Programs of All-Inclusive Care for the 
Elderly (PACE) 
 
Chapter 6  Services 
Table of Contents 
(Rev. 2, Issued: 06-09-11) 
 
Transmittals for Chapter 6 
 
10 - Basic Rule 
 
20 - No Co-payments/Deductibles/Fee-for-Service Limits on Medicare or Medicaid 
Services 
 
30 - Emergency Care 
 
40 - Urgently Needed and Post Stabilization Care 
 
50 - Service Delivery 
 
50.1 - Primary Care 
 
50.2 - Meal Requirements 
 
50.3 - Sanitary Conditions 
 
50.4 -Transportation Services 
 
50.5 - Safety, Accessibility, and Equipment 
 
50.6 - Maintenance of Vehicles 
 
50.7 - Communication with PACE Center 
 
50.8 - Training 
 
60 - Required Services for Medicare Participant 
 
70 - Excluded Services 
 
  10 - Basic Rule 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE benefit package is required to include for all participants, regardless of source 
of payment, all Medicare covered services, all Medicaid covered services as specified in 
the States approved Medicaid plan, and any other services determined necessary by the 
IDT to meet the participants needs and which improve or maintain the participants 
overall health status. IDT Assessment is the foundation for provision of participant
specific, appropriate services. See Chapter 8 for composition and description of the scope 
of IDT responsibilities. 
 
The PACE organization must establish and implement a written plan to provide care that 
meets the needs of its participants across all care settings on a 24-hour basis each day of 
the year. The PACE organization must furnish comprehensive medical, health, and social 
services that integrate acute and long-term care. These services must be furnished at least 
in the PACE center, the participants home, and inpatient facilities such as acute and long 
term care hospitals and nursing/rehabilitation facilities. The PACE organization must not 
discriminate against any participant in the delivery of required PACE services based on 
race, ethnicity, national origin, religion, sex, age, sexual orientation, mental or physical 
disability, or source of payment. 
 
[42 CFR  460.92, 460.98(a) and (b)] 
 
20 - No Co-payments/Deductibles/Fee-for-Service Limits on Medicare 
or Medicaid Services  
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
If a Medicare beneficiary or Medicaid recipient chooses to enroll in a PACE program, 
Medicare and Medicaid benefit limitations and conditions relating to amount, duration, 
scope of services, deductibles, copayments, coinsurance, or other cost-sharing do not 
apply. The amount, duration and scope of services provided to PACE participants are 
participant-specific and are specified by the IDT in the plan of care. The scope of benefits 
under PACE includes any other item or service determined necessary by the IDT to 
improve and maintain the participants overall health status.  
 
Under Sections 1894(a) and 1934(a) of the Act, PACE participants must receive 
Medicare and Medicaid benefits solely through the PACE organization. PACE 
organizations are required to provide enrollees with all medically necessary services, 
including drugs, without any limitation or condition as to the amount, duration, or scope. 
The PACE benefit includes all outpatient prescription drugs, as well as over-the-counter 
medications indicated by the participants care plan. PACE programs cannot charge 
deductibles, copayments, coinsurance or other cost-sharing for medications. 
 
The PACE organization may contract with other providers for specialty medical or other 
services to meet participant needs. The PACE organization must maintain primary 
responsibility and accountability for participant care in all settings and for all provided  services. Refer to Chapter 9 for a description of PACE organization oversight 
requirements for all services. 
 
[42 CFR  460.90; 71 FR 71248 and 71280 (Dec. 8, 2006)] 
 
30 - Emergency Care  
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Emergency care is appropriate when services are needed immediately because of an 
injury or sudden illness and the time required to reach the PACE organization, or one of 
its contract providers, would cause risk of permanent damage to the participants health. 
Emergency services include inpatient and outpatient services that meet the following 
requirements: 
 
  Are furnished by a qualified emergency services provider, other than the 
PACE organization or one of its contract providers, either in or out of the 
PACE organizations service area; 
 
  Are needed to evaluate or stabilize an emergency medical condition. An 
emergency medical condition means a condition manifesting itself by acute 
symptoms of sufficient severity (including severe pain) such that a prudent 
layperson, with an average knowledge of health and medicine, could 
reasonably expect the absence of immediate medical attention to result in 
serious jeopardy to health of the participant, serious impairment to bodily 
functions, or serious dysfunction of any bodily organ or part. 
 
The organization must ensure that the participant or caregiver, or both, understand when 
and how to access emergency services and that no prior authorization is needed. 
 
A PACE organization must establish and maintain a written plan to handle emergency 
care. The plan must ensure that CMS, the State, and PACE participants are held harmless 
if the PACE organization does not pay for emergency services. The written plan also 
must provide for an on-call provider to be available 24-hours per day to address 
participant questions about emergency services and respond to requests for authorization 
of urgently needed out-of-network services and post stabilization care services following 
emergency services. 
 
[42 CFR  460.100(a), (b), (c), (d), and (e)(1)] 
 
40 - Urgently Needed and Post Stabilization Care  
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Urgent care means the care provided to a PACE participant who is out of the PACE 
service area, and who believes their illness or injury is too severe to postpone treatment 
until they return to the service area, but their life or functioning is not in severe jeopardy. 
Post-stabilization care means services provided subsequent to an emergency that a  treating physician views as medically necessary after an emergency medical condition 
has been stabilized. They are not emergency services, which PACE organizations are 
obligated to cover. Rather, they are non-emergency services that the PACE organization 
should approve before they are provided outside of the service area. 
 
The PACE organization must establish and maintain a written plan which provides for 
coverage of urgently needed out-of-network and post-stabilization care services when 
either of the following conditions is met: 
 
  The services are preapproved by the PACE organization; or 
 
  The services are not preapproved by the PACE organization because the 
PACE organization did not respond to a request for approval within one hour 
after being contacted or cannot be contacted for approval. 
 
An on-call provider must be available 24-hours per day to address participant questions 
about emergency services and respond to requests for authorization of urgently needed 
out-of-network services and post stabilization care services following emergency 
services. 
 
Periodic education of participants is necessary to ensure they and their caretakers can 
distinguish between urgent and emergent care needs, and to emphasize that PACE 
authorization is never required before seeking emergency care. The PACE organization 
needs to educate its participants in the difference between emergency care (where prior 
authorization is not required), and urgent care (where prior authorization is appropriate). 
Participants need to understand when to request prior authorization and when to request 
urgent care. 
 
[42 CFR  460.100(e)(2) and (3); 71 FR 71284 and 71297 (Dec. 8, 2006)]  
 
50 - Service Delivery  
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE organization must operate at least one PACE center either in or contiguous to 
its designated service area with sufficient capacity for routine attendance by its 
participants. 
 
The PACE organization must ensure accessible and adequate services to meet the needs 
of all its participants. When necessary, the organization must increase the number of 
centers, staff, and other PACE services. 
 
If a PACE organization operates more than one center, each PACE center must offer the 
full range of services and have sufficient staff to meet the needs of participants. 
 
The frequency of a participants attendance at the center is determined by the IDT based 
on the needs and preferences of each participant.   
At a minimum the following services must be furnished by each PACE center: 
 
  Primary care services including physician and nursing services;  
 
  Social work services;  
 
  Restorative therapies, including physical therapy, occupational therapy; 
 
  Personal care and supportive services;  
 
  Nutritional counseling;  
 
  Recreational therapy;  
 
  Meals.  
 
These services and others are described in detail below, however, if there is a service a 
participant needs, that service will be required. For a comprehensive list of possible 
required services, refer to 42 CFR  460.92, 66 FR 66286-66287. 
 
[42 CFR  460.98(c), (d), and (e)] 
 
50.1 -Primary Care  
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Primary medical care must be furnished to a participant by a PACE primary care 
physician. Each primary care physician is responsible for managing a participants 
medical situation and for overseeing a participants use of medical specialists and 
inpatient care. Other primary care services provided by physicians and/or nurses include: 
 
  Medical and medication history, assessment, diagnosis, treatment, education 
and team care planning by a primary care physician; 
 
  Management of a participants medical condition; 
 
  Referral to and oversight of specialists; 
 
  Oversight of inpatient care; 
 
  Informing female participants about their right to select a qualified specialist 
for womens health services; 
 
[42 CFR  460.102(c), 460.104(b)] 
  50.2 - Meal Requirements 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Except when a participant has a problem and must receive substitute foods or nutritional 
supplements or needs nutrition support (as discussed below) the PACE organization must 
ensure, through the assessment and care planning process that each participant receives 
nourishing, palatable, well-balanced meals that meet the participants daily 
nutritional/medical and special dietary needs. Meals should be procured, prepared and 
provided by appropriately trained/certified/experienced food service staff (i.e., qualified 
by training/certification in food safety and sanitation). Each meal must meet the 
following requirements: 
 
  Be prepared by methods that conserve nutritive value, flavor, and appearance; 
 
  Be prepared in a form designed to meet individual needs; and 
 
  Be prepared and served at the proper temperature. 
 
The PACE organization must provide substitute foods or nutrition supplements that meet 
the daily nutritional and special dietary needs of any participant who has any of the 
following problems: 
 
  Refuses the food served; 
 
  Cannot tolerate the food served; 
 
  Does not consume adequate calories and nutrients appropriate in meeting the 
individuals estimated nutritional needs determined at the initial and interim 
assessments. 
 
The PACE organization must provide nutrition support to meet the daily nutritional needs 
of a participant, if indicated by his or her medical condition or diagnosis. Nutrition 
support consists of tube feedings, total parenteral nutrition, or peripheral parenteral 
nutrition. 
 
[42 CFR  460.64(a)(1), 460.78(a)] 
 
50.3 - Sanitary Conditions 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE organization must do the following: 
 
  Procure foods (including nutritional supplements and nutrition support items) 
from sources approved or considered satisfactory, by Federal, State, Tribal, or 
local authorities with jurisdiction over the service area of the organization; 
    Store, prepare, distribute, and serve foods (including nutritional supplements 
and nutrition support items) under sanitary/safe conditions; 
 
  Dispose of garbage and refuse properly. 
 
Should Nutrition Services be contracted outside of the PACE organization, the contractor 
must be able to show appropriate/current state and/or local certification demonstrating 
adequate food preparation facilities, transportation and have staff with training and 
experience able to provide safe, nourishing, palatable, well-balanced meals that meet 
national standards for the population being served. 
 
[42 CFR  460.70, 460.78(b)] 
 
50.4 - Transportation Services 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Transportation must be provided as indicated in a participants plan of care. As part of the 
IDT process, PACE organization staff (employees and contractors) must communicate 
relevant changes in a participants care plan to transportation personnel. The IDT must 
have a process in place to get input from the transportation personnel regarding status and 
changes noted in participant condition. 
 
[42 CFR  460.76(e), 460.92(i), 460.102(e)] 
 
50.5 - Safety, Accessibility, and Equipment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
A PACE organizations transportation services must be safe, accessible, and equipped to 
meet the needs of the participant population. 
 
[42 CFR  460.76(a)] 
 
50.6 - Maintenance of Vehicles 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
If the PACE organization owns, rents, or leases transportation vehicles, it must maintain 
these vehicles in accordance with the manufacturers recommendations. 
 
If a contractor provides transportation services, the PACE organization must ensure that 
the vehicles are maintained in accordance with the manufacturers recommendations. 
 
[42 CFR  460.76(b)] 
 
50.7 - Communication with PACE Center 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
  The PACE organization must ensure that transportation vehicles are equipped to 
communicate with the PACE center. 
 
50.8 - Training 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE organization must train all transportation personnel (employees and 
contractors) in the following: 
 
  Managing the special needs of participants; 
 
  How to, and types of issues to communicate to the PACE center staff about 
participants; 
 
  Handling emergency situations; 
 
  Transportation workers are considered direct care workers. All health 
requirements and background checks must be assured by human resources or 
contractor oversight staff. 
 
[42 CFR  460.64, 460.71(b), 460.76(d), 460.102(e)] 
 
60 - Required Services for Medicare Participants 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE benefit package for Medicare participants must include, in addition to the 
service required by 42 CFR  460.92, the scope of hospital insurance benefits described 
in 42 CFR Part 409 and the scope of supplemental medical insurance benefits described 
in 42 CFR Part 410. In addition, some requirements of Title XVIII of the Act are waived 
and do not apply to services under the PACE program, which include: 
 
  The provisions of subpart F of Part 409 of 42 CFR that limit coverage of 
institutional services;  
 
  The provisions of subparts G and H of 42 CFR Part 409 and Parts 412 through 
414 that relate to rules for payment for benefits;  
 
  The provisions of subparts D and E of 42 CFR Part 409 that limit coverage of 
extended care services or home health services;  
 
  The provisions of subpart D of 42 CFR Part 409 that impose a 3-day prior 
hospitalization requirement for coverage of extended care services; and  
 
  The provisions of 42 CFR  411.15(g) and (k) that may prevent payment for 
PACE program services to individuals enrolled in the PACE program. 
  [42 CFR  460.94] 
 
70 - Excluded Services  
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The services that are excluded from coverage under the PACE program are as follows: 
 
  Any service that is not authorized by the IDT, even if it is listed as a required 
service, unless it is an emergency service; 
 
  Services rendered in a non-emergency setting or for a non-emergency reason 
without authorization;  
 
  Prescription and over-the-counter drugs not prescribed by the PACE provider 
physician;  
 
  For services in inpatient facilities, private room and private duty nursing services, 
(unless medically necessary) and non-medical items for personal convenience 
such as telephone charges, radio or television rental, (unless specifically 
authorized by the IDT as part of a participants plan of care); 
 
  Cosmetic surgery, which does not include surgery required for improved 
functioning of a malformed part of the body resulting from an accidental injury or 
for reconstruction following mastectomy; 
 
  Experimental medical, surgical or other health procedures. 
 
PACE will not cover services rendered outside the United States, except as may be 
permitted in accordance with 42 CFR  424.122 regarding conditions for payment for 
emergency inpatient hospital services and 42 CFR  424.124 regarding conditions for 
payment for physician services and ambulance services or as may be permitted under the 
States approved Medicaid Plan. There are limited exceptions to this rule. For example, a 
State that borders another country might include some Medicaid coverage across the 
border, and Medicare covers some emergency hospital, ambulance, and physician 
services outside the United States. (As defined in 42 CFR  400.200, the United States 
includes the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, 
and the Northern Mariana Islands). 
 
[42 CFR  460.96; 71 FR 71282 (Dec. 8, 2006)]  Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R2PACE 06/09/2011  Initial Publication of Manual  06/03/2011 NA 
06/03/2011  Initial Publication of Manual - Rescinded and  06/03/2011 NA 
R1_SO 
replaced by Transmittal 2 
 
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