PACE in New York: 2026 Senior Guide to All-Inclusive Care

Programs of All-Inclusive Care for the Elderly (PACE) in New York run through ten PACE organizations, counted from the rows of the state's Managed Long Term Care Plan Directory in July 2026. That is a snapshot rather than a published figure. PACE wraps a senior's primary care, specialty care, prescription drugs, long-term services and supports, transportation, meals, and family caregiver respite into one fully capitated plan built around a community day center, and it has become one of the most consequential paths to integrated dual-eligible care in the state.1

What makes PACE matter most in 2026 New York is the September 1, 2025 Minimum Needs Requirement, a new activities-of-daily-living (ADL) eligibility floor that now governs Managed Long Term Care (MLTC) Partial Capitation and Medicaid Advantage Plus (MAP) enrollment. PACE is explicitly exempt from that floor. For a senior who clears nursing-home level of care but does not clear the new ADL floor, PACE is the operative integrated-care option.1

What PACE Covers in New York

PACE folds all Medicare benefits and all Medicaid benefits, long-term services and supports included, into a single capitated plan. The PACE organization is both the payer and the provider of most services, which puts it structurally closer to a staff-model HMO than to a conventional health plan with a contracted network.1

The federal authority is unusual: it lives in two parallel statutes. Section 1894 of the Social Security Act (42 U.S.C. 1395eee) establishes the Medicare side and section 1934 (42 U.S.C. 1396u-4) the Medicaid side, both added by the Balanced Budget Act of 1997, with the program requirements codified at 42 CFR Part 460.2

New York authorizes PACE plans as a category of MLTC plan under the Managed Long Term Care architecture at PHL 4403-f, but that federal authority is independent of New York's Section 1115 Medicaid Demonstration.1

Who Qualifies for PACE in New York in 2026

Under 42 CFR 460.150(b), four basic requirements govern every PACE applicant in New York:2

1. Age 55 or older. PACE is structurally an aging-services program.2
2. Nursing-facility level of care (NF-LOC) certification. The state administering agency, the New York State Department of Health, determines that the applicant needs the level of care the State Medicaid plan requires for coverage of nursing facility services.2
3. Residence within the PACE organization's service area. Service areas are designated by ZIP code or county in the three-way program agreement. A senior outside the service area cannot enroll, even if every other test is met.2
4. Any additional program-specific condition in the plan's program agreement. A PACE program agreement may add eligibility conditions of its own, but it may not modify the three requirements above. Ask the plan what, if anything, it adds.2

A fifth requirement sits separately at 42 CFR 460.150(c)(1): at the time of enrollment the applicant must be able to live in a community setting without jeopardizing their health or safety. That is a clinical judgment by the interdisciplinary team, not a categorical floor, and it is the test that most often decides a borderline case.2

Under 42 CFR 460.150(d), eligibility to enroll is not restricted to Medicare or Medicaid beneficiaries, so PACE accepts full-benefit dual-eligibles, Medicaid-only participants, and Medicare-only or private-pay participants, even though the vast majority of New York participants are full duals.2 PACE is also voluntary: a senior cannot be auto-assigned into PACE the way a dual-eligible can be auto-assigned into an MLTC plan, and must affirmatively elect enrollment.

The September 1, 2025 ADL-Floor Exemption

Under MLTC Policy 25.04 (issued June 30, 2025), NYSDOH set a new Minimum Needs Requirement floor for MLTC Partial Capitation and Medicaid Advantage Plus enrollments effective September 1, 2025. An applicant must need at least limited assistance with physical maneuvering with more than two activities of daily living, or, for an individual with a documented dementia or Alzheimer's diagnosis, at least supervision with more than one ADL. The companion personal-care and consumer-directed directive, 25 OHIP/ADM-03, was revised August 22, 2025.1

PACE is explicitly carved out. Policy 25.04 states that the Minimum Needs Requirements do not apply to enrollment in Programs of All-Inclusive Care for the Elderly (PACE) plans. The logic is straightforward: PACE eligibility has always been gated by NF-LOC, a deeper clinical test than any ADL count, so the state did not overlay a corrective ADL floor on top of it.1

The carve-out makes PACE the operative integrated-care route for several senior populations:

• Seniors whose nursing-home-level need is driven primarily by skilled-nursing demand (complex wound care, frequent IV therapy, advanced cardiovascular monitoring) rather than ADL impairment, and who therefore clear NF-LOC without meeting the ADL floor.
• Seniors with mid-range dementia whose primary clinical concern is supervision and behavioral redirection, and who do not satisfy the supervisory-with-more-than-one-ADL-plus-dementia route.
• Seniors at the assessment edge whose UAS-NY scores are borderline on ADL impairment but whose hospital and primary-care records establish NF-LOC.
• Pre-September 1, 2025 MLTC Partial Capitation enrollees who lose Legacy Status because of an enrollment break, and who would not clear the new floor on re-application but still clear NF-LOC.1

In each case, PACE is open and MLTC Partial Capitation and MAP are not.

How the Day-Center Model Works

A typical PACE day center has a primary care clinic, therapy gyms for physical and occupational therapy, activity rooms for group programming, a dining area for hot lunch, a nursing area for vitals and wound care, and a van bay for pickup and drop-off.

Most participants attend three to five days per week, on a schedule the interdisciplinary team sets and reviews at every comprehensive reassessment (at enrollment, every six months, and on any change in condition). For a senior with advanced dementia or significant ADL needs, the day center is also where bathing and other ADL assistance happens, which for an unpaid family caregiver is often the most concrete relief PACE provides.

Transportation is included in the capitation: the PACE van takes the participant from home to the day center and to specialty appointments and back.

Under 42 CFR 460.102, every PACE organization must staff an interdisciplinary team covering at least eleven roles, among them a primary care provider, a registered nurse, a master's-level social worker, physical and occupational therapists, a recreational therapist, a dietitian, a center manager, a home care coordinator, and a transportation representative. An MLTC Partial Capitation care manager, by contrast, is typically one nurse or social worker coordinating services for dozens of members.

The Active 2026 New York PACE Programs

New York's active PACE programs in 2026 are listed below, with sponsors and county service areas. Plan rosters shift with openings and consolidations, so confirm the current list against the live NYSDOH Managed Long Term Care Plan Directory before any enrollment decision.1

PACE at Hudson Headwaters, sponsored by a Federally Qualified Health Center (FQHC), is among the newer entrants.

Two corrections worth flagging, because they appear in older directories: Independence Care System was not a PACE plan but an MLTC Partial Capitation plan that ceased managed-care operations on March 31, 2019, and LiveOn NY is an advocacy and aging-services organization, not a PACE provider.

How PACE Differs From MLTC and Medicaid Advantage Plus

PACE, MLTC Partial Capitation, and Medicaid Advantage Plus (MAP) are the three integrated or near-integrated long-term-care managed-care products in New York. They share some surface features and differ in load-bearing ways.3

In plain terms: PACE delivers more, costs nothing for full duals, and asks more in return (day-center attendance). MLTC Partial Capitation is broader geographically. MAP is the closest substitute for a senior who wants integrated dual-eligible care without a day-center commitment.3

How to Apply for PACE in New York

Application starts directly with the plan, not with an enrollment broker. Ask the plan at intake whether a New York Independent Assessor (NYIA) Community Health Assessment is also required in your case: NYIA's three-stage assessment under 22 OHIP/ADM-01 applies to new MLTC enrollees, and New York classifies PACE as one of its MLTC product types, so do not assume you can skip it on the strength of the federal rule alone.1

A senior already enrolled in MLTC Partial Capitation can switch into PACE even while inside the 9-month MLTC lock-in: MLTC Policy 21.04 states in terms that lock-in does not "impact an enrollee's ability to transfer from an MLTCP plan to an integrated plan," and PACE is one of the integrated plans it names. A senior in MAP is not subject to the lock-in at all. A senior in fee-for-service Medicaid can enroll through the same direct route.1

What PACE Costs the Member

For a participant who is eligible for Medicaid, the monthly premium is $0, and that is a federal rule rather than a plan's marketing promise: under 42 CFR 460.186(d) a PACE organization may not charge a Medicaid-eligible participant a monthly premium, and under 42 CFR 460.182(c) it must accept the Medicaid capitation as payment in full and may not bill, charge, collect, or receive any other payment. So a full-benefit dual-eligible, and a Medicaid-only participant who is not yet Medicare-eligible, has no premium, no deductible, no coinsurance, and no copay for a covered service.2

The regulation carves out exactly two things a Medicaid-eligible participant can still owe: an applicable Medicaid spend-down liability, and amounts due under the post-eligibility treatment of income process. How much that is turns on where the participant lives, and the difference runs to well over a thousand dollars a month, so get it right before you budget.2

• Living in the community, which is the normal PACE case. The 2026 non-MAGI Medicaid income level is $1,836/month for a household of one and $2,489/month for a household of two. Income above that level is the excess-income amount. A PACE participant living at home is not on the nursing-home patient-pay calculation and does not have their income reduced to a personal needs allowance. New York also lets a senior with excess income deposit it into a pooled income trust rather than spend it down, which is often the better route for a PACE applicant.4
• Permanently placed in a nursing facility. Only then does the Net Available Monthly Income (NAMI) patient-pay calculation apply: monthly income minus the $50/month personal needs allowance that 18 NYCRR 360-4.6 sets for nursing-facility residents, minus health-insurance premiums, any monthly income allowance diverted to a community spouse, a dependent-family allowance, and certain incurred medical costs.4

A Medicare-only or private-pay participant pays the Medicaid portion of the capitation out of pocket, plus any Medicare cost-sharing. Private-pay PACE is uncommon in New York, and rates vary widely by service area and acuity; ask the specific plan for its current private-pay rate.

Disenrollment and the Absence of Lock-In

PACE is structurally easy to leave on the Medicaid side. Under 42 CFR 460.162(b), a participant may voluntarily disenroll without cause at any time, effective the first day of the month following the plan's receipt of notice.2 The 9-month MLTC lock-in under Policy 21.04 does not apply to integrated plans, and the policy names PACE, MAP, and FIDA-IDD.1

After Medicaid-side disenrollment, the participant routes back to whatever Medicaid pathway they elect: fee-for-service Medicaid for LTSS plus original Medicare or a Medicare Advantage plan, or MLTC Partial Capitation, MAP, or another D-SNP.

Involuntary disenrollment is permitted only for the reasons listed at 42 CFR 460.164(b), which include nonpayment of a premium, spend-down, or NAMI contribution after a 30-day grace period, disruptive or threatening behavior, loss of NF-LOC at recertification, moving out of the service area, and termination of the PACE organization. It is not the plan's call alone: under 42 CFR 460.164(f) the State administering agency must review the disenrollment and find that the organization has adequately documented acceptable grounds before it takes effect. That is a real due-process safeguard, and worth citing back to a plan that threatens disenrollment.2

One asymmetry to flag: while Medicaid-side disenrollment is immediate, the Medicare side follows standard Medicare timing. A dual-eligible can use the dual Special Enrollment Period to switch Medicare options at any time; a non-dual participant may need to wait for the Annual Enrollment Period.

Long-Stay Nursing-Home Coverage Under PACE

If a PACE participant requires long-term nursing-home placement, the three-month disenrollment rule that ends a partially capitated MLTC enrollment does not reach them. The participant stays enrolled in PACE and the same interdisciplinary team keeps managing care in the new setting.1

That rule rests on three layers on the MLTC side: New York Public Health Law 4403-f(7)(b)(v) clause (13) excludes from MLTC a person permanently placed in a nursing home for three consecutive months or more; the 1115 Medicaid Redesign Team waiver amendment CMS approved December 19, 2019 limits the partially capitated nursing-home benefit to three months for enrollees designated Long-Term Nursing Home Stays, after which the enrollee is involuntarily disenrolled and nursing-home payment moves to Medicaid fee-for-service; and NYSDOH policy MRT-11202 implements it. MRT-11202 states the reach of the limit in its own terms: it "only impacts the NH benefit for Partial Capitation plans," and there is "no impact to the nursing home benefit for MAP, PACE, FIDA, or Medicaid Managed Care."1

Read that for exactly what it says: the cutoff does not apply to PACE. It is not a published statement of how long PACE pays for an institutional stay, so before a placement decision, ask the PACE organization in writing what its program agreement covers for a long-stay admission.

How Appeals Work for PACE Participants

PACE participants have a layered appeals system. At the plan level, a participant or representative can file a grievance or appeal directly with the PACE organization for service-authorization disputes, quality concerns, or administrative actions, under 42 CFR Part 460 Subpart G and the program agreement.

For Medicaid-side issues, once the plan-level appeal is decided the participant can pursue a New York State Fair Hearing, filed with the New York State Office of Temporary and Disability Assistance (OTDA). The fair hearing is not requested for you. Two different clocks run at once here, and confusing them is how families lose services they were entitled to keep:5

• To file the fair hearing at all: 120 days. Under 42 CFR 438.408(f)(2) the enrollee gets "no less than 120 days from the date of the adverse appeal resolution (Final Adverse Determination) to request a state fair hearing." Missing day 10 does not forfeit the appeal.5
• To keep the existing service running while the hearing is pending (Aid Continuing): 10 calendar days. The fair hearing has to be requested within 10 calendar days of the plan's appeal decision, or by the date that decision takes effect, whichever is later. This is the short clock, and it governs whether the aide keeps showing up in the meantime, not whether the appeal survives.5

For Medicare-side issues, the participant follows the standard Medicare appeals process: reconsideration, then an independent reviewer, an administrative law judge, the Medicare Appeals Council, and federal court if necessary.

Ask the PACE organization for its appeal decision in writing rather than accepting a phone explanation: both clocks run from that decision, and you will need its date on paper to prove you filed in time.

Common Misconceptions About PACE

• PACE is not a nursing home. Day-center attendance is part of the model; institutional residence is not.
• PACE eligibility is not gated by an ADL count. It is gated by NF-LOC.1
• PACE includes Part D-equivalent drug coverage automatically. No separate Prescription Drug Plan enrollment is required once PACE is effective.
• The $50 personal needs allowance is not a PACE figure. It applies to nursing-facility residents. A PACE participant living at home who is over the income level has an ordinary excess-income spend-down instead.4

Learn More

Find personalized help comparing PACE, MLTC Partial Capitation, and MAP at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.