The New York State PACE Program: A Guide for Providers

As uncertainty in the healthcare industry persists, programs that integrate medical and long-term care services are becoming increasingly important for seniors who desire to maintain their independence and age in place. One such initiative is the Program for All-Inclusive Care for the Elderly (“PACE”), which aims to provide coordinated, patient-centered care to older adults throughout New York State.

What is the PACE Program?
The Program of All-Inclusive Care for the Elderly (“PACE”) is a federally recognized, comprehensive, and integrated Medicare and Medicaid program that provides medical, social, and long-term care services to eligible seniors across New York State. The PACE program is designed for individuals aged 55 and older who are dually eligible for Medicare and Medicaid services and require a nursing home level of care but can safely remain in their community. The overall goal of the PACE program is to allow seniors to maintain their independence and dignity while preventing the need for nursing home placement. For PACE providers, the program offers a unique opportunity to deliver high-quality support services to vulnerable populations outside of the traditional model.

What are the Core Elements of the PACE Program?
The PACE program was conceived and developed with the patient at the forefront of all healthcare decisions. PACE involves (1) an interdisciplinary team of various healthcare professionals to provide coordinated and streamlined care; (2) a comprehensive benefits package that enables recipients to remain in their community; (3) the operation of central PACE centers where recipients receive medical care, socialization, and other services; and (4) capitated payment system, allowing providers to receive a fixed, monthly payment amount for each member in exchange for delivering all necessary services. This payment system is a contrast from the typical fee-for-service plan model.

What are the Benefits of the PACE Program?
The PACE model offers several benefits including reduced hospital admissions, enhanced preventive care measures, increased rates of community residence, and higher satisfaction rates among service recipients. This model offers comprehensive medical and social services to members so they can remain in their homes, without the traditional nursing home or hospital stays.

What is the process for starting a PACE Plan?
Whether you are a healthcare provider, nonprofit organization, or hospital system looking to explore this model, it is crucial to understand the approval process. Becoming an approved PACE plan requires certification through both the New York State Department of Health (“NYSDOH”) and the Centers for Medicare and Medicaid Services (“CMS”).

To begin, interested parties should assess whether a PACE Program is viable within their desired service area; this involves identifying your target population, assessing the existing healthcare infrastructure in your area, and evaluating your community’s need for such services. Next, you will need to complete a non-binding notice of intent to apply to both NYSDOH and CMS, detailing basic information regarding your proposed organization and the population you wish to serve.

Once approved, you will need to complete the PACE initial and service area expansion application. Due to federal requirements mandating that PACE operators show competence and fiscal soundness through rigorous formal review processes, New York State requires that a single PACE entity hold both Article 44 and Article 28 Licenses (Health Maintenance Organizations & Hospital/healthcare facilities, respectively). These processes are accomplished by filing a Certificate of Authority (“COA”) with the Department of Health.

Once the Commissioner issues your operating entity a COA, CMS will conduct a formal review to ensure compliance with federal requirements and initiate a State Readiness Review (“SRR”). The SRR will be performed by NYSDOH at your proposed PACE center. The purpose of the SRR is to assess whether your healthcare organization is prepared and fully equipped to provide quality care and enroll participants consistent with the State’s regulations. Upon completion of the SRR, the State will be responsible for preparing and submitting the completed SRR report to CMS. If CMS is satisfied with the assessment, they will issue federal approval. Lastly, to conclude this process, you will seek licensure from the Commissioner of the Department of Health.

If you have any questions regarding starting a PACE Plan or need guidance on the application process, please contact our experienced team of attorneys and healthcare consultants at 518.462.5601 or Colin Green directly at cgreen@oalaw.com.