PACE Expansion Application: How New Service Areas Get Approved

A PACE expansion application is the formal proposal a PACE organization submits through CMS's PACE application process, with state involvement, to extend its approved geographic service area into additional counties or ZIP codes or to add a PACE center. A new organization seeking to start a PACE program files an initial PACE application instead. If your parent needs nursing-home-level care but lives outside an existing PACE service area, an approved expansion is one possible route — but it does not enroll families immediately.

Understanding how this process works matters because PACE — the Program of All-Inclusive Care for the Elderly — remains geographically limited. At the time of writing, the National PACE Association's directory lists 204 programs in 33 states and the District of Columbia, so many families still live outside a PACE service area.

What a PACE Expansion Application Actually Is

There are two related application paths:

1. Service area expansion — an existing PACE organization applies to add counties or ZIP codes, add a physical PACE center within its existing service area, or do both. CMS treats these as different expansion scenarios.
2. Initial PACE application — an entity that has never operated PACE applies for a new PACE Program Agreement. This is not technically a service-area expansion, but it is the route for bringing PACE to an area with no existing program.

A service-area expansion cannot be approved by CMS alone. CMS says the organization must obtain approval from the State Medicaid Agency and State Administering Agency, while CMS reviews and decides the federal application. An initial program uses a separate initial application and, if approved, a three-party program agreement among CMS, the State Administering Agency, and the PACE organization.

The CMS Application Process

A PACE organization pursuing expansion completes the PACE application in CMS's Health Plan Management System (HPMS) with state involvement. The exact materials vary by state and by whether a new center is involved, but the current CMS application focuses on:

• Service area and access — a defined geographic area, detailed maps of counties and ZIP codes, the PACE center and other service sites, travel information, and evidence that center capacity supports routine participant attendance.
• State assurances and payment information — a signed assurance from the State Administering Agency, plus the state's CMS-approved Medicaid capitation amount or payment methodology and related state processes.
• Operational readiness — if a new PACE center is added, a State Readiness Review. For a geographic expansion without a new center, the state generally considers whether the existing center can serve additional participants.
• Financial information when requested — a service-area expansion application does not generally require a financial upload, but CMS may request financial information if it cannot verify that the organization remains fiscally sound.

CMS reviews the application against federal PACE regulations (42 CFR Part 460) and may request additional information. Current CMS instructions also require an existing organization to have completed its first trial-period audit before submitting a service-area expansion application; adding a new center generally triggers a state readiness review.

The State's Role

The State Medicaid Agency and State Administering Agency are not just rubber stamps. State rules determine whether PACE is authorized, how the state contracts and sets payment rates, and how enrollment and oversight work. CMS's application requires state assurance that the state is willing to enter or amend the PACE program agreement. A state that has not elected PACE or does not authorize service in the target area can prevent expansion even if CMS is willing to review it.

In states where PACE already operates, the state may set service-area, enrollment, payment, and procurement requirements. Medicaid capitation payments must be less than what would otherwise have been paid under the state plan for comparable participants, taking participant frailty into account; the specific payment methodology is state-specific. That makes state budget and contracting decisions important, but the approval path and reasons for delay vary by state.

The practical effect for families: even after a PACE organization files its expansion application, the timeline depends heavily on how quickly the state processes its side of the approval.

How Long Expansion Takes

There is no single federal end-to-end timeline from a PACE expansion application to enrollment of the first participant. State review, CMS questions, readiness work, and any new-center build-out can all affect the schedule, so any date supplied by a PACE organization or state should be treated as an estimate.

Delays commonly stem from:

• State review, contracting, and budget cycles
• CMS requests for additional information and subsequent review cycles
• Facility construction or renovation and readiness review for a new PACE center
• Workforce recruitment for the interdisciplinary team (physician, nurse, social worker, therapists, aides, transportation staff)

What This Means if Your Parent Needs PACE Now

If your aging parent lives in an area without PACE coverage, the expansion process — even when an application is pending — may take longer than your parent's immediate care window. You need a workable care plan in the interim.

Check whether an application is pending. Ask your state's Medicaid or PACE administering agency, a PACE organization serving a nearby area, or an Area Agency on Aging (AAA) whether an expansion has been submitted or approved. Public information about pending applications is uneven, so do not assume that an online list is complete. If an expansion is in progress, any projected date is still an estimate.

Look at what's available now. Depending on the state and your parent's eligibility, Medicaid home and community-based services (HCBS) waivers or state-plan services may offer an alternative pathway to support a parent at home. These programs do not bundle Medicare and Medicaid through PACE's model. A parent may keep existing doctors, but provider and managed-care rules vary; possible services include personal care, home modifications, respite, and other long-term supports. Coverage, waitlists, and financial rules vary significantly by state.

Consider whether your parent would actually choose PACE. PACE coordinates primary and specialist care through its interdisciplinary team and provider network, so a parent with established relationships with specific doctors should ask whether those clinicians participate and how referrals work. PACE center attendance is individualized: the team sets the frequency based on the participant's needs and preferences, although many participants attend regularly. For a parent who prefers care delivered entirely at home, compare PACE with HCBS or self-directed options.

Tracking PACE Expansion Nationally

Medicare.gov lets families search for PACE in their area, while states and individual PACE organizations may publish more detailed service-area maps. CMS publishes the provider application and expansion materials for organizations; it is not necessarily a public tracker of every pending expansion.

The National PACE Association maintains a searchable directory and a regularly updated PACE-in-the-States report. Those listings can help identify current programs, but a pending expansion still needs confirmation from the state or the PACE organization.

Understanding Your Parent's Full Range of Options

Whether or not PACE expands to your parent's area, navigating dual eligibility for Medicare and Medicaid is one of the most complicated pieces of the elder care puzzle. The interaction between the two programs determines what your parent pays out of pocket, which services are covered, and whether they can access coordinated care models like PACE or Dual Eligible Special Needs Plans (D-SNPs).

Our Dual Eligible: Coordinating Medicare and Medicaid guide walks through how the two programs interact, what cost-sharing protections dual-eligible beneficiaries receive, and how to evaluate coordinated care options — including PACE, D-SNPs, and state waiver programs — based on your parent's specific situation and location.

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