Regulators Fear Some All-Inclusive Medicare Plans Skimp on Specialty Care

What You Need to Know

The country has 151 PACE plans and about 60,000 PACE plan enrollees.
The plans can provide long-term care services in the home for eligible enrollees.
CMS did not give numbers, but it said problems with PACE plan participant access to specialty care have hurt patients.

Medicare program managers want to make sure a relatively new type of Medicare home care plan offers patients quick access to all necessary care.

The Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare, has included rule updates for Programs of All-Inclusive Care for the Elderly, or PACE plans, in the new final regulations for the 2024 contract year.

CMS has added a requirement that PACE organizations must have contracts in place for 26 types of specialists, including neurologists, radiologists, surgeons and palliative care specialists, or professionals who focus on making patients more comfortable by, for example, treating the severe pain caused by terminal cancer.

In the past, delays in PACE plan participant access to specialists “have, in some instances, contributed to adverse impacts to participants, including injuries, hospitalizations and death,” CMS officials said when they proposed the new regulations.

What It Means

PACE plans could eventually help your clients solve the long-term care funding puzzle, by leading to the creation of a new Medicare long-term care benefits program.

But federal regulators’ belief that they had to add a specialty care access list to the PACE plan requirements shows how difficult getting LTC programs right can be.

PACE Plans

Medicare rules usually keep the program from covering long-term care services.

PACE plans can get around those rules. They provide tightly managed, comprehensive care, including home health care and some homemaker services, for Medicare enrollees who have enough trouble with the activities of daily living to qualify for Medicaid nursing home benefits and who meet their states’ PACE plan eligibility guidelines.

The plans operate under Medicare Part C, which is the same law that governs the operations of Medicare Advantage plans.