The Program of All-Inclusive Care for the Elderly (PACE) model provides fully integrated care to frail adults ages 55 and older who meet nursing-facility level of care criteria and can live safely in the community. Findings in the June 2025 report to Congress raised questions about transparency, particularly around state and federal monitoring of PACE compliance and quality. In January 2026, staff presented results from a review of three key oversight documents: required three-way program agreements among the Centers for Medicare & Medicaid Services (CMS), states, and PACE organizations; optional two-way agreements between states and PACE organizations; and waiver requests submitted under Section 903 of the Medicare, Medicaid, and the SCHIP Benefits Improvement and Protection Act of 2000 (P.L. 106-551) (BIPA 903 waivers). These documents define state authority and responsibilities but provide limited detail on the implementation of oversight activities or coordination between states and CMS.
In this session, staff presented findings from interviews with state Medicaid officials, CMS staff, and PACE experts to identify ways to address these gaps. Interview findings highlight state interpretation of oversight roles, monitoring beyond the initial three-year period, assessment of performance and quality, use of oversight tools, and coordination with federal partners. MACPAC found variation in state approaches, differences in oversight capacity, and areas of overlap or ambiguity between state and federal responsibilities.