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The Elderly

Of the more than 630,000 Marylanders 65 and older, about 85,600 people — or 14% — lived in poverty in 2003, according to US Census data analyzed by the Kaiser Family Foundation. In 2005, that meant that a single senior living in poverty had less than $9,600 in income. [The Center for Budget and Policy Priorities calculates that 31%, or 196,000 seniors were lifted from poverty by Social Security.]

With the pending launch in January 2006 of the Medicare Part D prescription drug program, many low-income Medicare-eligible seniors will have the option to receive substantial coverage for needed medications. (There are about 560,000 Medicare beneficiaries over 65 in Maryland.) Those with incomes above 150% of the FPL will face significant out-of-pocket costs in the form of deductibles, co-payments, and monthly premiums and have no coverage for most costs above $2,250 a year. Government and private agencies are working to educate seniors about the many options available to them under the program.

The most pressing needs of seniors living in or near poverty remain (1) a paucity of affordable housing with services that help individuals remain in their homes and community-based settings, and (2) a lack of viable transportation options. The risk of failing to meet these service and housing needs is a rapidly increasing population of seniors forced to live in high-cost institutionalized settings.

At the same time, more and more seniors are remaining in or returning to the workforce. The share of workers in Maryland who are 65 and older, the traditional age when most workers leave the labor force permanently, increased from 2.4% to 3.1%, from 1990 to 2002, according to the US Census Bureau. A total of 60,304 people age 65 and older were in the workforce in 2002, the latest year for which figures are available.

Current Services

Medicaid

Medicaid is a jointly funded State/federal program that covers health services to certain individuals and families with low incomes. People over age 65 generally are eligible for Medicaid if their income is no higher than $350 a month for individuals ($392 for couples), and their assets do not exceed $2,500 ($3,000 for couples), or if they receive benefits from the federal Supplemental Security Income (SSI) program. Financial criteria for skilled nursing care are higher if an applicant is deemed medically eligible. Seniors make up about 8% of Maryland's Medicaid caseload and about 23% of costs, according to the Maryland Department of Health and Mental Hygiene. However, the 3-year growth rate of Medicaid services to seniors, at about 8%, has been the lowest of all Medicaid populations.

Medicaid also pays for some of the out-of-pocket costs of Medicare Part A (hospital coverage) and B (physician coverage) for those eligible for the federal Medicare program, but whose income and assets are somewhat above the Medicaid limits. These programs are known as the Qualified Medicare Beneficiary Program (QMB) and the Special Low-Income Medicare Beneficiary Program (SLMB).

In Maryland, about 3,575 seniors a year may take advantage of a Medicaid Waiver for Older Adults which provides coverage for some forms of care at home and in community-based settings, such as assisted living. The income and asset requirements are higher than for the primary Medicaid program. The waiver is available to those over age 50 who meet Maryland's medical standards for long-term care in a skilled nursing facility.

Maryland’s Medicaid program also covers Medical Adult Day Care for those who qualify medically and financially. (The State also offers a limited subsidy to about 500 seniors a year who do not qualify for Medicaid, through the State-funded Adult Day Care Human Service Grants Program.) Finally, Maryland’s Medicaid Personal Care Program provides assistance with activities of daily living to qualified individuals who have a chronic illness, medical condition, or disability.

Prescription Drugs

Maryland has a patchwork of programs that help some seniors and others pay for medications. Some will be changed or eliminated with the launch of Medicare Part D on January 1, 2006:

Maryland Pharmacy Assistance Program (MPAP). Helps about 48,000 Marylanders with incomes at or below $10,417, or 116% of the poverty level, and assets below $4,000, pay for their prescription drugs. However, seniors who are eligible for the new Medicare prescription drug program will no longer be eligible for the MPAP after December 31, 2005.

Maryland Pharmacy Discount Program (MPDP). Helps Maryland residents on Medicare pay for medically necessary prescription drugs at a discounted price. However, the program will cease to exist after December 31, 2005.

Senior Prescription Drug Program. This program, funded by the value of CareFirst Blue Cross Blue Shield’s premium tax exemption serves Medicare beneficiaries with incomes up to 300% of the FPL who have no other drug coverage. It also will cease to exist soon after the launch of Medicare Part D, and $14 million of the $23 million in the program will be redirected to offset some of the out-of-pocket costs for lower-income Part D members.

Maryland Medbank Program. The Maryland Medbank Program allows people to get free medicines for a limited time from drug manufacturers. To be eligible, a participant must be low-income and must not be enrolled in any other prescription medicine plan. Referrals are made by physicians.

Mental Health Care

In Maryland, there are more than 125,000 older adults with depression and at least 70,000 older adults with severe and persistent mental illnesses. Older patients with significant symptoms of depression have roughly 50% higher health care costs than non-depressed older adults.

Low-income seniors who receive Medicare but not Medicaid are responsible for a co-pay of 50% of the Medicare allowable reimbursement for any outpatient mental health treatment. The required co-pay is usually prohibitive and serves as a significant barrier to treatment for this vulnerable population.

For many with both Medicare and Medicaid, the Medicaid benefit covers an additional 12.5% of the allowable Medicare rate, but the client is still responsible for a co-pay of up to 37.5%, still a substantial and often prohibitive amount.

Transportation

Next to prescription drug costs, the most commonly cited concern among many seniors is the lack of affordable transportation, especially for frail seniors for whom mass transit is not viable. The State took a positive step with the creation of the Maryland Senior Rides Demonstration Program, a grant program intended to foster the creation of assistive ride programs for frail low- to moderate-income seniors. At $100,000 in funding, it will reach only a limited pool of eligible seniors.

Maryland’s Statewide Special Transportation Assistance Program (SSTAP) is a primary source of transportation assistance for older adults throughout the state. According to the Maryland Mass Transit Administration, funding for SSTAP has remained level at about $4.3 million for the past few years.

Gaps and Challenges

• Because of its focus on medical impairments, the Medicaid Older Adults Waiver has been criticized for preventing people with cognitive and functional disabilities, such as Alzheimer's disease and other dementia-causing disorders, from being determined eligible for long-term care services. It still serves only a fraction of the population that needs it, at about 3,575 members despite a 1999 law that called for expansion to 7,500 participants. The Older Adults Waiver should be expanded, and reformed to include individuals with serious cognitive and behavioral disabilities, such as Alzheimer’s disease and geriatric dementia disorders.
• Unlike other populations, older adults who are of low-income but do not qualify for Medicaid — the so-called gray zone population — do not receive any State subsidy for mental health care. The State should subsidize mental health co-payments for older adults identified as “gray zone” to achieve parity with other populations. Furthermore, the State should increase the Medical Assistance reimbursement rate for outpatient mental health services to older adults who are eligible for both Medicare and Medicaid.
• The creation of Medicare Part D brings with it enormous challenges in educating and reaching out to Maryland’s seniors to help them make the best choice of provider for their needs. Despite tremendous outreach efforts by groups such as AARP and many others, local agencies on aging will be overwhelmed by the challenge unless they are provided the resources to educate seniors. The State should give aging service providers the tools and resources to inform seniors about the new Medicare prescription drug coverage.
• Maryland’s senior transportation programs can only meet a fraction of the need for ride services for frail, low-income seniors, even as the number of seniors continues to rise. The Statewide Special Transportation Assistance Program (SSTAP) and the Senior Rides Demonstration Program should be expanded to meet the growing need for affordable transportation for seniors.

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