PACE Program Texas: What DFW Families Discover When They Search for Nursing Home Alternatives

The Phone Call Karen Webb Wasn't Expecting

Karen Webb spent three weeks convinced she had found the answer.

Her mother, Margaret, was 77 years old, a retired middle-school science teacher who had lived in the same split-level home in Allen, Texas for thirty-one years. She had been diagnosed with Parkinson's disease fourteen months earlier. The tremors were manageable with medication, but her balance had become unreliable — she had fallen twice in her bathroom — and her doctor had made a formal determination that Margaret required nursing-facility-level care to safely manage her daily needs. The family understood what that meant: either Margaret moved to a facility, or the family found a way to bring the care to her.

Karen, who worked as a project manager in Plano and had done what any organized daughter would do, had spent evenings researching online. She had found it: something called the PACE program. Program of All-Inclusive Care for the Elderly. The description sounded almost too good. PACE combined Medicare and Medicaid into one integrated care system. It provided an adult day health center — a place Margaret could go during the day for therapies, social interaction, and medical oversight — plus home visits, transportation, prescriptions, and specialist care, all coordinated by a single care team, all fully covered with no copays for participants who qualified for both Medicare and Medicaid. No nursing home. No fragmented billing. No fighting between providers about who covered what.

Karen called Texas Health and Human Services to ask about enrollment. The caseworker asked where Margaret lived. "Allen?" A pause. "Collin County?" Another pause. "I'm sorry, ma'am. We don't have a PACE organization serving that area."

Karen asked which counties did have PACE. The answer was short. And it contained no county in the Dallas-Fort Worth metroplex.

What PACE Actually Does — and Why Texas Has So Little of It

The PACE program is, by most objective measures, one of the more elegant structures in American elder care. It was designed in the early 1970s in San Francisco's Chinatown neighborhood, where a community health organization recognized that elderly Chinese immigrants who needed nursing-home-level care were, culturally and practically, not going to nursing homes. The program that emerged — eventually called On Lok, from the Cantonese for "peaceful, happy abode" — demonstrated that intensive community-based care coordinated by a single interdisciplinary team could keep very frail seniors living at home, often at lower total cost than institutional placement, with measurably better health outcomes.

Congress noticed. PACE became a permanent Medicare benefit in 1997 and was incorporated into Medicaid. Today, according to the National PACE Association, PACE serves more than 70,000 participants across 32 states. Those participants are, on average, 77 years old and have eight chronic conditions. About 90 percent of PACE participants live at home — not in a facility — for the duration of their enrollment.

What the national statistics conceal is the extreme geographic concentration. PACE organizations are clustered in the Northeast, the mid-Atlantic, the Pacific Northwest, and California. States like Massachusetts, Pennsylvania, New York, and Maryland have dozens of PACE sites. Texas, a state with more than 30 million residents, has operated historically with a tiny fraction of that coverage. As of 2026, Bienvivir All Inclusive Senior Health in El Paso is the primary established PACE provider in Texas. That is roughly 600 miles from McKinney.

The reasons for Texas's sparse PACE landscape are structural. PACE organizations require significant upfront capital — an adult day health center, a full interdisciplinary care team including physicians, nurses, social workers, physical and occupational therapists, dietitians, and transportation coordinators — before they can enroll a single participant. Reimbursement comes on a capitated per-member-per-month basis from Medicare and Medicaid, which means the organization bears the full financial risk of caring for a very sick population. In states where Medicaid rates are lower, the math is harder. Texas's Medicaid reimbursement rates, compared to northeastern states, have historically made it a more difficult environment for PACE organizations to launch sustainably.

Texas HHS has expressed interest in expanding PACE access. But expansion is measured in years, not months. For a family in Collin County, Denton County, Tarrant County, or Dallas County in 2026, PACE is, functionally, not available.

What Is Available: The Two Programs North Texas Families Actually Use

The good news — which Karen Webb did not know when she made that phone call — is that Texas has built Medicaid-funded alternatives to PACE that can, for the right candidate, accomplish a similar goal: keeping a medically complex senior out of a nursing home, living in the community, with services coming to them.

Understanding the difference between these programs matters, because they have different rules, different waitlists, and different planning requirements.

Community First Choice (CFC)

Community First Choice is a Medicaid State Plan option that Texas adopted, and it has a feature that makes it unusual in the world of Medicaid benefits: there is no waitlist. Community First Choice is an entitlement, which means that if you are eligible, you receive the benefit. Period. Nobody is waiting ahead of you.

CFC covers personal attendant services — help with bathing, dressing, meal preparation, medication reminders, and similar activities of daily living — as well as habilitation services, home modifications for accessibility (ramps, grab bars, widened doorways), and personal emergency response systems. Consumer Directed Services allows participants to choose their own attendant, which means, with proper documentation and a financial management services agency, a family member can in some cases be paid to provide care.

The trade-off is income. To access CFC through traditional State Plan Medicaid, an individual's monthly income must fall below $994 in 2026. Most retirees with Social Security income and any pension will not qualify through that pathway. There is a route through the STAR+PLUS HCBS waiver — which we will explain below — that allows a higher income limit, but CFC through the waiver still requires navigating that program's rules.

STAR+PLUS Home and Community-Based Services (HCBS) Waiver

The STAR+PLUS HCBS waiver is Texas's primary Medicaid waiver program for seniors and adults with disabilities who need nursing-home-level care but prefer to receive it at home or in a community setting. The program covers a broader array of services than CFC alone: adult day care, respite care, home-delivered meals, personal assistant services, adaptive aids, minor home modifications, and emergency response systems.

The income limit for STAR+PLUS HCBS is more workable than basic CFC: in 2026, an individual can have monthly income up to $2,982. A participant who earns more than that can still qualify — but only by establishing a Qualified Income Trust, commonly called a Miller Trust, which channels the excess income into a trust account that Medicaid treats as unavailable for eligibility purposes.

The critical limitation is the waitlist. As of 2026, approximately 15,850 Texans are waiting for STAR+PLUS HCBS slots. Wait times vary by region and by the applicant's assessed level of need — individuals with greater functional limitations receive higher priority — but in many parts of North Texas, families are waiting anywhere from several months to over a year. For a family in crisis mode, that gap is significant.

This is why elder law planning is not something to begin when a parent needs care. By the time Margaret's balance problems had progressed to two bathroom falls, the family's window to plan ahead had narrowed considerably.

The Medicaid Planning Problem That PACE Would Have Avoided

PACE, for families who can access it, handles a problem that trips up nearly every family navigating Texas Medicaid on their own: the financial eligibility rules.

STAR+PLUS HCBS, like nursing-facility Medicaid, requires that applicants meet both income and asset limits. An individual applicant cannot have more than $2,000 in countable assets. An applicant's home is generally exempt, as is one vehicle and certain personal property. But savings accounts, investment accounts, a second vehicle, and certain other assets count — and a family that tries to transfer assets to get under the limit without understanding the five-year look-back period can find themselves in serious trouble.

Texas Medicaid looks back at five years of financial transactions before the date of application. Gifts, transfers below fair market value, and asset transfers to family members during that window can result in a penalty period during which Medicaid will not pay for care, even if the applicant is otherwise eligible. The penalty is calculated by dividing the value of the improper transfer by the average daily cost of nursing home care in Texas — in 2026, the Texas Health and Human Services Commission uses a divisor of $262.37 per day. A $100,000 transfer to a grandchild during the look-back period generates a disqualification period of approximately 381 days. During that time, the family pays out of pocket.

For a married couple, the rules are more complex — and more protective, if structured correctly. When one spouse (the "institutionalized spouse") applies for Medicaid, the other spouse (the "community spouse") is allowed to keep significantly more than the $2,000 individual limit. In 2026, the Community Spouse Resource Allowance (CSRA) is $162,660. Assets above that amount must be spent down before the institutionalized spouse qualifies — but the spend-down itself, if done with planning, can fund legitimate expenses like home modifications, a vehicle, pre-paid funeral arrangements, or debt payoff. And the community spouse's Minimum Monthly Maintenance Needs Allowance (MMNA) — the income guaranteed to the well spouse — is up to $4,066.50 per month in 2026, meaning a community spouse living on a modest income can potentially receive a portion of the institutionalized spouse's Social Security or pension to maintain a reasonable standard of living.

These numbers change every year. The planning strategies that work legally under current HHSC rules are not intuitive. And the cost of getting them wrong — a penalty period during which care costs tens of thousands of dollars out of pocket — is severe.

What Families in Collin County, Denton County, and the DFW Area Should Do Instead

Karen Webb's situation, when she called WG Law, was manageable — but only because she called before Margaret had spent down her savings trying to cover home care out of pocket, and before anyone in the family had made a gift or transfer that would have triggered a look-back penalty.

The path for Margaret looked like this: assess her countable assets and the CSRA for Karen's father, who was still living; identify what, if any, spend-down was required; determine whether a Miller Trust was needed given Margaret's income from Social Security and a teacher's pension; enroll Margaret in CFC through the STAR+PLUS pathway to begin receiving personal attendant services while waiting for an HCBS waiver slot; and document the level-of-care determination from her physician, which is required for any Medicaid long-term services application.

It is not a simple checklist. It is a sequenced legal and financial process that, done correctly, can preserve a family's savings, protect a well spouse's quality of life, and keep an aging parent where she wants to be — home, in Allen, in the house she has lived in for three decades.

The families who do it right are not the families who waited until there was a crisis. They are the families who started when they still had options: when the account balances were above the threshold but the look-back window hadn't yet been triggered by a panicked transfer; when the community spouse still had income to project; when the physician's records could establish the medical necessity for care before anyone had applied for anything.

The WG Law Approach to Elder Law in North Texas

Taylor Willingham, founding attorney at WG Law, has spent more than fifteen years helping North Texas families navigate exactly this terrain. He has authored five books on estate planning and elder law and has worked with families across McKinney, Frisco, Plano, Allen, Southlake, and the broader DFW metroplex who are facing the same question Karen Webb faced: how do we keep Mom home without spending everything we have?

The answer almost always begins before the crisis — with an elder law consultation that maps the family's specific asset and income picture against current Medicaid rules, identifies which program the senior is likely to qualify for, and builds a plan that protects the community spouse's financial security while positioning the applicant for care.

Texas's elder care system is not a single program. It is a layered set of options — STAR+PLUS HCBS, Community First Choice, nursing-facility Medicaid, private long-term care insurance, Veterans' benefits for qualifying families — and the best outcome for a given family depends on which layer applies, in which sequence, and under which rules. That analysis is what an elder law attorney does.

PACE would have been a good answer for Margaret. But it wasn't available in Collin County. What was available — properly planned — was enough.

Key Takeaways for DFW Families

• PACE is not available in the DFW metro area as of 2026. The nearest established PACE provider in Texas is Bienvivir in El Paso. Families in Collin, Denton, Dallas, and Tarrant counties cannot enroll in PACE today.
• Community First Choice has no waitlist and covers personal attendant services. Income limits are strict for the standard pathway, but there is a route through STAR+PLUS for higher-income applicants.
• STAR+PLUS HCBS offers broader services but has approximately 15,850 Texans on the waiting list in 2026. Early application and proper documentation of medical need improves priority.
• The five-year look-back applies to transfers of assets before a Medicaid application. Gifts made to reduce countable assets during that window generate penalty periods — potentially months of uncovered care costs.
• The CSRA in 2026 is $162,660. A married couple with assets below that threshold may not need to spend down anything before the applicant qualifies. Assets above that threshold can often be repositioned — not simply spent — with proper planning.
• A Miller Trust is the solution when a Medicaid applicant's monthly income exceeds $2,982. It is not optional; without it, income above the cap disqualifies the applicant regardless of their assets.

When to Contact an Elder Law Attorney

The right time to consult an elder law attorney is before a parent's health requires nursing-home-level care. The second-best time is now. The worst time is after a family has already transferred assets, spent savings without a plan, or received a denial letter from HHSC citing a look-back penalty.

WG Law serves families across Collin County — McKinney, Frisco, Plano, Allen, Prosper — and the greater DFW metroplex from offices in McKinney and Southlake. If your family is navigating an aging parent's care needs, Medicaid eligibility questions, or long-term care planning, we can help you understand what programs are actually available in North Texas and how to position your family to qualify.

Call 214-250-4407 or request a consultation online.

This article is for general informational purposes only and does not constitute legal advice. Medicaid rules and income/asset thresholds change annually. Consult a licensed Texas elder law attorney for advice specific to your situation.