or Medicaid, or both, to join PACE.
• Medicare eligible participants must apply for Medicare and get Medicare. PACE participants are not required to enroll in Medicaid. 

Medicare and Medicaid pay the PACE program to take care of your medical needs. Your Medicare and/or Medicaid card are replaced with a PACE card. The PACE center becomes your primary care provider's office. All your care has to be coordinated by the PACE team.

Monthly Share & Costs

You may have a monthly share of cost to remain eligible for Medicaid. If you live in an assisted living facility you have to pay for your room and board each month. If you are enrolled in Medicaid, you may have a monthly financial responsibility for your care. It is possible that you may have to pay for both. 

However, the absence of Medicare or Medicaid copays and deductibles are a major benefit to the PACE program.

Covered Services & Appointments

PACE services include, but are not limited to, all Medicare and Medicaid services. 

A PACE center is facility where the PACE organization is housed and provides medical services to support and assist you. 

Other medically necessary services that cannot be provided at the PACE center or in your home will be coordinated for you. PACE staff will schedule appointments for you and schedule transportation to your appointments, if needed. Any services not available at the PACE center must be authorized by the PACE team of professionals. 

Appointments for medical care outside of the PACE center are required to have prior authorization by the PACE team. You will need to pay for unauthorized appointments and services. 

If approved, the services listed can be provided, but are not limited to the following: 

Urgent Care

Call a PACE center if you need urgent care. Urgent care examples include: 

• Fever
• Acute respiratory conditions
• Vomiting
• Common cold or flu
• Other common infections including bladder, ear, skin, etc.
• Falls
• Minor injuries

Please note: Emergency services are the exception and do NOT need prior approval.

Emergency Care

An emergency is any condition that places your life in danger or causes permanent disability if not treated immediately. If you have an emergency:

• Call 911 or go directly to the nearest hospital emergency room.
• Take your PACE card with you.
• You do not need to call your PACE center first. 

However, call, or ask someone to call your PACE center as soon as possible to let the PACE staff know that you needed emergency care. PACE staff will assist you with any follow-up care that you need. The following are examples of emergencies: 

• Serious accidents or falls
• Poisoning
• Heart attack
• Stroke
• Severe bleeding
• Severe burns
• Severe shortness of breath

Follow-up Care After Emergencies

You must contact your PACE center for all follow-up care. Do not return to the emergency room for follow-up care. The PACE center will either provide or authorize this care for you. Please remember that you will need to pay for services that are not authorized by the PACE organization.

How to Apply

Contact the PACE program for the county in which you live. A representative will explain the comprehensive benefits package available through PACE and assist with the application process. The PACE representative can also provide guidance related to the Medicaid application process. 

Estate Recovery Program

The State of Iowa has the right to ask for money back from your estate after your death, called the Estate Recovery Program. All medical assistance paid out by the Department is subject to recovery. This includes: fee-for-service (FFS) claims, capitation fees to manage care organizations (MCOs), including PACE (regardless of how much the actual services cost) and interest.

Estate recovery only applies to Medicaid recipients who:

• Are age 55 or older, or
• Are under age 55 and live in a medical facility and will probably not return home.

You Have The Right To Appeal

• Appeals
• How to Appeal

Iowa Counties & PACE

At this time, PACE is not available in all Iowa counties. To learn more about the PACE program or for assistance with an application, contact the PACE center in the county where you reside.

Frequently Asked Questions

Explore answers to frequently asked questions about PACE.

What is "nursing facility level of care"?

"Nursing facility level of care" means that the following conditions are met: 

• The presence of a physical or mental impairment which restricts the participant's daily ability to perform the essential activities of daily living, bathing, dressing, and personal hygiene, and impedes the member's capacity to live independently.
• The participant's physical or mental impairment is such that self-execution of required nursing care is improbable or impossible.

Following a functional assessment, level of care eligibility is determined by the Iowa Department of Health and Human Services (HHS) Quality Improvement Organization (QIO). Eligibility is determined at the time of application and annually thereafter. 

Can I keep seeing my current doctor or use my current pharmacy?

No. PACE employs their own medical staff to serve participants. If you are in need of a specialist outside of what is available at the PACE center, PACE will schedule your appointment and provide transportation to and from the appointment. PACE contracts with a pharmacy to provide prescribed medication to participants. 

Appointments for medical care outside of the PACE center are required to have prior authorization by the PACE team. You will need to pay for unauthorized appointments and services. 

What is an Interdisciplinary Team? 

This team will help you plan and coordinate your care across any number of support settings that may include home, hospital, nursing facility, or hospice care.

The team must include the following professionals:

• Primary Care Physician (PCP)
• Registered Nurse
• Master's Level Social Worker
• Physical Therapist
• Occupational Therapist
• Recreational Therapist
• PACE Center Manager
• Home Care Coordinator
• Personal Care Attendant
• Transportation Driver
• Dietician

How are decisions about my care made?

Decisions about your health care, long-term care and medications are made by you and your PACE team. The PACE team of healthcare professionals are committed to providing quality care to keep you as healthy as possible. Your PACE team will identify the best way to meet your needs and authorize additional supports and services as needed. 

What if I disagree with a decision made regarding my services? 

A grievance or complaint can be submitted to PACE staff verbally or in writing.

Any grievance or complaint that you submit must be documented and resolved by the PACE team.

If you feel that the PACE team is not trying to work with you to resolve your complaint, you may contact Iowa Medicaid Member Services at 1-800-338-8366.

What does the PACE program expect from me?

As a PACE participant, you will work with your PACE team to help them develop a care plan to meet your medical and social needs. Your participation in developing and following your care plan is essential to achieving your health goals. 

As a PACE participant, you will be required to:

• keep your care team up-to-date on changes in your condition
• notify your care team of changes in your living arrangements
• utilize PACE providers or receive approval from the care team prior to receiving services outside of PACE center

What are my rights and responsibilities for the PACE program?

Your PACE center will give you a copy of your rights and responsibilities, and discuss them with you.

Patient Rights

• To be treated with respect.
• To be protected against discrimination.
• To information and assistance.
• To choice of providers.
• To emergency services.
• To confidentiality.
• To make treatment decisions.
• To file grievances and appeals.
• To disenroll from the PACE program at any time. 

Patient Responsibilities

• To communicate with my PACE center regarding my needs, any changes in my care, and my choices.
• To understand that all medically necessary services are provided through my PACE centers.
• To understand that any unauthorized services (except emergency care) will be my financial responsibility.
• To contact my PACE center if I received emergency care.
• To contact my PACE center if I am going to move out of the PACE service area.