It was a Tuesday afternoon in late March, and Mavis had not slept eight hours in two years.
She told me this in the parking lot of the church where we hold the Seasons of Grace gathering, with the dogwoods just beginning to bud and the air still carrying winter's edge. She is 71. Her husband Bernard has Lewy body dementia. She has been the only person turning him in the night, the only person making sure he doesn't wander out the back door, the only person remembering which pill goes with which meal. Her own blood pressure was 178 over 102 the last time her doctor checked it. Her daughter lives in Charlotte and calls every Sunday.
I asked her if anyone had ever mentioned PACE.
She looked at me the way people look when you say a word they have never heard. Not even once. In two years of doctor's appointments, hospital discharges, social work consultations, and church casseroles. Not once.
I have been thinking about Mavis ever since. Because PACE — the Program of All-Inclusive Care for the Elderly — is one of the best-kept secrets in senior care, and the people who need it most are usually the last to find out it exists.
What PACE Actually Is
PACE is a Medicare and Medicaid program that wraps every kind of care a frail older adult needs into one organization. Primary care, specialists, prescriptions, transportation, adult day health, home aides, hospital stays, dental, vision, hearing, mental health, physical therapy, and yes — respite for the family caregiver. All of it. Coordinated by a single team that knows your loved one by name.
It is not insurance in the usual sense. It is a delivery system. Medicare and Medicaid pay PACE a fixed monthly amount per participant, and PACE then provides whatever care that person needs, for as long as they need it. There are no copays, no deductibles, no prior authorizations to fight over. A 2026 directory from the National PACE Association lists active programs in 33 states plus the District of Columbia, with new programs opening almost every quarter.
The centerpiece of most PACE programs is the adult day health center — a place participants visit anywhere from one to five days a week. They get meals, social activity, supervised therapies, and time with the medical team. And while they are there, the family caregiver gets something they have probably been desperate for. Hours that belong to them.
Mavis's Question
"How is this not on every refrigerator in the country?"
That was Mavis's exact response, in the parking lot, after I spent ten minutes explaining what PACE could do for Bernard. I laughed. Then I cried a little, in the way you do when something is both funny and not funny at all. Because she's right. It should be.
There are reasons it isn't. PACE only operates in service areas — usually a county or a cluster of counties around a host organization. If you don't live in one of those zip codes, you cannot enroll. The Centers for Medicare & Medicaid Services notes that as of 2026 there are roughly 180 PACE programs nationwide, serving about 80,000 participants. Compared to the 7 million Americans over 65 who need long-term services and supports, that's a sliver. The program is growing fast — Medicare and Medicaid have been pushing expansion since 2020 — but it is still rationed by geography.
The other reason is that PACE doesn't market the way private Medicare Advantage plans do. There are no commercials with happy retirees walking on beaches. There is no agent calling at dinnertime. Most families learn about PACE the way Mavis did. Someone, eventually, says the word out loud.
Who Qualifies — and the Four Numbers That Matter
PACE eligibility comes down to four things.
You must be 55 or older. That's it for age — there's no upper limit, and you don't need to be on Medicare yet (though most participants are).
You must need a nursing-home level of care, as determined by your state's assessment. This is the hardest threshold to explain in plain language because every state writes it slightly differently. Generally it means you need help with several activities of daily living — bathing, dressing, transferring, toileting, eating — or you have cognitive impairment significant enough that being alone is unsafe. The assessment is done by your state Medicaid agency or its contractor, and it's the same threshold that would otherwise qualify someone for nursing home placement under Medicaid.
You must live in the service area of an existing PACE program. This is the wall that stops a lot of families. The National PACE Association directory is the place to start — type in a zip code and see what shows up. As of April 2026, the program is active in 33 states plus DC, with the largest concentrations in California, Pennsylvania, North Carolina, and New York.
You must be able to live safely in the community at the time of enrollment, with the help PACE provides. This is sometimes the kindest part of the program. PACE is designed to delay or prevent nursing home placement — that's its whole reason for being. If circumstances change later and a participant does need nursing home care, PACE pays for that too, and the participant stays enrolled.
What It Pays For (and the Word "Respite")
Let me say this plainly, because Mavis asked me to repeat it three times.
PACE pays for respite care.
Not as a special add-on. Not after a paperwork battle. Not with a 30-day waiting period. Respite is built into how PACE works. When Bernard goes to the day health center three or four days a week, those are Mavis's hours. When she needs a weekend away to see her sister in Greenville, PACE can arrange overnight respite at a contracted facility. When she catches the flu and cannot safely care for him for five days, PACE handles it.
The full list of covered services is long enough to surprise people. Primary and specialist medical care. Prescription drugs, with no donut hole and no copays. Hospital and emergency care. Adult day health, including meals and activities. Physical, occupational, and speech therapy. In-home personal care and home health visits. Transportation to and from the center, doctor's appointments, even some non-medical trips. Dental care. Vision and hearing services, including glasses and hearing aids. Mental health and counseling. Nutritional counseling and meals. Nursing home care if it eventually becomes necessary.
What I want you to notice is what's missing from that list: limits. PACE doesn't cap your prescriptions at a certain number per month. It doesn't ration physical therapy visits. It doesn't tell you that hearing aids are excluded. The team decides what you need based on the care plan they build with you, and then they provide it.
What It Costs
This is where families either exhale or start doing math on a napkin.
If the participant has both Medicare and Medicaid — what's called dual eligibility — there is no cost. None. No premium, no copay, no deductible, no coinsurance. Medicare and Medicaid jointly pay PACE the per-participant amount, and that's the end of the conversation.
If the participant has Medicare but doesn't qualify for Medicaid based on income or assets, they pay the Medicaid-equivalent portion themselves. According to Medicaid Planning Assistance, this typically runs between $4,500 and $6,500 a month depending on the state and the program. That sounds like a lot. Compared to the cost of skilled nursing care in most states — averaging $9,000 to $12,000 a month in 2026 — it is roughly half. And it includes everything, not just the bed.
A third option exists, too: private pay. Some PACE programs accept participants who don't qualify for Medicaid and aren't on Medicare yet (the 55-to-64 group), at the same monthly rate.
But here is the conversation I have with families more often than any other, because most of them assume they make too much for Medicaid and stop right there. They don't. The income and asset rules for long-term services Medicaid are different from the rules for regular Medicaid, and they are more generous than people think. If you've been told Medicaid won't help with assisted living or in-home care, please ask a second time, with a long-term care benefits counselor or an elder law attorney. The answer surprises people.
The Tradeoffs Nobody Hides
I want to be honest about this part, because PACE is not the right fit for every family.
PACE participants must use the PACE provider network. That means the doctor your father has been seeing for 20 years — the one who knows him, the one he trusts — is no longer his doctor unless that doctor happens to be in PACE's network. The cardiologist, the neurologist, the dentist, the eye doctor — all switch. The PACE team becomes the medical home.
For some families this is welcome. The team coordinates everything. Records don't get lost between offices. Medications get reconciled at every visit, not at the once-a-year wellness check.
For others, it is a wall. I sat with a man last summer — Henry, 79, a retired engineer — whose wife had advanced Parkinson's. Their neurologist at Duke had been with them for fifteen years. Henry could not bring himself to switch, even when PACE would have given his wife transportation, day care, and home aides he was paying $4,200 a month out of pocket for. He chose what he chose. I didn't argue. There is no argument to make. You love your providers, or you don't, and the weight you can carry is the weight you can carry.
The other tradeoff is the day center itself. Some participants love it — the meals, the company, the music, the routine. Others find it patronizing or exhausting. PACE does not require attendance every day, and the team will work with you on what fits. But it is the spine of how the program delivers care, and if your loved one will refuse to go, that has to be part of the decision.
How Enrollment Actually Works
The process is more straightforward than people fear.
You contact your local PACE program. Not Medicare's 1-800 number. Not your state Medicaid office, at least not first. The program itself. You can find them through the National PACE Association directory or by calling your local Area Agency on Aging at 1-800-677-1116.
The program schedules an intake. Someone — usually a social worker or a nurse — comes to your home or has you come to the center. They ask about your medical history, your daily life, your support system. They explain the program. They answer questions. This visit is free and carries no obligation.
If the program looks like a fit, they refer you to your state for the nursing-home-level-of-care assessment. The state's contractor visits and evaluates. This determination, in most states, takes between two and six weeks.
If you meet the level of care, the PACE interdisciplinary team — primary care doctor, nurse, social worker, therapists, dietitian, recreation staff — meets to discuss your case and build a care plan. They have to agree that PACE can serve you safely in the community.
And then you enroll, on the first of the following month.
That's the whole arc. Two visits, an assessment, a team meeting, a start date. For families managing care from a distance, every step can be coordinated by phone and visit-by-visit; you don't have to be in the room for every conversation, though I'd recommend being there for the first.
Where to Start This Week
If any of this sounds like it might fit your family, here is what I'd do, this week, in this order:
Go to npaonline.org and find your local program. Write down the phone number. Call it. Ask for an intake screening. The first call takes about fifteen minutes.
While you're waiting for that intake, check whether your loved one might qualify for Medicaid long-term services. Your local Area Agency on Aging can do a benefits screening, often at no charge. The dual-eligible math is what makes PACE free for most participants.
If there's no PACE program in your area — and there are still 17 states where PACE is sparse or absent — that doesn't end the search. Many of the same services exist through Medicaid Home and Community-Based Services waivers, the VA's Home Based Primary Care program, and contracted home care agencies. If your body is already telling you something — short fuse, broken sleep, the cold-coffee feeling at 4 PM — please read about the signs of caregiver burnout before another month goes by. The screening is still worth doing. Sometimes the answer isn't PACE. Sometimes it's a home care agency you can trust plus a Medicaid waiver, plus an adult day program at the senior center down the road.
And if you're already past the point where you can do this yourself — if reading this article feels like one more thing on a list that has been growing for years — please ask someone in your circle to make the call for you. A daughter. A neighbor. The volunteer coordinator at your church. PACE intake teams will talk to anyone you authorize. The asking is the hardest part. The rest is paperwork.
A Last Word for Mavis — and for You
Mavis made the call to her local PACE program three weeks after our conversation. Bernard had his intake last week. The state assessment is scheduled for next Thursday. She came to Seasons of Grace this past Tuesday with her hair done — it had been months — and she sat down next to me and said, "I slept seven hours last night. Just so you know."
I did not say anything. I just took her hand.
That is the thing about programs like PACE. They don't fix the diagnosis. They don't bring back the husband Bernard used to be, or give Mavis back the years she spent vigilant in a quiet house. What they do is much smaller and much more important. They make it possible to keep going.
You have been carrying something enormous. There may be hands waiting that you have not yet asked.
