PACE Enrollment, Spending and Fraud Statistics: The Head Count Is Only the Beginning

PACE enrollment and spending figures show the size of the Program of All-Inclusive Care for the Elderly, while fraud statistics require evidence tying false information to government payments. Payment audits identify specific duplicate or post-death payments. If you work in finance, enrollment or care delivery, you may know why the paid roster differs from the enrollment file, or why a correction never reached the payment system. That connection matters more to a whistleblower case than a large number without an explanation.

This page follows enrollment totals, state rates and operator finances to the money they describe. Our PACE program fraud questions address how care failures, eligibility and payment records fit a potential case.

Which PACE Enrollment Count Are You Using?

The Centers for Medicare & Medicaid Services counts Medicare enrollees in PACE and the contracts covering them in its monthly summaries. In January 2009, that series reported 15,499 enrollees and 63 contracts. By October 2026, it reported 82,218 enrollees and 208 contracts.

The unit matters inside an organization, too. A center is a place where care is organized, a contract identifies the organization responsible to CMS, and a member month measures enrollment over time. The parent company’s name can cover several operating entities. A national count of contracts cannot be read as a count of centers or independent owners.

Can Medicare and Medicaid Both Pay PACE for the Same Person?

Yes, Medicare and Medicaid can each pay PACE for the same participant who has both kinds of coverage. Each program supplies its own monthly capitation under the PACE payment rules. The same person can therefore appear in both enrollment series.

The Medicaid tables for July 1, 2024 report 77,723 PACE participants, including 58,171 with both Medicare and Medicaid, omitting Tennessee’s program-type data. These overlapping populations show why the payer matters as much as the head count.

For a finance employee, the payment question is more specific than overlapping enrollment. Duplicate capitation concerns the same program paying more than one plan or organization for the same participant and month. We connect the payer, recipient, covered month and later adjustment to determine what money the organization received and retained.

What Does a PACE Payment Number Measure?

A PACE capitation payment is a monthly advance to cover an integrated health care benefit. The organization takes financial responsibility across care settings. That benefit includes Medicare services, state Medicaid services and additional care the interdisciplinary team finds necessary. Internal staffing and transportation costs sit beside outside hospital, specialist, nursing-facility and pharmacy costs.

Medicare Parts A and B, Part D drug financing and Medicaid have distinct payment inputs and reconciliation paths. A Medicaid total-funds figure already contains its federal matching share. Adding that share again, or adding an operator’s revenue to the government payments that financed it, would count the same money twice.

The payment year matters when a diagnosis changes the Medicare amount. Under CMS’s calendar-year 2026 policy, PACE uses 90 percent of the older risk-model score and 10 percent of the newer score. The final policy for 2027 changes that blend to equal halves.

Frailty adds a separate contract-level input from the HOS-M survey of participants’ activities of daily living. A team’s clinical assessment and the survey information used for payment are separate records. Part D brings prescription drug event data, bids, subsidies and later reconciliation into the picture. For an insider who saw an input changed, the accepted submission and resulting payment adjustment show what that change did to the money.

What Do PACE Medicaid Rates Say About Spending?

A published PACE Medicaid rate describes a payment method or rate cell. Actual spending follows the enrolled months, selected rates and adjustments. Medicaid’s negotiated capitation must remain below the amount otherwise payable without PACE, commonly called AWOP. That benchmark estimates the alternative cost under the state plan.

California’s Midpoint Is a Rate-Setting Number

California’s published rate dataset gives a useful example. For On Lok’s San Francisco Full-Dual – SIS rate cell in 2026, the monthly midpoint rounds to $10,996, against an AWOP benchmark of $10,669. The midpoint sits above the benchmark, while the federal rule concerns the negotiated payment.

The selected rate, certification method and payment record are what connect that apparent mismatch to government money. A finance employee may know which value was used, which adjustments followed and what the state actually paid. The published midpoint alone leaves those decisions out of view.

Wisconsin Separates Months From People

Wisconsin’s 2026 rate report projects an average Medicaid payment of $5,564 per member per month, rounded to whole dollars, and 5,920 member months. Member months count each enrolled month, so a participant can contribute repeatedly during a year.

The state’s enrollment snapshot answers a different question. Its August 1, 2026 report lists 552 PACE participants, with Family Care and Partnership reported separately. For someone reconciling payment, the PACE enrollment months belong with the PACE rate cells and actual receipts.

Virginia Shows How an Average Can Move

Virginia’s statewide average for the same fiscal-year PACE payment period changes when the enrollment weights change. The June 2025 ratebook reports a combined fiscal-year 2026 monthly average that rounds to $6,242. The June 2026 ratebook’s comparison, using later enrollment weights, puts it at $6,263. The changed average reflects the mix of participants used in the calculation.

These published amounts are before patient liability, which reduces actual capitation. Virginia also uses different weights for its statewide cost-without-PACE and capitation averages. The matched rate cell and net payment are the useful comparison for a suspected category or liability error.

Why Is PACE Revenue Different From Profit?

InnovAge’s fiscal-year 2024 annual report reported $762,570,000 in capitation revenue and a company-defined center-level contribution of $132,064,000. That contribution leaves out corporate overhead. For the fiscal year ended June 30, 2026, InnovAge’s financial statements reported $989,707,000 in consolidated revenue and still showed a net loss of $2,537,000.

The distinction matters to someone who sees a center’s financial target discussed alongside staffing or outside care costs. We see the problem with calling a center contribution profit before counting the company’s other expenses. The corporate bills still count.

InnovAge’s fiscal-year 2024 annual report lists 20 centers, a period-end capitated census of 7,020 and 80,840 annual member months. Those measures describe locations, people at a particular time and enrollment time across the year. Revenue recognition also includes estimated retroactive risk adjustments and drug risk sharing, so recognized revenue and cash receipts can differ.

On Lok Senior Health Services’ tax return for the year ended June 30, 2025 separates payer revenue differently. It reports $202,376,042 in Medi-Cal premiums, $71,177,701 in Medicare premiums and $704,099 in participant premiums. Its revenue less expenses was negative $777,754.

The return says On Lok served over 1,942 elders during that year. That annual service count differs from InnovAge’s closing census and annual member months. These filings let an insider distinguish the payer, period and accounting measure before comparing what an operator earned with the care it funded.

What Can PACE Audit Numbers Show?

PACE payment audits can identify particular duplicate or post-death payments, with a defined period and payer. An August 2009 HHS Office of Inspector General audit counted 28 PACE payments within 373 remaining duplicate Medicare Advantage and PACE payments. Its $300,894 figure covers that mixed-program group.

A separate March 2009 Medicare audit identified $145,007 in PACE improper payments within a larger review of payments after death. The Inspector General’s North Carolina audit identified 41 post-death PACE payments totaling $129,234, including an $85,699 federal share. Here, the federal money is already inside the total. The agency’s follow-up tracker marks the recommendations closed and implemented in July 2021.

An audit’s purpose also determines what its counts mean. The Centers for Medicare & Medicaid Services targets service requests, appeals, grievances and clinically significant medical records for review. A percentage of problems in those selected records cannot become a national fraud rate by multiplying it across enrollment. A count of cited conditions measures audit findings, not the number of people with false payments.

CMS and state agencies share oversight, and state agreements can add reporting and corrective-action requirements. The Medicaid and CHIP Payment and Access Commission’s June 2026 examination found no centralized database of the state agreements and waivers it studied. The applicable agreement matters when an insider knows that the information sent to an overseer differed from the original care record.

Does a CMS Sanction or Company Accrual Establish a Settlement?

No. A CMS sanction is an administrative action, and a company accrual is an accounting estimate. Under CMS’s audit overview, accepting a corrective-action plan closes an audit. Carrying out that correction and meeting a sanction’s release conditions require their own evidence.

InnovAge’s fiscal-year 2026 filing disclosed approximately $37 million accrued for litigation, substantially all related to investigative demands, with negotiations subject to government approval. We would be declaring victory over an accounting entry if we called that recovered taxpayer money. The accrual has a place on the books, not a settlement headline.

When Does a PACE Number Become a Payment Question?

A number becomes useful to a payment inquiry when it connects an underlying event to what the organization told the government and what the government paid. The whistleblower complaint concerning InnovAge alleged that 852 of 975 outside-consult and imaging orders remained outstanding for at least 30 days. It also alleged that management withheld a service-request spreadsheet from CMS and asked the whistleblower to falsify logs.

Behind those outstanding orders were elderly participants waiting for consults and scans, according to the complaint. For a scheduler, clinician or compliance employee, the original request and the submitted version may explain how missing care disappeared from an oversight report.

We connect those care and submission records to the paid months, accepted payment data and later corrections. The finance side then shows the adjustment, refund or money retained, including who received any return. That is where an unexplained number becomes a specific question about government money and who knew what happened to it.

If you are considering reporting PACE program fraud, we work through that connection with you. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know Which Number Changed

If you know why a PACE enrollment, care or payment record changed, speak with our whistleblower experts about the decision behind the number. We work beside you to connect the records, the people responsible and the public money, and bring in healthcare fraud whistleblower lawyers who understand capitation and payment corrections. Talk to us about building your strongest PACE whistleblower case from what you saw.