PACE for Seniors: Who It Fits and Who It Does Not

Written & Reviewed by

Analic Mata-Murray

Managing Editor

Yolanda Taylor

Senior Healthcare Editor

Last updated: May 5, 2026

Bottom line: PACE can be a strong fit for adults age 55 and older who need nursing-home level care, can still live safely in the community with help, and want one team to coordinate most care. It is often a weaker fit for people who want to keep outside doctors, travel for long periods, or only need light help at home.

Important: PACE is not a grant, cash benefit, or direct payment to a senior or family. It is a Medicare and Medicaid care program that provides or arranges approved care through a local PACE organization.

Quick start: which path fits?

If you are sorting through more than one need, the GrantsForSeniors.org senior help tools can help you decide which topic to check next.

Emergency help now

• Check the ZIP code first: PACE is not in every county. Use the finder above or call 1-800-MEDICARE at 1-800-633-4227. TTY users can call 1-877-486-2048.
• If the person is unsafe today: PACE enrollment can take time. Call 911 for a medical emergency. If the issue is unsafe care at home, possible neglect, abuse, no food, or no caregiver, contact local Adult Protective Services through your state or call the Eldercare Locator at 1-800-677-1116 for local aging-services help.
• Get records moving today: Ask the doctor, hospital, rehab, or social worker for a current medication list, discharge papers, diagnosis list, and notes that show why nursing-home level care may be needed.
• Do not sign blind: Before enrollment, ask for the written start date, exact monthly cost, current hospital system, pharmacy process, and outside-provider rules.
• Ask about the handoff: If the person is leaving rehab or a hospital, ask who will handle medicines, rides, home care, equipment, and after-hours calls during the first week.

What this means for seniors

PACE is not just adult day care. It is not just another Medicare plan. In plain English, it is a full care system. It combines medical care, long-term services, prescription drugs, transportation, and care coordination.

The trade is simple. You gain one team and one plan of care. But you give up much of the freedom to use any outside doctor, hospital, pharmacy, or specialist for routine care.

That trade can be worth it when care is getting messy. Maybe the older adult keeps missing appointments. Maybe medicines keep changing. Maybe falls, emergency room visits, home aides, equipment, and bills are too much for one family to manage. In that kind of case, PACE may reduce chaos.

But the same rules that make PACE strong can also make it hard. If the person is stable, travels often, or strongly wants to keep a longtime outside doctor, PACE may feel too limiting.

Quick facts

• The basic federal eligibility rules are age 55 or older, live in a PACE service area, need nursing-home level care as certified by the state, and be able to live safely in the community with PACE help.
• PACE covers Medicare- and Medicaid-covered care and other services the care team decides are needed to improve or maintain health.
• Common covered services include primary care, hospital care, home care, therapy, social services, mental health counseling, nutrition support, transportation, prescription drugs, and dental care.
• If the care team cannot keep someone safe in the community, PACE can still provide care in a long-term care facility.
• For approved care, PACE does not charge deductibles, copayments, or coinsurance. Monthly premiums can still apply for Medicare-only or private-pay participants.

Who this is for

• An older adult whose medical needs and daily-care needs are both growing.
• A family caregiver trying to avoid nursing-home placement but struggling with scattered care.
• An adult child who needs a clear starting point before calling local programs.
• A Medicare-only or dual-eligible household that wants to know how PACE changes doctors, costs, and control.
• A senior who may need help with rides, medicines, therapy, meals, and personal care under one care plan.

PACE compared with common care paths

If a family is deciding between PACE, Medicare home health, assisted living, or a nursing home, the biggest difference is this: Medicare generally does not pay for long-term custodial nursing-home care. It may cover short skilled nursing facility care only when rules are met. PACE is built for people who already need nursing-home level care but may still live safely in the community with support. You can read Medicare’s basic rule on nursing-home care before making a decision.

What PACE is in plain English

The name stands for Program of All-Inclusive Care for the Elderly. Even though the name says “elderly,” federal rules start at age 55. PACE helps people who meet a nursing-home level-of-care test get broad care in the community instead of relying on many separate medical and long-term care programs.

The key issue for families is not the name. It is the role PACE plays. During intake, the program must explain that the PACE organization becomes the participant’s main service provider for covered care. It also has to explain that PACE guarantees access to services, not access to any one specific doctor or specialist. The PACE enrollment manual is clear on that point.

This point is easy to miss. It is one of the biggest reasons families regret rushed enrollments. Before signing, ask which doctors, hospitals, pharmacies, therapy providers, and specialists are actually used by the program.

What PACE replaces and what it does not

For most routine care, PACE replaces the old patchwork. It takes over covered primary care, specialist referrals, hospital care, home care, therapy, drugs, transportation, and long-term care services. If the participant has Medicare, PACE also becomes the source of Part D drug coverage. Joining a separate Medicare drug plan after PACE starts can cause disenrollment from PACE.

PACE does not block emergency care. A participant can get emergency services anywhere in the United States without prior approval. Urgent out-of-area care is different. CMS service rules explain how emergency, urgent, and post-stabilization care work. This is one reason PACE can be a poor fit for snowbirds or families who spend long stretches away from the service area.

PACE also does not mean the person can use any outside doctor and send the bill to Medicare. Routine outside care usually must be approved by PACE first. If the family pays outside bills without asking, they may be stuck trying to undo the problem later.

Who usually qualifies

Most people who join PACE have both Medicare and Medicaid. But Medicaid is not the only path. The Medicaid PACE overview says most participants are dually eligible. Medicare and CMS guidance also make clear that a person can sometimes join with Medicare only, Medicaid only, or private pay if the local program allows it.

The four main tests are age, ZIP code, state level-of-care certification, and safe community living with PACE support. The state level-of-care test can vary by state. That is why two people with similar needs may get different answers in different places.

That fourth rule matters. PACE is designed to help avoid or delay nursing-home placement, but it is not meant to keep someone in an unsafe home no matter what. During intake, the state and the PACE program assess whether the person can be cared for safely in the community. If the program denies enrollment because community living would put health or safety at risk, it must give a written reason and refer the person to other options.

If Medicaid rules are part of the decision, read more about Medicaid for seniors before you sign. Medicaid income, asset, spenddown, and long-term care rules can be different by state.

Signs PACE is often a good fit

• Frequent hospital visits, medication mix-ups, falls, or missed appointments.
• Help is needed with bathing, dressing, transfers, toileting, meals, or transportation.
• The caregiver is worn out from managing several providers and agencies.
• The older adult is open to a center-based model and a network-based care team.
• The family wants one care plan instead of separate offices giving separate answers.

Signs PACE may be the wrong fit

• The person strongly wants to keep outside doctors, hospitals, or pharmacies.
• The household spends long periods outside the local service area.
• The older adult mainly needs light housekeeping or companionship, not a full care model.
• The person strongly resists the PACE center or shared scheduling.
• The family wants to keep a Medicare Advantage or separate Part D plan that cannot run alongside PACE.

What services are included

Medicaid lists many PACE benefits, including adult day care, dentistry, emergency services, home care, hospital care, lab and X-ray services, meals, medical specialty services, nursing-home care, nutrition counseling, therapy, prescription drugs, primary care, recreation therapy, social services, social work counseling, and transportation.

That means PACE can cover both medical care and day-to-day supports that families often piece together elsewhere. It can also cover services beyond ordinary Medicare or Medicaid limits when the interdisciplinary team decides they are needed to improve or maintain the participant’s health.

The key phrase is “approved by the team.” In PACE, one team builds the care plan. Separate insurers and providers do not each handle one small piece.

What day-to-day care often looks like

A typical participant may have some days at the PACE center and other care at home. A center day can include a van ride, nursing check-in, a primary care or therapy visit, meals, medication review, and activities.

Home days may include aide visits, therapy, equipment delivery, or specialty appointments arranged through PACE. Not every participant goes to the center the same number of days. Families should ask what the first 30 to 60 days are likely to look like and who decides when that schedule changes.

What seniors may like about PACE

• One phone number: Families no longer have to chase separate doctors, pharmacies, therapists, ride services, and home-care agencies.
• Transportation included: For non-drivers, this can decide whether care actually happens.
• Fewer surprise charges for approved care: PACE-approved services do not have the usual deductible, copayment, or coinsurance layers.
• More social contact: The center model can reduce isolation for some participants.
• Nursing-home backup: If the person later needs facility care, PACE can still arrange and cover care in that setting.

Tradeoffs and frustrations that matter most

• Doctor choice narrows: The participant must usually use PACE doctors, hospitals, pharmacies, and specialists or get prior approval.
• Travel gets harder: Emergency care is covered anywhere in the United States, but routine outside care is not simple.
• The center model is not for everyone: Some older adults like it. Others find the rides, group schedule, or long day tiring.
• Medicare-only costs can be serious: No copays does not mean no monthly cost.
• Everything runs through one system: That helps coordination, but it can feel limiting if the family disagrees with the care plan.

A practical way to think about the tradeoff is this: PACE works best when the older adult values coordination more than unrestricted provider choice. If keeping a specific cardiologist, hospital system, or retail pharmacy is the top priority, ask hard questions before enrolling. Get the provider list in writing.

How costs work

Costs depend mainly on whether the older adult has Medicaid. People with Medicaid usually do not pay a monthly PACE premium. Medicare-only participants usually pay the PACE premium for the long-term care part, the Part D premium that PACE collects, and the Part B premium unless Medicaid or another program pays it. In 2026, the standard 2026 Part B premium is $202.90 a month, although higher-income beneficiaries can pay more.

If the person is struggling with Medicare premiums, ask about Medicare Savings Programs. These programs may help some low-income Medicare users with Part B costs, but state rules and income limits vary.

Most important cost rule: Do not focus only on the monthly premium. Ask for the total monthly cost, including Part B, Part D, any Medicaid spenddown rules, and what happens if nursing-home care becomes necessary. Then get that answer in writing.

How enrollment and assessment usually work

PACE intake rules say intake must include one or more visits to the person’s home and one or more visits to the PACE center. The program has to explain the enrollment agreement, provider rules, premiums if any, and other duties. The state also has to assess whether the person meets the nursing-home level-of-care standard. The PACE program has to assess whether the person can live safely in the community with PACE help.

The start-date rule says enrollment usually begins on the first day of the month after the signed agreement is received. That date matters. If a family is trying to line up discharge from a hospital, rehab, or nursing home, a late signature can push the start to the next month.

Ask the program what paperwork deadline applies this month. Also ask who is still holding up the file. A missing doctor note, proof of address, Medicaid notice, or level-of-care review can slow things down.

How to start without wasting time

1. Check service area and basic fit by phone first. Ask, “Do you serve this ZIP code? Do you accept Medicare-only participants? What hospital system do you use?”
2. Ask for a paper packet. Request the enrollment agreement, current provider list, center address, transportation information, and premium quote by mail or email.
3. Gather records that speed review. Medication list, discharge summary, recent diagnoses, insurance cards, and legal papers matter more than old routine records.
4. Prepare for both assessments. One looks at nursing-home level of care. The other asks whether community living is safe with PACE support.
5. Read the agreement like a contract. Check the start date, sole-provider rule, premium amount, and how prescriptions will move over.
6. Plan the first month before coverage starts. Confirm doctor assignments, medicine refill timing, rides, home care, equipment, and after-hours calls.

If the participant already has a trusted caregiver or adult child doing the paperwork, ask PACE to add that person as the designated representative. This helps notices, explanations, and appeal rights go to the right person.

Document checklist

• ☐ Medicare card
• ☐ Medicaid card or Medicaid notice
• ☐ Photo ID and proof of address
• ☐ Social Security number or benefit paperwork
• ☐ Full medication list, including over-the-counter items
• ☐ Recent hospital, rehab, or nursing facility discharge papers
• ☐ List of current doctors, specialists, and pharmacies
• ☐ Recent test results or care notes that show daily-care needs
• ☐ Power of attorney, guardianship, health care proxy, or advance directive papers
• ☐ Any recent bills, denial letters, service cut notices, or insurance explanations of benefits

Questions families should ask before joining

• Which doctors, specialists, hospitals, and pharmacies are in your network right now?
• Can the participant keep any current doctors, or will all care shift?
• How many center days are likely at the start, and can that change?
• What home-care hours are realistic, and how quickly can they begin?
• What is the exact monthly cost for this person?
• How do after-hours calls, urgent out-of-area care, and hospital admissions work?
• What happens if the participant later needs assisted living or nursing-home care?
• Can the family review your latest CMS or state findings and any correction plan?
• Who handles appeals if a service is denied, reduced, or delayed?

Reality checks

• PACE is not everywhere. The program may exist in your state but not in your county or ZIP code.
• “All-inclusive” does not mean “any provider you want.” It means PACE covers approved care through its own team or approved providers.
• Free for Medicaid is not free for everyone. Medicare-only and private-pay costs can be high.
• Fast enrollment is possible, but a sloppy handoff can cause problems. Medicines, rides, home care, and billing should be planned before the start date.
• Appeal rights matter. Ask for written notices. Do not rely only on a phone explanation.

Common mistakes to avoid

• Assuming PACE is just an adult day center and not realizing it becomes the main source of covered care.
• Signing the enrollment agreement without checking which hospital system and specialists the program uses.
• Forgetting that Medicare-only participants usually still owe the Part B premium.
• Joining a separate Medicare drug plan after PACE starts.
• Paying outside bills before asking PACE whether the care was emergency, urgent, approved, or billed wrongly.
• Waiting too long to challenge a denied or reduced service instead of asking for written appeal rights right away.
• Not asking how a current Medicaid waiver, hospice election, or Medicare Advantage plan will end or change.

Best options by need

• Best when one team is the priority: Choose PACE when the older adult needs many services and the family wants one accountable system.
• Best when only short-term skilled care is needed: If the main need is temporary recovery at home, Medicare home health may be enough.
• Best when housing is the main problem: If the person mainly needs room, meals, and basic support, assisted living may be a better housing answer than PACE.
• Best when 24/7 facility care is already needed: Standard nursing-home Medicaid may be simpler if community living is no longer safe or realistic.
• Best when provider freedom or travel matters most: Original Medicare or a Medicare Advantage plan with separate long-term care supports may fit better, even though coordination may be harder.

The right question is not “Is PACE good?” The right question is “Is PACE the best fit for this person’s medical needs, daily-care needs, provider preferences, and family capacity right now?”

Troubleshooting denials, delays, bills, notices, and missing paperwork

If enrollment is denied

Ask whether the problem was the state level-of-care test, the safety-in-the-home review, or missing records. If the reason is that the person cannot live safely in the community, federal guidance says the program must give a written reason and refer the person to other services. Keep that notice.

If a service is delayed or cut

If the participant wants a new service, more hours, or continuation of a service being reduced, ask PACE to treat it as a service determination request. Federal rules say the request must get to the full interdisciplinary team as fast as the person’s condition requires and no later than three calendar days. The team must then decide and notify the participant as fast as the condition requires and no later than three calendar days after the team receives it, unless a limited extension applies.

If the situation is urgent

Ask for an expedited appeal. Federal rules say PACE must respond no later than 72 hours when delay could seriously harm life, health, or the ability to regain or keep function. A limited extension may apply in some cases. If the person has Medicaid and PACE is trying to reduce a current service, ask whether the service can continue during the appeal. In some cases it can, although the participant may owe costs if the appeal is lost.

If billing looks wrong

Do not pay first. Call PACE billing and the outside provider. Explain that the participant is enrolled in PACE. Ask whether the visit was emergency care, urgent out-of-area care, post-stabilization care, approved care, or unauthorized routine care. Once someone is in PACE, outside providers often cannot bill regular Medicare or Medicaid for nonemergency care the usual way.

If notices or paperwork are missing

Keep a paper log with dates, names, direct numbers, and what was promised. Ask for duplicate notices by mail, fax, or secure email. If a family member is doing the work, make sure PACE has representative paperwork on file so denial notices and appeal instructions do not go to the wrong person.

Most useful evidence: the denial notice, current care plan, doctor or therapist notes, hospital discharge papers, medication list, fall history, caregiver notes, and any bills or call logs with dates. Short, recent, specific evidence works better than a large stack of old paperwork.

Escalation path: Start with the PACE social worker, nurse, or member services contact. If that fails, use the formal grievance or appeal process. Grievance rules generally require PACE to resolve grievances as fast as the case requires and no later than 30 calendar days after the oral or written grievance is received. If the issue is still not fixed, call Medicare and ask for your State Administering Agency contact. Ask a SHIP counselor to help organize the case. If the program tries to disenroll the participant against their will, ask for the written notice and state review information.

Phone scripts you can use

Calling a local PACE program

“Hello, I am calling about PACE for my [mother/father/spouse/self]. The ZIP code is [ZIP]. Do you serve this address? If yes, what documents do you need to check nursing-home level of care and safe community living?”

Calling from a hospital or rehab

“My family member may need nursing-home level care but wants to return home if it is safe. Can the discharge planner send records to the local PACE program today and ask about the earliest possible start date?”

Calling about cost

“Before we sign anything, can you give us the total monthly cost in writing? Please include the PACE premium, Part D, Part B, Medicaid spenddown, and any income contribution rules that apply.”

Calling after a denial or service cut

“I am asking for the written notice, the reason for the decision, and the appeal steps. If waiting could harm health or function, please treat this as an expedited appeal.”

Official help and local help

• PACE program search: Use the national finder linked near the top of this guide.
• State PACE pages: Medicaid.gov keeps a state PACE website list that can help when a ZIP-code search is confusing or when a local program is new.
• Medicare: Call 1-800-633-4227, also called 1-800-MEDICARE. TTY users can call 1-877-486-2048.
• State Medicaid: Contact your state Medicaid agency for local level-of-care and cost rules.
• Free Medicare counseling: Contact SHIP at 877-839-2675.
• Local aging services: Use the Eldercare Locator or call 1-800-677-1116.
• Civil rights complaints: Contact HHS civil rights at 1-800-368-1019. TTY users can call 1-800-537-7697.

If a family does not use the internet, every option above has a phone path. Ask the caller to spell the program name, give the exact mailing address, and state the name of the person who took the call.

Other help if PACE is not enough

PACE can help with health care and long-term care, but it may not fix every household problem. A family may still need help with food, housing, utilities, caregiving gaps, repairs, or local support.

If PACE is not available near you

If there is no PACE program serving the home address, do not stop there. Many states have other home and community-based services through Medicaid, and local aging agencies may know about adult day care, respite, transportation, and caregiver support.

• If groceries are the pressure point, review food programs.
• If shutoff notices or high bills are causing stress, check utility bill help.
• If rent or housing stability is the main issue, start with housing and rent help.
• If the need is local support outside government programs, see charities helping seniors.

Do not use these pages as a replacement for PACE medical advice. Use them when the family has other bills or daily-life needs that PACE does not solve.

Resumen en español

PACE significa Program of All-Inclusive Care for the Elderly. Es un programa de Medicare y Medicaid para algunas personas de 55 años o más que necesitan un nivel de cuidado parecido al de un hogar de ancianos, pero que todavía pueden vivir con seguridad en la comunidad con ayuda.

PACE reúne en un solo sistema la atención médica, medicinas, terapia, cuidado en el hogar, transporte y, si hace falta, cuidado en un hogar de ancianos. La ventaja principal es la coordinación. La desventaja principal es que casi toda la atención no urgente debe pasar por PACE o por proveedores autorizados por PACE.

Antes de inscribirse, la familia debe pedir por escrito el costo mensual exacto, la lista de médicos y hospitales, la fecha de inicio, cómo se manejarán las medicinas y cómo apelar si niegan o reducen un servicio. Medicare también tiene una guía PACE.

PACE puede ser una buena opción si la persona necesita mucha ayuda médica y personal y la familia quiere un solo equipo de cuidado. Puede ser mala opción si la persona quiere mantener sus médicos actuales, viaja por mucho tiempo, o solo necesita ayuda ligera en casa.

FAQ

Is PACE only for people 65 and older?

No. The federal age floor is 55.

Does joining PACE mean changing doctors?

Usually, yes. Most nonemergency care must come from the PACE network or from a provider PACE approves.

Is PACE free?

Only for some people. If the person has Medicaid, there is usually no monthly PACE premium. Medicare-only participants usually pay a PACE premium, a Part D premium, and the Part B premium unless another program pays it.

Is PACE the same as adult day care?

No. PACE may use an adult day center, but it is a full Medicare and Medicaid care model. It can include medical care, drugs, home care, transport, therapy, and long-term care services.

Can someone with dementia join?

Possibly. The key questions are whether the person meets the state level-of-care test and can live safely in the community with PACE help at the time of enrollment.

Can a participant leave PACE?

Yes. A participant can disenroll at any time. The change is generally effective on the first day of the next month after the PACE organization receives the notice.

What if the participant travels or lives part of the year elsewhere?

PACE is usually a weak fit for long out-of-area stays. Emergency care is covered anywhere in the United States, but routine and urgent care away from the service area is more complicated.

What should a family do if PACE denies more home care or therapy?

Ask for the written service determination or denial notice right away. Then file an appeal. If waiting would seriously harm health or function, ask for an expedited appeal.

Can PACE help someone stay out of a nursing home?

Sometimes. PACE is built for people who need nursing-home level care but may still live safely in the community with the right support. It does not promise that every person can stay at home forever.

Editorial note: This guide is produced based on our Editorial Standards using official and other high-trust sources, regularly updated and monitored, but not affiliated with any government agency and not a substitute for official agency guidance. Individual eligibility outcomes cannot be guaranteed.

Verification: Last verified May 5, 2026. Next review September 5, 2026.

Corrections: Please note that despite our careful verification process, errors may still occur. Email info@grantsforseniors.org with corrections and we respond within 72 hours.

Disclaimer: This article is for informational purposes only. It is not legal, medical, tax, disability-rights, insurance-broker, financial-planning, or government-agency advice. Eligibility, provider networks, premiums, appeals, and coverage details can change by state, by PACE organization, and by the facts of an individual case. Before enrolling, disenrolling, paying a bill, or filing an appeal, contact the PACE organization, Medicare, your state Medicaid agency, or a SHIP counselor for case-specific guidance.

About the Authors

Analic Mata-Murray

Managing Editor

Analic Mata-Murray holds a Communications degree with a focus on Journalism and Advertising from Universidad Católica Andrés Bello. With over 11 years of experience as a volunteer translator for The Salvation Army, she has helped Spanish-speaking communities access critical resources and navigate poverty alleviation programs.

As Managing Editor at Grants for Seniors, Analic oversees all content to ensure accuracy and accessibility. Her bilingual expertise allows her to create and review content in both English and Spanish, specializing in community resources, housing assistance, and emergency aid programs.

Yolanda Taylor, BA Psychology

Senior Healthcare Editor

Yolanda Taylor is a Senior Healthcare Editor with over six years of clinical experience as a medical assistant in diverse healthcare settings, including OB/GYN, family medicine, and specialty clinics. She is currently pursuing her Bachelor's degree in Psychology at California State University, Sacramento.

At Grants for Seniors, Yolanda oversees healthcare-related content, ensuring medical accuracy and accessibility. Her clinical background allows her to translate complex medical terminology into clear guidance for seniors navigating Medicare, Medicaid, and dental care options. She is bilingual in Spanish and English and holds Lay Counselor certification and CPR/BLS certification.