PACE stands for "Program of All-inclusive Care for the Elderly." PACE is a comprehensive, coordinated health care program sponsored by Medicare, Medicaid and private funds. PACE provides medically-necessary care and services for chronically-ill adults who choose to remain living in their community rather than a nursing home.
When an individual enrolls in PACE, an Interdisciplinary Team of medical and support service experts develops and implements a customized plan of care designed specifically for that person. It includes the team's recommendations on areas such as primary care needs; recreational therapy; nutrition; medicines; medical equipment; dentures; hearing aids -- everything the Team determines is necessary for that individual's care and well-being.
When you enroll with PACE, the PACE physician will become your primary care doctor. You will have the chance to meet with the PACE physician who will be serving you when you come to the Center before joining the program. We recognize that some PACE participants wish to continue seeing their former primary care doctor even though he or she has no role with PACE. In these cases, PACE allows you to continue to see your current doctor up to twice a year for consultation; however, the PACE physician is the sole provider who can prescribe your medications and authorized care and services.
PACE may refer you to other providers, such as specialists. PACE assures access to necessary services but does not guarantee access to a specific provider.
Yes; all prescriptions that the Team determines are necessary for the individual are included.
While there are some programs that enable a participant to choose what they want, PACE is not like that. Rather, the PACE Interdisciplinary Team of medical and support service experts develops and implements a comprehensive, all-inclusive plan of care, customized for each individual. Focusing on only one or two aspects of care, and not the fully-integrated level of care that PACE provides, will not enable a chronically-ill individual to live safely and independently in the community.
Once enrolled, PACE participants go to the PACE Center where the majority of care and social services are provided. PACE provides door-to-door transportation to and from the Center, and even to other appointments outside of the Center. How often a participant goes to the Center and other appointments will be specified in the participant's care plan
PACE North will provide access to the necessary care you need 24 hours a day, 7 days a week.
The goal of PACE is to prevent or delay nursing home placement for as long as possible. If, at some point, it is in the best interest of the participant to receive care in a nursing home, PACE will pay for the care and the Interdisciplinary Team will continue its medical oversight of the participant.
To be eligible, an individual must be 55 or older; certified by the State of Michigan to need nursing home level of care; able to live safely in the community, with the support of PACE North services, at the time of enrollment; and live in the PACE North defined service area.
More than 90% of participants are enrolled in both Medicaid and Medicare. To qualify for Medicaid, an individual must meet income and asset eligibility requirements and provide proof of the information in a Medicaid Application. PACE staff can help determine a person's Medicaid eligibility.
Yes. As an example, if a person does not meet the income and asset limits to qualify for Medicaid, they may pay out of pocket for services normally covered by Medicaid. Long-term care insurance is also accepted.
The PACE program is a managed healthcare plan. PACE uses a capitated payment -- a set payment for each enrolled participant, per period of time. Medicaid and Medicare (or private pay sources) are combined into one monthly payment. Almost all participants are dual eligible with Medicare and Medicaid; these individuals pay nothing out of pocket.
No; you can only enroll in one Medicare health plan. However, the PACE health plan is both a Medicare provider and long-term care provider. By enrolling in a PACE health plan, you will be automatically disenrolled from your current Medicare HMO.
First, call us or fill out a form under Contact Us. We'll follow up with you. There are four main steps to the enrollment process.
All of this process must occur prior to the 24th of the month for enrollment to the PACE program on the 1st of the next month.
You are free to disenroll from PACE and resume your benefits in traditional Medicare and Medicaid programs at any time. However, disenrollment must officially take place at the end of the month.
A grievance is a complaint, either written or oral, expressing dissatisfaction with the services or the quality of your care provided by PACE North. You may file a grievance with any PACE staff member at any time. Grievances can be filed in person, fax, mail, or telephone. To file a grievance by telephone or for status updates and process questions regarding a filed grievance, please contact our Quality Assurance Director at (231) 252-2767. Other options include:
In person or by Mail:
Attention: Quality Assurance Director
2325 Garfield Rd. N.
Traverse City, MI 49686
Or by Fax: (231) 252-3751
Link to: Grievance Form - We Are Listening!
You or your representative have the right to request an appeal of PACE North's decision. If PACE denies a request for services or payment or reduces your services, you will receive written information about the denial and how to file an appeal. There are two types of appeals: internal and external through the Medicare and/or Medicaid appeals process.
Internal appeals are received either verbally or in writing to PACE North. An appeal must be submitted within 30 days from the day that you are notified that your request has been discontinued, reduced, or denied. Until you receive notice of a final decision, you may choose to continue to receive any services in question, but you may have to pay for these services if the final decision is not in your favor. You also have the right to file an appeal with the State of Michigan at the same time of filing through PACE North. You have the right to request an expedited appeal.
You can file an external appeal to either Medicare or Medicaid, but not both. PACE staff will assist you, at your request, with an external appeal.
To appeal to Medicaid, you may contact:
Michigan Administrative Hearing System
PO Box 30763
Lansing, MI 48909
Phone: (877) 833-0870
Regarding filing an appeal with Medicare, you need to go through the PACE North appeal process first. PACE North staff will help file with Medicare if that is your choice.
Link to: Participant Appeal Form
Yes. If you would like to appoint a person to file a grievance or request an appeal on your behalf, you and the person accepting the appointment must complete the CMS Appointment of Representative Form (or a written equivalent) and submit it with the request. You can download the form with instructions from the following link:
Link to: Appointment Representative Form