The federal Medicare program is hard for most people to understand and recent changes have added to the confusion, according to Social Security officials who administer the medical insurance program locally.
Medicare is for people 65 and older and for people who have disabilities. Eligibility is based mainly on eligibility for Social Security.
During an interview last week, Norm Franker, manager of the local Social Security Administration office, and Connie Meyer, a service representative there, said increases in deductibles and premiums were the most important recent changes for local residents to understand.
"Out of pocket" costs that Medicare beneficiaries pay for coverage increased as of Jan. 1, Franker said. The basic medical insurance premium, sometimes called Part B, increased from $29.90 to $31.80 monthly. For most people covered by Medicare, that amount is deducted from their monthly social security checks.
DEDUCTIBLE amounts for Medicare hospital insurance, sometimes called Part A, increased as follows:
From $628 to $652 for the first 60 days of inpatient care. This is a one-time charge for up to 60 days.
From $157 to $163 a day for the 61st through the 90th day of inpatient care.
From $314 to $326 a day for 60 hospital "reserve days." Medicare beneficiaries are given 60 reserve days each that can be used once in their lifetime. At the end of 90 days in the hospital, beneficiaries have only their once-in-a-lifetime 60 reserve days left.
From $78.50 to $81.50 for the 21st through 100th day of care in a skilled nursing facility.
THE AMOUNT OF deductible for Medicare Part B has remained at $100 for the entire year.
Franker explained that Part B pays 80 percent of medical costs, which are primarily doctors' bills, and Medicare goes by "reasonable" or "customary" charges.
If the customary charge for a procedure is $40, Medicare will base its coverage on that charge. If a physician charges more than the customary charge, he or she will be asked to "accept assignment" charge the customary fee.
Meyer said a list of local physicians willing to accept assignment is available at the Social Security office.
The federal program also pays for durable medical equipment such as wheelchairs but not such things as eyeglasses or hearing aids.
Medicare also does not cover dental work or prescriptions.
Two other recently passed federal laws also affect Medicare beneficiaries, Franker and Meyer said. One is a new policy on "Medigap" insurance; the other pertains to "advance directives."
MANY OLDER Americans buy Medigap insurance as a supplement to the federal plan because Medicare doesn't cover all possible medical needs.
The new Medigap directive, set forth in a November 1991 law, guarantees that for six months after qualifying for Part B Medicare insurance, people 65 and older cannot be denied supplemental Medigap insurance because of health problems.
Franker said a list of private insurance companies that sold the supplemental insurance is available at the Social Security office but staff there do not make recommendations about the companies.
The "advanced directives" law, which went into effect Dec. 1, requires that health care providers inform people of their right to plan ahead for medical care.
An "advance directive" is a written statement detailing how medical decisions should be made for a person if that person isn't able to make his or her own decisions. Such directives also have been referred to as "living wills" or "durable powers of attorney for health care."
SPECIFICALLY, the new law requires most hospitals, nursing homes, hospices, home care programs and health maintenance organizations to give out information on state laws covering advance directives.
Meyer, who works with local residents who have Medicare coverage questions, said most people aren't informed about Medicare policies or changes.
"I think a lot of people are not aware of changes until they are personally affected," she said. "I would encourage people to call if they ever have questions."
The local Social Security Administration office, 545 Columbia, is open 9 a.m. to 4 p.m. Monday through Friday. The phone number is 843-2254. Service representatives also are available from 7 a.m. to 7 p.m. weekdays by calling (800)772-1213.