PACE Program Eligibility Requirements, and What It Costs

Every PACE brochure in the country carries a version of the same warning, and it is printed there because a federal regulation orders it printed.

PACE participants may be fully and personally liable for the costs of unauthorized or out-of-PACE program agreement services.

That is 42 CFR 460.82(d)(2), word for word, read through the eCFR on 7 September 2026 against a title 42 issue date of 13 August 2026. The sentence just above it in the same paragraph is the other half of the deal: marketing materials must tell a prospective participant that they "must receive all needed health care, including primary care and specialist physician services (other than emergency services), from the PACE organization or from an entity authorized by the PACE organization."

Put those two lines together and PACE stops looking like a benefit you add to what a parent already has. It is a benefit you switch to, and most of the late surprises families report trace back to that rather than to anything an intake coordinator got wrong. What follows is the eligibility test, the premium arithmetic, the doctor question, and the dates, each with the regulation or manual section behind it.

Four requirements, and only one of them is arithmetic

The eligibility rules live in 42 CFR 460.150, and they are short enough to read in a minute.

A fifth line, 460.150(b)(4), lets a program agreement add "program specific eligibility conditions," then immediately forecloses the obvious abuse: those conditions "may not modify the requirements of paragraph (b)(1) through (b)(3)."

Two things about that table matter more than their length suggests.

The first is that Medicaid eligibility is not on it. Paragraph (d) is explicit that enrollment "is not restricted to an individual who is either a Medicare beneficiary or Medicaid beneficiary," and that an enrollee may be entitled to Part A, enrolled in Part B, eligible for Medicaid, any combination, or none of them. 42 CFR 460.152(a)(3) goes further and requires the state to assess a potential participant for nursing facility level of care "including any individual who is not eligible for Medicaid." A private payer gets the same state assessment as everyone else.

The second is that the last row is the soft one. The criteria for whether living at home would jeopardize health or safety are state-written, and the Medicaid and CHIP Payment and Access Commission heard complaints about exactly that. In interviews staff presented to the Commission on 24 January 2025, one state and several consumer advocates "raised concerns about PACE organizations selectively enrolling participants," noting that organizations "sometimes use the eligibility criterion of being able to live safely in the community to exclude high cost, high need individuals," and that state officials described their own language as "often broad and open to interpretation" (MACPAC, Understanding the PACE Model, read 7 September 2026).

Which is why a denial on that ground belongs on paper. 460.152(b) requires a PACE organization that turns someone away for community-safety reasons to notify the individual in writing of the reason, refer them to alternative services as appropriate, keep supporting documentation, and report the denial to CMS and the state administering agency. A verbal "we don't think it's a fit" is not what the rule describes. Ask for the written notice, and ask which state criteria it applies.

The sole provider rule reaches the specialist, not just the clinic

Enrollment agreements have to spell this out, and the intake visit has to say it out loud. Under 460.152(a)(1)(ii), staff must explain "the requirement that the PACE organization would be the participant's sole service provider and clarification that the PACE organization guarantees access to services, but not to a specific provider." 460.154(p) requires the applicant's written acknowledgment of the same point, and 460.90(b) states the rule flatly: while enrolled, a participant "must receive Medicare and Medicaid benefits solely through the PACE organization."

The participant right that sits opposite it is narrower than it first reads. 460.112(d)(1) gives each participant the right "to choose his or her primary care physician and specialists from within the PACE network." Choice, yes. Within the network.

So the network is the thing to inspect before signing, and the regulation makes that easy. 460.70(a)(1) requires every PACE organization to hold contracts covering 26 named medical specialties, from cardiology and nephrology through oral surgery and palliative medicine, unless it directly employs someone in that specialty. 460.70(c) then says a current list of contractors "must be on file at the PACE center and a copy must be provided to anyone upon request." Anyone, not just participants. You can ask for it on the first visit.

If the organization loses or cannot obtain a contract in a specialty, 460.70(a)(3) requires it to meet the need "through a different mechanism to include hospitalization" and to report the gap to CMS and the state. That is a reporting duty, not a promise about a particular surgeon.

Emergencies are carved out, and the carve-out is generous. Under 460.100, emergency services from a provider outside the PACE network are covered in or out of the service area, no prior authorization is required, and the written emergency plan must hold CMS, the state, and participants harmless if PACE does not pay. An on-call provider must be reachable 24 hours a day, and urgently needed out-of-network care and post-stabilization services are covered either when PACE preapproves them or when PACE "did not respond to a request for approval within 1 hour after being contacted or cannot be contacted for approval." Note the hour. It is the only clock here short enough to run during a call from an emergency department.

The page worth putting at the front of the intake folder is not about coverage at all. It is a list of names: the doctors a parent actually sees now, checked one at a time against the contractor list, before anybody signs anything. That comparison takes ten minutes, and it is the part of the decision least likely to be fixed by a later phone call.

What you pay, and two things that are not premiums

42 CFR 460.186 sets the entire premium schedule in four paragraphs.

Neither Medicare nor Medicaid, and the statute is silent. CMS filled that gap in its own manual: it is "acceptable for a PACE organization to charge the combined Medicare and Medicaid capitation rates as the premium for these individuals" (PACE manual chapter 13, section 40.7, Rev. 2, issued 9 June 2011, read 7 September 2026).

Against that sits the genuinely unusual part of PACE. 460.90(a) switches off the ordinary machinery: Medicare and Medicaid "benefit limitations and conditions relating to amount, duration, scope of services, deductibles, copayments, coinsurance, or other cost-sharing do not apply." Medicare.gov, read 7 September 2026, says it plainly: "you won't have a deductible, copayment, or co-insurance for any drug, service, or care your PACE team approves." No 20 percent, and no day-21 coinsurance of the kind that governs the 100-day skilled nursing benefit.

Three costs survive anyway, and families are routinely surprised by two of them.

The Part B premium is still yours. Chapter 13, section 40.4 says that unless a participant is Medicaid eligible they remain responsible for paying it, and explains why a PACE organization cannot simply absorb it: doing so would be an inducement to enroll, prohibited by 460.82(e)(3) and potentially by the civil money penalty provision at 42 U.S.C. 1320a-7a(a)(5). The standard 2026 Part B premium is $202.90 a month, higher for higher incomes (Medicare costs, read 7 September 2026).

Part D carries its own premium for Medicare-only participants. Chapter 13, section 40.5: participants with Medicare only get drug coverage through Part D and "will be responsible for a monthly premium," while participants who also qualify for Medicaid are deemed eligible for the low-income subsidy that covers it.

Spend-down and post-eligibility income are not premiums, but missing them ends enrollment the same way. Chapter 13, section 40.1 is careful about the vocabulary: a Medicaid share-of-cost obligation "is not considered a premium." Then 460.164(b)(2) makes failure to pay a spend-down liability or an amount due under post-eligibility treatment of income, after a 30-day grace period, an independent ground for involuntary disenrollment, sitting right beside failure to pay a premium in (b)(1). Post-eligibility treatment of income is applied the way it is under a 1915(c) waiver, per 460.184, which means the amount is a state calculation and changes at a state border.

None of the figures above except the Part B premium is national. The Medicaid capitation amount is negotiated between each organization and its state and written into the three-way program agreement, so the only number that governs your case is the one in your own paperwork. 460.152(a)(1)(iv) requires intake staff to explain monthly premiums, and 460.154(f) and (g) require the enrollment agreement to describe them along with any spend-down or post-eligibility liability. Ask for the figure in writing before the signature, not after.

PACE and a waiver are two doors, not two benefits

Here is the sentence that connects PACE to every family already sitting on a Medicaid home and community based services list. It is not in the regulation. It is in the manual.

CMS, PACE manual chapter 4, section 10.1 (Rev. 3, issued 5 December 2023, read 7 September 2026):

A PACE participant may not be concurrently enrolled in any other Medicare Advantage, Medicare Prescription Drug, or Medicaid prepayment plan, or optional benefit, such as a 1915(c) Home and Community Based Services waiver or the Medicare Hospice benefit.

The regulatory engine behind it is 460.154(i), which requires the enrollment agreement to notify the applicant that enrolling in PACE disenrolls them from any other Medicare or Medicaid prepayment plan or optional benefit, and that electing one afterwards "is considered a voluntary disenrollment from PACE." Medicare.gov states one consequence in a single line: join a separate Medicare drug plan while in PACE, and "you'll be disenrolled from PACE."

Hospice works the same way, and it deserves its own sentence because it arrives at the worst possible moment for reading rules. Chapter 4, section 10.2 says end-of-life care is furnished by the PACE organization itself, and that a participant who wants the hospice benefit from a certified hospice organization "must voluntarily disenroll from the PACE program," with PACE coordinating the transition.

For a family holding a waiver approval letter, this is a fork rather than a supplement. Part 460 contains no waiting-list or enrollment-slot machinery of the kind a 1915(c) waiver runs on. What it does contain is 460.98(e)(1), which obliges an organization to run a center "with sufficient capacity to allow routine attendance by participants" — so whether a seat is open is a question for that particular program, not a position in a state queue.

Either way, PACE is not something to hold in reserve alongside a place on a list. The mechanics of that list, including which of your state's rules control who moves and when, are in what "approved but waiting" actually means, and the wider map of who pays for which stretch of care is in who pays for long-term care.

The dates that start running once someone signs

Enrollment is effective "on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement" (460.158). From there:

• 30 calendar days from enrollment for the interdisciplinary team to complete the initial plan of care (460.106(b)(1)).
• 180 calendar days between plan-of-care reevaluations, with a 14-day reevaluation after any change in the participant's status, or within 14 days of hospital discharge if a hospitalization intervenes (460.106(b)(2) and (b)(3)).
• At least annually, the state reevaluates whether the participant still needs a nursing facility level of care (460.160(b)). Two escape valves follow. The state may permanently waive the annual recertification where there is no reasonable expectation of improvement or significant change, and a participant who no longer meets the level of care may be "deemed" eligible until the next annual reevaluation if, without PACE, they would reasonably be expected to meet it again within six months.
• Any time, without cause, a participant may voluntarily disenroll (460.162(b)), effective under 460.162(a) on the first day of the month following the organization's receipt of the notice.

Involuntary disenrollment has eight grounds in 460.164(b) and a longer fuse. It takes effect "on the first day of the next month that begins 30 days after the day the PACE organization sends notice," and CMS works the arithmetic in chapter 4, section 40.3: notice sent 5 April, 30 days later is 5 May, effective date 1 June. Before any of that, 460.164(f) requires the state administering agency to review the case and determine that the organization has adequately documented acceptable grounds.

Two of the eight are worth reading closely. One is being out of the service area "for more than 30 consecutive days" unless the organization agrees to a longer absence for extenuating circumstances, which catches long stays with out-of-state family. Another is disruptive or threatening behavior, which 460.164(e) limits: a participant may not be disenrolled for noncompliant behavior related to a mental or physical condition unless the behavior jeopardizes health or safety, and the regulation treats "repeated noncompliance with medical advice and repeated failure to keep appointments" as examples of noncompliance rather than as grounds. Where the disenrollment is for nonpayment, 460.170(b) restores enrollment with no break in coverage if the premium is paid before the effective date.

Until the termination date arrives, 460.166(b) holds both sides in place: the organization "must continue to furnish all needed services," and the participant keeps using PACE and stays liable for premiums.

Leaving PACE starts two clocks nobody announces

Disenrolling does not restore the coverage a person had before. It restores their eligibility to go and get some.

460.168 obliges the organization to make appropriate referrals, make medical records available to new providers within 30 days, and work with CMS and the state to reinstate the person in other Medicare and Medicaid programs. The election windows are in chapter 4, section 50.2, and both are short:

• A Special Election Period to join a Medicare Advantage plan or a standalone Part D plan, ending two months after the effective date of the PACE disenrollment.
• For someone returning to Original Medicare, a guaranteed issue right to buy a Medigap policy offered in their state within 63 days of the last date of coverage. During that window the issuer may not deny the policy, price it by health status, or impose a preexisting condition exclusion.

A person who lets both windows close is not uninsured. They are back on Original Medicare with no drug plan and no supplement, which is a different and more expensive place to be. If disenrollment is even under discussion, put those two dates on a calendar the day the notice is written.

A denial inside PACE has its own vocabulary

Because PACE is both the provider and the plan, a refusal does not look like an insurance denial. It looks like a care plan that does not include the thing you asked for. The regulation gives that conversation a formal name.

Under 460.121, a request to start a service, change one, or keep a service the organization proposes to cut is a service determination request. The participant, a designated representative, or a caregiver can make it, orally or in writing, to any employee or contractor who provides direct care, at home, at the center, or in the van. It must reach the interdisciplinary team within 3 calendar days, and the team must decide and notify within 3 calendar days of receiving it, extendable by up to 5 days with notice of the extension inside 24 hours. If the team expects to deny, appropriate members must perform an in-person reassessment first.

Only after a denial does 460.122 open the appeal: review by an impartial third party who was not involved in the original action, resolution no later than 30 calendar days, and an expedited track answered within 72 hours where delay could seriously jeopardize life, health, or the ability to regain or maintain maximum function. A Medicaid participant who asks for it keeps the disputed service running during the appeal, with the understanding that they may be liable for its cost if the decision goes against them.

Outside the organization, 460.124 sets the external routes: a Medicare reconsideration by an independent review entity, requested in writing within 60 calendar days of the third party reviewer's decision; a Medicaid state fair hearing under part 431, subpart E; and, for dual eligibles, a choice between the two. Consumer advocates told MACPAC's interviewers that PACE denial notifications "are often vague and lack clear explanations," reason enough to insist on the written notice rather than the phone call, since 460.121(j)(2) requires it to state specific reasons and appeal rights. Same instinct as the fast appeal after a skilled nursing discharge.

Checking whether PACE exists where your parent lives

PACE is not everywhere, and geography is the first filter rather than the last. The National PACE Association reported on 26 February 2026 that the 200th program had opened, with programs in 33 states and the District of Columbia serving more than 91,000 older adults (NPA press release, read 7 September 2026). MACPAC counted 80,749 enrollees as of December 2024, 84 percent of them dually enrolled in Medicare and Medicaid.

Four things to establish first, all of them state-specific:

1. Whether a program's service area covers the address. Service area, not county, not city. 460.150(b)(3) makes it a hard requirement rather than a preference. Medicare's plan finder lists PACE plans by ZIP code, and the state Medicaid office can confirm.
2. What the state's nursing facility level of care assessment is, and who administers it. This is the same determination that gates a Medicaid waiver, so a family already assessed for one may not be starting from zero.
3. The state's written criteria for living safely in the community. 460.150(c)(2) requires them to be specified in the program agreement, so they exist on paper somewhere. Ask which document, and ask for that page.
4. What the monthly obligation is in your case, including any spend-down or post-eligibility amount, in writing, before signing.

Your State Health Insurance Assistance Program gives free counseling on the Medicare side of all this and can be reached through shiphelp.org, and the Administration for Community Living's Eldercare Locator turns a ZIP code into the local Area Agency on Aging. Neither takes a referral fee. Neither will tell you what to choose, and neither should.

Sources

Every citation below was opened and read on 7 September 2026.

• 42 CFR part 460, retrieved through the eCFR versioner API, title 42 issue date 13 August 2026. Sections relied on above: 460.70 contracted services, 460.82 marketing, 460.90 benefits and cost sharing, 460.98 service delivery, 460.100 emergency care, 460.106 plan of care, 460.112 participant rights, 460.121 and 460.122 service determinations and appeals, 460.124 external appeal rights, 460.150 through 460.172 enrollment and disenrollment, 460.184 post-eligibility treatment of income, and 460.186 premiums. Each is linked at its first mention in the text above.
• CMS, PACE manual chapter 4, Enrollment and Disenrollment (Rev. 3, issued 5 December 2023), sections 10.1 and 10.2 (concurrent enrollment and hospice), 40.3 (the involuntary disenrollment example) and 50.2 (Special Election Period and Medigap window); and PACE manual chapter 13, Payments to PACE Organizations (Rev. 2, issued 9 June 2011), sections 40.1 through 40.7 on premiums.
• Medicare.gov, PACE for the four eligibility conditions in plain language and the no-cost-sharing statement, and Medicare costs for the 2026 standard Part B premium of $202.90.
• MACPAC, Understanding the Program of All-Inclusive Care for the Elderly (PACE) Model, staff presentation of stakeholder interviews, 24 January 2025, for the December 2024 enrollment count, the 84 percent dual enrollment figure, and the concerns about selective enrollment and vague denial notices. Interview findings from six states, not a national audit.
• National PACE Association, PACE Reaches Major Milestone with 200 Programs Nationwide, 26 February 2026, for the count of states and participants. NPA is the programs' trade association, so treat its enrollment figures as self-reported.

This page is general information, not legal, medical, or financial advice. See the terms.