PACE Program in North Dakota: Eligibility, Services, and Northland PACE

What PACE Covers

The Program of All-Inclusive Care for the Elderly (PACE) is a federally structured model that bundles every medical, social, and long-term care service a qualifying senior needs into a single coordinated program. Instead of navigating separate providers for primary care, prescriptions, physical therapy, adult day care, personal care, and transportation, a PACE enrollee gets everything through one interdisciplinary team.

In North Dakota, PACE is operated by Northland PACE, which serves eligible seniors in its North Dakota service area. The program is jointly funded by Medicare and Medicaid for dual-eligible participants, and it also accepts private-pay enrollees who meet the clinical eligibility but not the financial criteria for Medicaid.

PACE is structured around an adult day health center where enrollees receive most of their care. The center provides medical appointments, rehabilitation therapy, meals, socialization, and health monitoring. For seniors with dementia, the structured daily environment provides cognitive stimulation and safety supervision while giving family caregivers a reliable daily break.

Eligibility Requirements

PACE eligibility has both a clinical and a geographic component:

Clinical eligibility: The applicant must be age 55 or older and certified by the state as needing a nursing facility level of care (NFLoC). This clinical requirement assesses functional impairment in Activities of Daily Living and the need for ongoing supervision or skilled care.

Geographic eligibility: The applicant must live within the Northland PACE service area. PACE programs are geographically limited because the model depends on proximity to the day health center for regular attendance and emergency response.

Financial eligibility: PACE accepts both Medicaid-eligible and private-pay participants. For dual-eligible enrollees (Medicare + Medicaid), Medicare and Medicaid services are provided through the PACE organization. For private-pay participants, the participant pays the program's cost out of pocket.

How PACE Works for Dementia Families

For families managing a parent's dementia, PACE addresses several of the most common care coordination failures:

Medical management: The PACE interdisciplinary team includes physicians, nurses, social workers, therapists, and dietitians who all work from the same care plan. Medication management — one of the highest-risk areas for dementia patients — is monitored centrally rather than split across a primary care physician, a neurologist, and a pharmacy.

Daily structure: Enrollees attend the day health center regularly, which provides cognitive activities, social interaction, and health monitoring. For a parent whose days have become unstructured and increasingly characterized by agitation and wandering, the predictable routine of a PACE center can reduce behavioral symptoms.

Caregiver respite: Because the parent spends significant time at the day center, the family caregiver gets reliable daily breaks without arranging separate respite services. This built-in respite is one of PACE's most underappreciated features.

Hospitalization avoidance: PACE teams actively manage chronic conditions to prevent the acute episodes — falls, infections, medication errors — that lead to hospital admissions. For dementia patients, hospitalization carries additional risks of delirium, accelerated cognitive decline, and post-discharge placement in a facility rather than returning home.

PACE vs. Other North Dakota Programs

PACE sits between home care programs (SPED, HCBS waiver) and residential facility placement:

• SPED covers in-home services for families with up to $50,000 in assets but doesn't provide the comprehensive medical coordination that PACE includes
• Medicaid HCBS waiver covers a broader range of home and community services but requires the family to coordinate among multiple providers
• PACE bundles everything — medical, pharmacy, personal care, day care, transportation — into a single program but requires the enrollee to receive most services through the PACE center and team

The tradeoff: PACE offers more comprehensive and coordinated care, but enrollees generally use PACE-affiliated providers for covered services. Outside non-emergency care should be approved by PACE in advance; otherwise, the participant may be financially responsible. For some families, this feels like gaining a care team; for others, it feels like losing provider choice.

How to Explore Enrollment

Contact Northland PACE directly to determine whether your parent's address falls within the service area and to schedule an eligibility assessment. The assessment evaluates both the clinical NFLoC criteria and the practical question of whether PACE's center-based model fits the parent's needs and preferences.

If PACE isn't available in your area or doesn't fit your parent's situation, ask the local Human Service Zone about the Medicaid HCBS waiver or other community-based services; those programs require their own eligibility screening. The North Dakota Dementia & Memory Care Guide compares PACE, SPED, and the HCBS waiver side by side — including the financial thresholds, service caps, and provider flexibility of each program — so families can match the right program to their parent's stage of care.

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