The following is a guest post by Sonja Love Felton, Executive Director of Huron Valley PACE (Program of All-Inclusive Care for the Elderly). Altarum is working with Huron Valley PACE on a pilot project to expand the program to reach more older adults who need medical and at-home care, but cannot afford it and are not eligible for Medicaid.
Huron Valley PACE, in Ypsilanti, Michigan, was established only 4 years ago. Today we provide comprehensive, high-quality, person- and family-centered care, mostly to dually-eligible beneficiaries 55 and older—but we have larger ambitions. One of our top priorities is tackling the challenge of expanding to serve a population of Medicare-only beneficiaries who can’t enroll today, because they do not require a nursing home level of care, or because they are not financially eligible (in Michigan, less than $2,250 in gross monthly income and less than $2,000 in assets).
To do this work, we’re partnering with Altarum in a project supported by a grant from the Michigan Health Endowment Fund. We’ve identified a major barrier for enrollment of Medicare-only participants—the cost of prescription drug coverage. Here’s the dilemma: dually-eligible participants have all of their Part D costs covered, but due to conflicting provisions in the original PACE statute and the 2003 law that established the Part D program, Medicare-only participants are now forced to pay exorbitantly high premiums for their drug coverage—$1099 per month in 2018 in our program. That compares to the average $45.15 for a local Part D Prescription Drug Plan (PDP).
To resolve the cost barrier for Medicare-only participants, we’ve crafted a PACE and Part D waiver that has been submitted to the Centers for Medicare and Medicaid Services (CMS). We developed a pricing strategy to allow Medicare-only participants to pay Huron Valley PACE a premium that covers the cost of a market-based plan, and also covers out-of-pocket copays, deductibles, and over-the-counter medications. The monthly amount of $320 is an innovative solution that we believe would allow people to both keep their Medicare Part D plan while remaining enrolled in PACE.
We’re also gratified that the PACE Association of Michigan and other experts who are updating Michigan’s Nursing Facility Transition (NFT) Program are looking at how to include PACE as an option for people who want to move back to the community. Including PACE as an option for people who want to transition out of nursing homes is good policy that will provide a more complete and choice-based set of options for our elders and people with disabilities.
For others who could be served well by PACE, but have a bit too much income to qualify for Medicaid, Huron Valley PACE and Altarum are working with national and state experts on Medicaid policy to develop a pathway that would enable older adults and Medicaid to share the costs of long-term services and supports. Currently, these individuals often wind up in a nursing home. We believe that the cost to Medicaid is lower in PACE, and that our comprehensive services will allow elderly persons to keep living at home longer. As we blaze new trails, we hope that many others will take note and work to make PACE much more broadly available.