The day somebody tells you your mother qualifies for a nursing home, you hear a verdict. Everyone in the room does. Shoulders drop, nobody says much, and within about a week somebody floats selling the house.
Here's what almost nobody tells you in that room. In 33 states and the District of Columbia, that same determination is the key that unlocks a program built specifically to keep her out of a nursing home. Not a waiting list, not a pamphlet. A real benefit with a federal rulebook, where qualifying for institutional care is the entrance requirement for staying home.
I spent 8+ years buying houses from families in transition, and I walked away from that side of the business. The calls came in a pattern I could set my watch by. They came right after a level of care determination, when a family had just been handed a number they couldn't afford and had decided, in about four days, that the house had to go by the end of the month. Most of them had never heard the word PACE. Several of them lived inside a service area.
That's the part worth your attention. You're probably weighing two doors: keep your father home and pay for it, or move him and pay for that. There's a third door, it's older than most of the people reading this, and it's invisible because nobody sells it to you. Nobody buys television ads for it. Your parent's doctor may never mention it.
So here's what it is, what it costs, what it protects, and the two real tradeoffs that get glossed over everywhere else.
What PACE Is, In The Government's Own Words
PACE stands for Program of All-Inclusive Care for the Elderly. According to Medicare.gov, it's "a Medicare and/or Medicaid comprehensive medical and social services program available in some states" that "helps eligible older adults who need nursing home-level care meet their health care needs in the community, by giving them coordinated care and support services (instead of having them go to a nursing home or other care facility)."
CMS describes the population plainly: PACE "provides comprehensive medical and social services to certain frail, elderly people (participants) still living in the community," and notes that most participants are dually eligible for both Medicare and Medicaid.
Medicare.gov lists four conditions your parent has to meet. They have to be at least 55. They have to live in the service area of a PACE organization. They have to need a nursing home level of care, as certified by the state. And they have to be able to live safely in the community with help from PACE.
The scale is small and growing. The National PACE Association, the trade group that tracks the programs, reported on its program finder as of August 26, 2026 that there are 204 PACE programs serving more than 96,400 participants in 33 states and the District of Columbia. For comparison, roughly 96,000 people nationwide is smaller than the population of most mid-size cities. This is not a mass-market benefit, which is exactly why you haven't heard of it.
Now the money, because that's the comparison you're actually running. In the 2025 Cost of Care Survey, conducted July through November 2025, CareScout put the national median cost of an assisted living community at $6,200 a month, or $74,400 a year, up 5% year over year. It put non-medical in-home caregiver services at a median $35 an hour, which CareScout calculates as $80,080 a year at 44 hours a week. A semi-private nursing home room came in at a median $9,581 a month.
Against those figures, here's what Medicare.gov says PACE costs: "If you have Medicaid, you won't pay a monthly premium for PACE." If your parent doesn't qualify for Medicaid but has Medicare, they pay a monthly premium covering the long-term care part of the benefit plus a premium for Part D drugs. And then the line that matters most: "Regardless of your financial situation, you won't have a deductible, copayment, or co-insurance for any drug, service, or care your PACE team approves."
What "All-Inclusive" Actually Means
That word does real work here, and it's worth being precise about it, because you've been promised comprehensive care before by people who meant something much smaller.
Federal regulation at 42 CFR 460.92 requires the PACE benefit package to include all Medicare-covered services, all Medicaid-covered services under the state's plan, and "other services determined necessary by the interdisciplinary team to improve and maintain the participant's overall health status." Read that third category twice. It's the one that has no analogue in a normal insurance plan. If the team decides your father needs something to stay healthy, the fact that no billing code exists for it is not the end of the conversation.
The coverage obligation is written the same way. Under 42 CFR 460.98, a PACE organization is responsible for care that meets each participant's needs across all care settings, "24 hours a day, every day of the year," and those services must be furnished in at least the PACE center, the home, and inpatient facilities.
Who decides is spelled out too. 42 CFR 460.102 requires an interdisciplinary team with eleven roles: a primary care provider, a registered nurse, a master's-level social worker, a physical therapist, an occupational therapist, a recreational therapist or activity coordinator, a dietitian, the PACE center manager, a home care coordinator, a personal care attendant, and a driver. The driver is on the clinical team. If you've ever tried to get a straight answer about why your mother missed an appointment, you understand why that's not a joke.
Medicare.gov lists the kinds of services PACE may cover, and the list includes adult day primary care, home care, hospital care, prescription drugs, physical and occupational therapy, personal care and support services, mental health counseling, social services, nutritional counseling, dentistry, and transportation to and from the PACE center and medical appointments. Nursing home care is on that list as well, for the times it's genuinely needed.
The Protection Assisted Living Cannot Match
This is the piece I'd underline if you only take one thing from this post.
Assisted living has no federal floor on discharge. It's licensed and regulated state by state, which means the answer to "can they make my mother leave?" depends entirely on which state she's in and what her contract says. Families discover this at the worst possible moment, usually after a hospitalization, when the facility decides her care needs now exceed what they offer.
PACE runs on a different rule. Under 42 CFR 460.160, "Enrollment continues until the participant's death, regardless of changes in health status," unless the participant voluntarily disenrolls or is involuntarily disenrolled under a narrow list. NC Medicaid states the same thing in its own program description: "PACE enrollment will continue until the participant's death regardless of changes in health status."
Getting sicker is not grounds for removal. That's the entire point of the sentence.
The involuntary list at 42 CFR 460.164 is short and specific: failure to pay a premium or a Medicaid spend-down after a 30-day grace period, disruptive or threatening behavior by the participant or a caregiver, moving out of the service area or being gone more than 30 consecutive days, no longer meeting the state's nursing facility level of care and not being deemed eligible, or the program itself losing its agreement or licenses. There's also a protection against being pushed out sideways: 42 CFR 460.162 requires the organization to ensure its employees and contractors don't engage in any practice "that would reasonably be expected to have the effect of steering or encouraging disenrollment of participants due to a change in health status."
And that level of care item has a cushion built into it. Under 42 CFR 460.160, if the state determines a participant no longer meets nursing facility level of care, the participant may be "deemed" to continue to be eligible until the next annual reevaluation, if without PACE they'd reasonably be expected to meet that standard again within six months. In other words, getting better on PACE doesn't automatically cost your parent PACE.
Going the other direction is easy on purpose. 42 CFR 460.162 says a participant "may voluntarily disenroll from the program without cause at any time." Your parent isn't locked in.
The Two Tradeoffs Nobody Leads With
I'm not going to sell you the brochure version, because the tradeoffs here are real and one of them is a dealbreaker for some families.
Your parent will probably change doctors. During intake, 42 CFR 460.152 requires PACE staff to explain that the PACE organization will be the participant's sole service provider, and that it "guarantees access to services, but not to a specific provider." South Carolina's Medicaid agency puts it in plainer language on its member page: "When you enroll in PACE, you may be required to use a PACE-preferred doctor." If your mother has seen the same internist for twenty-two years and that relationship is holding her together, weigh this honestly before anything else.
Geography decides for you. PACE only exists where a PACE organization has an approved service area, and those are drawn by county and ZIP code. South Carolina's Medicaid agency lists PACE as currently available in Anderson, Bamberg, Berkeley, Calhoun, Charleston, Dorchester, Greenville, Lexington, Orangeburg, Pickens and Richland counties, served by four organizations: BoldAge PACE, Prisma Health SeniorCare PACE-Midlands, Prisma Health SeniorCare PACE-Upstate, and The Orangeburg Senior Helping Center. Look at what's missing from that list. Horry County, Georgetown, York, Spartanburg, Beaufort. A family in Myrtle Beach reading this has no PACE option today, and I'd rather you learn that in ten seconds here than after a month of hope.
North Carolina operates PACE as well, through NC Medicaid, with the same core rules: 55 or older, certified as needing nursing facility level of care, living in a PACE organization's service area, and able to live in a community setting without jeopardizing health or safety. NC Medicaid publishes the current list of organizations and service areas, and its Contact Center at 888-245-0179, Monday through Friday 8 a.m. to 5 p.m., can tell you what's active where your parent actually lives.
The Part D Trap Worth Knowing Before October
Medicare's Open Enrollment Period runs October 15 through December 7, per Medicare.gov. Every year around then, a well-meaning adult child or a helpful neighbor goes shopping for a better drug plan.
Do not do that for a PACE participant. Medicare.gov states it flatly: "If you have Medicare and join PACE, you'll get your Part-D covered drugs and all other necessary medication from PACE. If you join a separate Medicare drug plan while you're in the PACE program, you'll be disenrolled from PACE."
One well-intentioned enrollment click can undo the whole arrangement. If your parent is in PACE, their drug coverage is already handled, and shopping it is how you lose everything else attached to it.
There's a flip side that works in your favor. PACE enrollment isn't a seasonal thing. 42 CFR 460.158 ties the effective date only to paperwork: enrollment is effective "on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement." You're not waiting for a window in the fall.
What To Do This Week
Step 1: Check the service area before anything else
This is a five-minute question with a yes or no answer, and it decides whether the rest of this matters. Use the PACE plan search on Medicare.gov, or call your state Medicaid office. In North Carolina, that's the NC Medicaid Contact Center at 888-245-0179. In South Carolina, SCDHHS lists the four PACE providers and their counties directly on its member page. Search by the ZIP code where your parent sleeps, not where you live and not where the hospital is.
Step 2: Ask the state for the level of care assessment
Your parent needs to be certified as needing a nursing facility level of care, and that determination comes from the state, not from the PACE program. Under 42 CFR 460.152, the state administering agency assesses the potential participant, including someone who isn't eligible for Medicaid at all. Ask your parent's care team or the state Medicaid office how a level of care assessment gets started where you are.
Step 3: Get the premium number in writing
If your parent has Medicaid, Medicare.gov says there's no monthly PACE premium. If they have Medicare but not Medicaid, there is one, and it varies by program. 42 CFR 460.152 requires the intake process to explain monthly premiums, any Medicaid spend-down obligations, and post-eligibility treatment of income before anybody signs. Ask for all three in writing, then set that number next to the $6,200 a month median for assisted living and the $35 an hour for in-home care and do the comparison on paper.
Step 4: Ask the doctor question out loud
Ask which of your parent's current physicians they'd keep, and which they'd give up. Then ask your parent. This is the tradeoff most likely to sink a placement three months in, and it's much cheaper to find out now.
Step 5: Take the house off the table for ninety days
Here's the move I care most about, because it's the one I watched families skip for eight years. The house is the biggest asset your family will ever handle, and the level of care determination is the moment people start treating it as the emergency fund. Before you list anything, find out whether the care math changes. If PACE covers your parent's county and your parent qualifies, you may be looking at a completely different monthly number than the one that scared you into calling an agent.
Calling a real estate agent starts a clock. That's not the agent being pushy, that's the job. Their job is to get the house sold, and a good one will have it listed by the weekend. If your family is genuinely years away from that, or if a program like PACE means you never get there at all, then starting that clock in month one costs you options you can't get back.
You're allowed to have the conversation before you're ready to sell. You're allowed to find out what the care actually costs before you decide the house has to pay for it.
Frequently Asked Questions
What is the PACE program for seniors?
PACE stands for Program of All-Inclusive Care for the Elderly. Per Medicare.gov, it's a Medicare and/or Medicaid program that helps older adults who need nursing home-level care meet their health care needs in the community instead of going to a nursing home or other care facility. Federal regulation at 42 CFR 460.92 requires the benefit package to cover all Medicare-covered services, all Medicaid-covered services under the state plan, and any other services the interdisciplinary team decides are necessary to improve and maintain the participant's health.
Does my parent have to be on Medicaid to join PACE?
No. Medicare.gov states that if you have Medicaid you won't pay a monthly premium for PACE, and that if you don't qualify for Medicaid but have Medicare, you'll pay a monthly premium for the long-term care part of the benefit plus a Part D drug premium. Medicare.gov also notes that someone with neither Medicare nor Medicaid can pay the PACE premium privately. Regardless of financial situation, there's no deductible, copayment, or coinsurance for any drug, service, or care the PACE team approves.
Can a PACE program remove my parent if their health gets worse?
No, and this is the sharpest contrast with assisted living. Under 42 CFR 460.160, enrollment continues until the participant's death regardless of changes in health status, unless the participant voluntarily disenrolls or is involuntarily disenrolled for one of the narrow reasons at 42 CFR 460.164, which include nonpayment after a 30-day grace period, disruptive or threatening behavior, or moving out of the service area. 42 CFR 460.162 separately bars the organization from steering or encouraging disenrollment because a participant's health changed.
Is PACE available in North Carolina and South Carolina?
Yes, both states operate PACE, but only in certain counties. SCDHHS lists PACE as currently available in Anderson, Bamberg, Berkeley, Calhoun, Charleston, Dorchester, Greenville, Lexington, Orangeburg, Pickens and Richland counties. NC Medicaid runs PACE statewide through approved organizations with defined service areas and publishes the current list. Because service areas are drawn by county and ZIP code and change over time, confirm coverage for your parent's specific address through Medicare.gov's PACE plan search or the NC Medicaid Contact Center at 888-245-0179.
Can you only join PACE during Medicare Open Enrollment?
No. Under 42 CFR 460.158, PACE enrollment is effective on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement, with no seasonal window attached. The Open Enrollment Period of October 15 through December 7 matters for a different reason: Medicare.gov warns that if someone joins a separate Medicare drug plan while enrolled in PACE, they'll be disenrolled from PACE.
About Ryan Riggins
Ryan Riggins is a senior transition advisor and former house flipper. After 8+ years buying homes from families in transition, he walked away from the cash-buyer side to help families avoid the $50K mistakes he used to profit from. Based in Greensboro, NC. NC Real Estate License #361546, eXp Realty. Founder of Riggins Strategic Solutions and the SeniorSafe app.
Running the numbers on staying home? The free Aging in Place vs Assisted Living calculator gives you the honest break-even in about four minutes: rigginsstrategicsolutions.com/tools/aging-in-place-break-even
Want a step-by-step guide? The Senior Transition Blueprint is free, all 20 modules and 69 tools: rigginsstrategicsolutions.com/the-blueprint
Not sure where your family stands? The free Family Readiness Score takes five minutes and shows the gaps across the home, the money, the legal documents, care, and family alignment: rigginsstrategicsolutions.com/tools/family-readiness-score
Need a personalized plan? The Senior Transition Roadmap is free, by application. It adds calls with Ryan and 90 days of email support: rigginsstrategicsolutions.com/the-roadmap
Selling a parent's home? Ryan finds and vets the right local agent for your situation and stays in your corner on the whole sale, at no added cost to your family: rigginsstrategicsolutions.com/in-your-corner
Coordinate the family in one place. SeniorSafeApp keeps daily check-ins, medications, and documents where the whole family can see them: seniorsafeapp.com
Sources
All sources checked August 26, 2026.
- Medicare.gov, PACE: definition of the program, the four eligibility conditions, the list of services PACE may cover, the cost structure for Medicaid and non-Medicaid participants, the absence of any deductible, copayment or coinsurance for team-approved care, and the warning that joining a separate Medicare drug plan results in disenrollment from PACE. https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/other-medicare-health-plans/PACE
- Medicare.gov, Joining a plan: Open Enrollment Period of October 15 through December 7. https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan
- Centers for Medicare and Medicaid Services, Program of All-Inclusive Care for the Elderly (PACE), page last modified March 16, 2026: description of the participant population and dual eligibility. https://www.cms.gov/medicare/medicaid-coordination/about/pace
- 42 CFR 460.92, Required services; 42 CFR 460.98, Service delivery, including the 24 hours a day, every day of the year obligation; 42 CFR 460.102, Interdisciplinary team composition; 42 CFR 460.152, Enrollment process, including sole service provider disclosure and state level of care assessment; 42 CFR 460.158, Effective date of enrollment; 42 CFR 460.160, Continuation of enrollment and deemed continued eligibility; 42 CFR 460.162, Voluntary disenrollment and the anti-steering requirement; 42 CFR 460.164, Involuntary disenrollment. Current as of the August 24, 2026 issue of Title 42. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-E/part-460
- NC Medicaid, Program of All-Inclusive Care for the Elderly (PACE): North Carolina eligibility criteria, enrollment continuing until death regardless of health status, payment methodology for Medicare-eligible participants not eligible for Medicaid, and the NC Medicaid Contact Center number. https://medicaid.ncdhhs.gov/providers/programs-and-services/long-term-care/program-all-inclusive-care-elderly-pace
- South Carolina Department of Health and Human Services, Program For All-Inclusive Care Of The Elderly (PACE), member page: the eleven counties where PACE is currently available, the four PACE providers and their service areas, and the note that enrollees may be required to use a PACE-preferred doctor. https://www.scdhhs.gov/members/managed-care-plan-information/program-all-inclusive-care-elderly-pace/members
- National PACE Association, Find a PACE Program: 204 PACE programs serving more than 96,400 participants in 33 states and the District of Columbia, as displayed August 26, 2026. https://www.npaonline.org/find-a-pace-program
- CareScout Cost of Care, 2025 Cost of Care Survey conducted July through November 2025: assisted living community national median of $6,200 per month and $74,400 annually, up 5% year over year; non-medical caregiver national median of $35 per hour and $80,080 annually at 44 hours per week; nursing home semi-private room national median of $9,581 per month. https://www.carescout.com/cost-of-care
