PACE, the Program of All-Inclusive Care for the Elderly, is an innovative program that provides high-quality, person and family-centered long-term services and supports (LTSS) to older adults, most of whom are lower-income and eligible for both Medicare and Medicaid (known as "dual-eligibles").
The PACE model is especially important today as we work to find solutions that enable more older adults to remain in their homes while receiving quality and affordable LTSS.
But there are barriers to expanding PACE to a larger share of aging low- and middle-income Americans. One of them is the cost of prescription drug coverage.
Dually-eligible beneficiaries, who make up the majority of PACE 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 forced to pay exorbitantly high premiums for their drug coverage.
To address this, Altarum has devised a set of policy solutions and advocacy tools that the documents on this page contain. They can be used by anyone to advocate on behalf of their PACE program or community. They include the following:
PACE and Part D Issue Brief This is a primer of how middle-class Medicare beneficiaries are effectively barred from choosing PACE due to exorbitantly high Part D costs, and the legislation and CMS waivers that can address it. This also includes infographics that illustrate both processes.
Huron Valley PACE Combined BIPA 903 and Part D Waiver Request and Letters of Support This document features the waiver request from Altarum and Huron Valley PACE to CMS to address high Part D costs. While this wavier was declined, there is still potential for this waiver to be granted in the future. We also include our rebuttal letter to CMS.
For those who would like to submit their own waiver to CMS, we include in this batch of documents letters of support for the waiver from the acting director of the Michigan Department of Health and Human Services and Representative Debbie Dingell.
Letter from CMS Granting VA PACE Waiver In 2011, CMS granted some PACE organizations a conditional waiver that permits any participant in the PACE program who is eligible for VA drug coverage to choose to receive their prescription drug coverage through the VA and avoid paying the Medicare Part D premium. This letter is helpful background information to understand the potential for such a waiver to be granted on a wider scale.
NPA PACE Part D Choice Issue Brief and Part D Pricing Study This succinct brief from the National PACE Association (NPA) summarizes a promising bipartisan legislative approach to solving the PACE Part D dilemma that has been introduced in the House of Representatives. Pages 3 and 4 highlight the enormous cost differential between prescription drug costs faced by Medicare-only PACE participants, who are forced to buy their prescription drug coverage through a PACE Part D plan with no federal cost subsidies, as compared to the costs of all other Part D plans available in the marketplace.
Altarum Medicare Part D for PACE Participants Without Medicaid This slide set, used to present to legislative and executive branch staff in early 2022, accompanies the Milliman financial impact study discussion slides, providing background on administrative and legislative possible solutions.
Milliman Medicare PACE Part D for PACE Participants Without Medicaid This slide set, used to present to legislative and executive branch staff in early 2022, accompanies the Altarum financial impact study discussion slides, providing actuarial analysis of the cost outcomes for key stakeholders, should all non-dual PACE participants switch to a Part D PDP: Beneficiaries, CMS, Rx Plans and Part D plan sponsors.
Leadership Council on Aging Organizations (LCAO) PACE Part D slides This slide set was prepared for presentation in the fall of 2021 to the 70 beneficiary advocacy organizations comprising the LCAO, and outlines a framework for these organizations to understand and help accelerate momentum for a solution to the PACE Part D dilemma.
We encourage anyone who is interested in expanding PACE to leverage these materials to advance this important policy reform. If you would like to use our consulting services to help your PACE program navigate this process, please contact Altarum Delivery System Transformation Senior Director Krissy Azeem.