PACE or the Elderly Waiver? Choosing Between Iowa's Two Big Programs

Two programs, one goal

The Elderly Waiver and PACE both exist to help people who need a nursing-home level of care live somewhere else, usually at home. Both require a level-of-care assessment. After that, they part ways. The Elderly Waiver is a Medicaid program that adds services, such as aides, attendant care, meals and adult day care, around a member's existing doctors and Medicare. PACE takes over all of a participant's care, medical and long-term, and coordinates it through one interdisciplinary team and a day center.

Side by side

Sources: 441 IAC 83 Division II; Iowa HHS PACE program page.

Who tends to prefer the Elderly Waiver

People with long-standing doctors they trust, people whose main need is help with daily tasks rather than medical coordination, and people who want to self-direct their care through the Consumer Choices Option, which can include hiring some relatives. Members living in assisted living can also use waiver services there, if the program participates.

Who tends to prefer PACE

People whose care is fragmented across many specialists, people who would benefit from going to a day center several times a week, and families who want one phone number for everything. PACE arranges transportation to the Windsor Heights center, provides primary care there, and covers hospital and nursing home care if needed, as long as care stays within PACE's network.

People who are 55 to 64 and need nursing-home-level care cannot use the Elderly Waiver, but can use PACE if they live in the service area.

What happens if needs grow

In PACE, the team adjusts services as needs change and pays for nursing home care if it becomes necessary, so a participant does not lose coverage by moving. On the Elderly Waiver, a member who moves into a nursing facility shifts from waiver services to Medicaid nursing facility coverage, usually through the same managed care plan. Either way, Iowa Medicaid's financial rules and the 60-month look-back apply.

Costs and paperwork

For a participant with Medicaid, PACE generally costs nothing out of pocket, and the Elderly Waiver costs nothing beyond any client participation the member owes. A PACE participant without Medicaid pays a monthly premium for the long-term care portion, and a Medicare Part D premium if applicable. Neither program pays room and board in assisted living.

Both programs involve paperwork: a Medicaid application with financial documents, a level-of-care assessment, and a service or care plan. PACE handles more of the coordination itself once a participant enrolls, which many families find a relief. The waiver leaves more choices, and more coordination, with the member and the case manager.

Can you switch later?

Yes. PACE enrollment is voluntary and a participant can leave at the end of any month, returning to regular Medicare and Medicaid and, if eligible, the Elderly Waiver. Elderly Waiver members can apply to PACE if they live in the service area and meet its criteria. Switching takes paperwork and careful timing so that no month falls between programs, so ask both Immanuel Pathways and the managed care plan to coordinate the dates in writing.

How to decide

Ask two questions: does your parent want to keep current doctors, and would a day center help? If the answers are yes and no, the waiver is usually the better fit; if no and yes, call Immanuel Pathways at (515) 270-5000. Aging Resources of Central Iowa (515-255-1310) can walk through both for free, and Iowa Medicaid Member Services (1-800-338-8366) can answer coverage questions.