A Health Savings Account (HSA) is a special account that can be paired with a High Deductible Health Plan (HDHP).  It enables you to contribute on a pre-tax basis to an account to help pay for future healthcare expenses (i.e. medical, prescription drug, dental, vision, etc). But how does it interact with Medicare? 

Let’s first clear up a common misconception. 

 

Most people believe that you must cease HSA contributions the moment you turn 65.  This is simply not true. You must cease HSA contributions IF you enroll in any portion of Medicare.  This means you can continue contributing to your HSA account (up to the individual or family HSA limits, based on whether you have individual or family health coverage), as long as the HSA account owner doesn’t have any portion of Medicare just yet.

Continuing to contribute to an HSA account beyond age 65 can be a great strategy for someone working beyond age 65 and staying in a group health plan. This is only a good strategy IF the group health plan has “creditable” prescription drug benefits, the Medicare-eligible employee is not receiving Social Security retirement benefits, and is in a large employer plan. That’s because in this situation, no Medicare enrollment of any kind would be required.  Reference our Misconception #2 in our Medicare Misconceptions blog post for more information on “creditable” prescription drug benefits.

When you do NOT have “creditable” prescription drug coverage through an employer, we see some Medicare-eligible folks knowingly accumulate a Part D late enrollment penalty in order to load up their HSA accounts while they can.  This really should be a short-term solution because the longer you do this, the larger the Part D late enrollment penalty will become — when you do enroll in a Part D prescription drug plan.  Typically, beneficiaries utilize this strategy when they know they will retire and/or lose group health coverage in a few years, usually 2 years or less.  Otherwise, the penalty gets larger, and the strategy might not make sense. 

 

If you contribute to an HSA during the year your Medicare starts, be careful to not over-contribute, as there can be tax consequences.  The amount you can contribute is on a prorated basis.

 

For example, if your Medicare starts June 1st, that means you weren’t on Medicare 5 months out of the year.  So you can contribute 5/12 of the HSA maximum contribution for the tax year, based on whether you have individual or family health insurance coverage.

If you over-contribute, there could be tax consequences…a 6% tax on the excess.  And those contributions will NOT be pre-tax, rather they will be considered after-tax.  Reference IRS Publication 969 for more details.

 

Contact a tax professional for confirmation of tax rules associated with excess HSA contributions, as tax law changes can occur often.

 

While on Medicare, you can use your HSA for any qualified medical expenses approved by the IRS*, including:

– Premiums paid to Medicare (i.e. Part B)

– Premiums paid to an insurance carrier for Stand-Alone Part D Prescription Drug Plans and Medicare Advantage Plans

– Medical copays, coinsurance, deductibles

– Prescription drug copays

 

Keep in mind, your HSA can’t be used for every medical expense you incur.  For example, you CAN’T use your HSA to pay your Medicare Supplement (Medigap) premiums to an insurance carrier. 

No matter if you’re currently on Medicare or are planning ahead, contact us to put your HSA to its best use. 

 

* Note: HSA account balances can be used for qualified medical expenses.  Reference IRS Publication 502 for the list of approved medical expenses.

 

Reference Links

www.medicare.gov

Medicare Misconceptions (2019)

IRS Publication 969

 

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015.  It made significant changes to Medicare Supplement (Medigap) plans as of January 1st, 2020.  

Here’s a quick reminder of the standardized Medigap plans available in 2019:

But in 2020, the plan offerings will change! The MACRA legislation will impact certain beneficiaries, depending on when you’re eligible for Medicare:

Those who are Medicare eligible January 1st, 2020 and after…

Medigap Plan F, Plan C, and High Deductible Plan F are no longer available to these Medicare beneficiaries.  Instead, a new plan has been created: High Deductible Plan G. This will be added to the list of existing Medigap plans still available in 2020 (Plans A, B, D, G, K, L, M, N).

 

Those who are Medicare eligible December 1st, 2019 and before…

All existing and new Medigap plans are available to these Medicare beneficiaries, even Plan F, Plan C, and High Deductible Plan F.  And if you’re already enrolled in one of these plans, you can keep it!

If you have additional questions on how this might affect you, contact us HERE for guidance.

Reference Links

www.medicare.gov

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

Each year, the Medicare Annual Election Period (AEP) runs from October 15th through December 7th.  This is a special time frame when Medicare beneficiaries have the option to make changes to certain types of Medicare health insurance plans.  Any changes made during AEP will take effect January 1st of the upcoming year (January 1st, 2020 in this case).

 

Insurance carriers are required to provide a detailed update each year by September 30th regarding your existing Medicare Advantage Plan or Part D Prescription Drug Plan.  This notice is called the Annual Notice of Change (ANOC).  Since these Medicare insurance plans run on a calendar year basis, there are usually some sort of changes in plan benefits and features from year-to-year.  This is exactly why the Medicare AEP exists. It provides you with the “option” to change your plan, if it’s beneficial.

 

Here are some of the scenarios that can take place during AEP:

 

Take No Action

If you’re happy with your plan and wish to accept the new plan provisions for next year, no action is required.  Your plan will automatically be renewed as of January 1st.

 

Change your Part D Prescription Drug Plan

If you feel your stand-alone Part D prescription drug coverage is no longer suitable for you, a plan change may be appropriate.  Your current Part D plan might no longer cover your particular list of prescriptions as well as before (i.e. formulary changes)…OR…you may have several new prescriptions causing you to question whether you’re still in the right plan…OR…the plan premium is increasing more than you’d like.  Regardless, you can switch to another Part D drug plan during AEP — with your current insurance carrier, or another carrier. 

 

Change your Medicare Advantage Plan

If you feel your Medicare Advantage plan coverage is no longer suitable for you, a plan change may be appropriate.  Since many Medicare Advantage plans include both medical and drug coverage, you might consider a plan switch during AEP if the medical and/or drug coverage changes to your detriment.  It could be a drug formulary change, or even one or more of your medical providers are no longer in-network. Additionally, the medical benefits can be impacted each year. For example, certain medical services may have increased copayments, or the plan’s medical maximum out-of-pocket limit may increase to a level that is out of your comfort zone.  And of course, a plan premium increase can affect the affordability of the plan.

 

Switch from Original Medicare to Medicare Advantage 

When you have Original Medicare and a Medicare Supplement Insurance Plan (Medigap), you use Medicare Part A (hospital) and Part B (medical/outpatient) as your primary coverage…and then your Medigap plan as your supplemental plan for medical services.  And you usually will also have a stand-alone Part D drug plan, unless you have creditable prescription drug coverage from another source (i.e. VA benefits). What if you aren’t happy with your plan coverage, pricing, or have other issues with the plan?

You can switch entirely from Original Medicare to Medicare Advantage during AEP.  If you switch to a Medicare Advantage plan that includes Part D coverage in this scenario, you will automatically be disenrolled from your existing stand-alone Part D drug plan with a January 1st effective date.  However, you will still need to request cancellation of your existing Medigap plan as of January 1st. NOTE: You cannot switch to a Medicare Advantage plan if you have end stage kidney failure (ESRD).

 

Switch from Medicare Advantage to Original Medicare

In this reverse scenario, you would first need to see if you can be approved medically for a Medicare Supplement (Medigap) Plan.  In this situation, insurance carriers are often allowed to ask you health history questions, and could deny you from purchasing the plan.  If you get the approval for a January 1st start date, then you know you can enroll in a stand-alone Part D prescription drug plan during AEP (do so no later than December 7th).  Everything will start January 1st, and your existing Medicare Advantage plan will automatically be cancelled, due to the stand-alone Part D plan enrollment.

 

We have a complete summary of the Parts of Medicare on our website. Click here to learn more or contact us for direct support.

 

Reference Links

www.medicare.gov

Joining a Health or Drug Plan 

Annual Notice of Change (ANOC)

 

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

Over time, we naturally lose our ability to hear well.  But does Medicare provide any coverage for hearing exams and hearing aids?  And what about medical issues with your ears…does Medicare cover that?  

 

Both Original Medicare and Medicare Advantage plans will cover medically necessary services related to medical issues with your ears and balance.  This will run through Part B medical/outpatient benefits.  However, there is a difference between Original Medicare and Medicare Advantage plans when it comes to routine hearing and hearing aids: 

 

With Original Medicare, there is no coverage for routine hearing exams and hearing aids.  However, your Medicare Supplement (Medigap) plan may include additional benefits/discounts for these services, so be sure to confirm with your plan.

 

With a Medicare Advantage Plan, there could be coverage for routine hearing exams and hearing aids.  Some plans include a built-in routine vision exam benefit and possibly even discounted hearing aids or allowances toward purchasing hearing aids.  There’s sometimes an option to “buy-up” and get more coverage for these supplemental benefits, as well. In the past few years, we have seen more Medicare Advantage plans begin to offer the hearing aid benefits.  Each plan is unique, so be sure to confirm the details in the plan’s Summary of Benefits.

 

Please Contact Us with questions!

 

Reference Links

www.medicare.gov

Routine Hearing & Hearing Aids

Hearing & Balance Exams

 

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

How to Appeal Your High Income Medicare Premiums

If you’ve received a notice from Medicare that your Medicare premiums will be increased because of high income, you might be wondering, “Can I appeal to reduce the premiums?”

If you have a Life Changing Event (LCE), you might be able to! Keep reading or click here to learn more on our YouTube Channel.

When you enroll in Medicare, the premium you pay is based on your income.  Typically, Medicare looks back at your tax return from two years ago or most recent tax return to determine your monthly premiums. 

See the table below for the 2019 Medicare premiums, based on your 2017 tax return:

As the above table shows, it’s all based on how much you earned in the past. But that may not always be the case. 

Your past income can be ignored when you retire and have a reduction of income.  A reduction of income (a.k.a. Work Stoppage or Work Reduction) is one of several Life Changing Events (LCEs) you can potentially use to lower your Medicare premiums NOW.  The other LCEs you can use are Marriage, Divorce/Annulment, Death of Your Spouse, Loss of Income-Producing Property, Loss of Pension Income, and Employer Settlement Payment. [Reference Form SSA-44 (Medicare Income Related Monthly Adjustment Amount – Life Changing Event)]

Let’s say that in the last few years you were working, your income was above the first income threshold listed in the table above (which is $85,000 for an individual tax filer).  We’ll assume you’re an individual tax filer and your Modified Adjusted Gross Income (MAGI) in 2017 was $140,000. Your retirement will lead to a sharp decline in income, placing you below $85,000 from here on out.  

Based on your 2017 income, Medicare will first mark you down for a Part B premium of $352.20/mo in 2019.  That’s comprised of the $135.50/mo base Part B premium plus an Income Related Monthly Adjustment Amount (IRMAA) of $216.70/mo.  

There is also a Part D IRMAA to pay when your income is higher (reference table above).  In this example, there would be an extra $51.40/mo premium for the Part D IRMAA in the event you enroll in a Part D prescription drug plan with an insurance carrier.  Note: The Part D IRMAA is completely separate and in addition to your Part D prescription drug insurance plan.

When you receive your Initial IRMAA Determination letter in the mail about your Medicare premiums being higher than normal, this is when you can take action and file an appeal.  

This appeal can make a big difference. Let’s see what would happen in our earlier example: 

— With an initial income somewhere between $133,500-$160,000, but reducing to below $85,000 in retirement, your Medicare premium savings will be substantial: 

— Instead of $352.20/mo for Part B + $51.40/mo for Part D IRMAA, you would only have to pay $135.50/mo for Part B + $0 for the Part D IRMAA.  

— That is savings of $268.10 every month!

So how do you appeal for a lower Medicare premium?  You will use SSA Form-44 (Medicare Income Related Monthly Adjustment Amount – Life Changing Event)Complete the required information on the form and turn in to a local Social Security office.  You’ll need to provide accurate estimates of what your income will be based on the life changing event you choose, so be prepared to answer the questions on the form as accurately as possible.  

After you submit the form and any supporting documentation to Social Security (in-person or by mail), Social Security will process your appeal and update you on their decision.

 

Reference Links

www.medicare.gov

Initial IRMAA Determination Letter

 

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

In our previous post, What is the Medicare Part D Late Enrollment Penalty, we detailed why and when a Part D late enrollment penalty is assessed.  Did you miss it? Please review that post to get up to speed before reading on.  

 

Now that you’re clear on what the Medicare Part D Late Enrollment Penalty is, what happens if you receive a penalty notice from your Part D prescription drug plan or Medicare Advantage plan that includes Part D? What actions do you need to take?

 

The answer depends on whether you had “creditable” prescription drug coverage that met or exceeded Medicare Part D minimum standards.  As discussed in our previous post, not all insurance plans have creditable prescription drug coverage.  Just because you’re covered in group health insurance plan through an employer doesn’t mean the drug benefits meet Medicare’s Part D standards.  In fact, we see group health plans that have non-creditable drug coverage quite often. 

 

Let’s break this down in two scenarios:

 

Scenario #1 – I DID Have Creditable Prescription Drug Coverage 

If you had creditable prescription drug coverage elsewhere and delayed Part D enrollment, you WON’T be assessed a Part D late enrollment penalty.  However, that doesn’t mean you won’t receive a late enrollment notice when you finally do enroll in Part D prescription drug coverage.

 

Here’s what happens when you enroll in a stand-alone Part D plan (or Medicare Advantage plan that includes Part D) AFTER your Initial Enrollment Period:

 

The Part D insurance carrier will send you a standardized letter alerting you of a possible gap in creditable prescription drug benefits.  It should provide the date range in question, which usually starts the month after your Initial Enrollment Period until when you finally purchased Part D prescription drug coverage.  You then have the opportunity to either call or complete a form to appeal. Either option is fine. Provide them with where you had the creditable coverage (i.e. employer’s name, VA, TriCare, etc) and the insurance carrier(s) involved during that time frame.  They will then research further to determine if you did indeed have creditable prescription drug coverage.

 

Be sure to watch your mail closely after that, as you will be informed of the decision once the investigation is complete.  If possible, keep the creditable drug coverage notices you received from your employer or other provider during that time frame.

 

Scenario #2 – I DIDN’T Have Creditable Prescription Drug Coverage

If you didn’t have creditable prescription drug coverage and didn’t enroll in a Part D plan during your Initial Enrollment Period in Medicare, you will receive a penalty. 

 

The penalty is assessed and charged only after you actually enroll in a stand-alone Part D plan (or Medicare Advantage plan with Part D benefits).  It’s calculated based on the number of months you are late enrolling in Part D.  

 

Here’s an example of how the penalty is calculated in 2019 for a Medicare beneficiary enrolling in a Part D plan 10 months late:

 

— 2019 Part D National Base Premium = $33.19/mo

— 1% of $33.19 = $0.3319

— Multiply $0.3319 by the number of months you are late enrolling ($0.3319 X 10)

— 2019 Part D penalty = $3.32/mo → rounded to the nearest ten cents → $3.30/mo

 

The penalty is assessed monthly, for life!  The constant factor will be that you were 10 months late in this example, but what will change is the Part D national base premium.  That means that as the Part D national base premium increases, so will your Part D penalty.

 

This particular topic is one of the most common sources of confusion for Medicare beneficiaries.  Many delay Medicare Part D because they think their employer group health plan is sufficient, but often later find out about the penalty.  This is why we recommend all Medicare eligible individuals should find out whether their existing health insurance has prescription drug benefits that meet the Medicare Part D minimum standards when first eligible.  Knowing this up-front and taking the proper steps can help you avoid a lifelong penalty.

 

Contact us if you have any questions about removing your late enrollment penalty or preventing one from the start. 

 

Reference Links

www.medicare.gov

Medicare Sign Up Periods

 

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

When you become Medicare eligible, the Part D Late Enrollment Penalty is added to your Medicare Part D monthly premium when you fail to obtain “creditable” prescription drug coverage, including:  

— A stand-alone Part D prescription drug plan

— A Medicare Advantage plan that includes Part D prescription drug coverage

— Employer group health coverage that includes creditable prescription drug coverage 

— The Department of Veterans Affairs (VA)

— TRICARE

 

To avoid the Part D late enrollment penalty when you’re first eligible for Medicare, you must obtain creditable prescription drug coverage during your Initial Enrollment Period (the 7-month time frame shown below), or within 63 days of losing creditable prescription drug coverage.

Creditable prescription drug coverage is drug coverage that meets or exceeds Medicare Part D minimum standards.  

 

If you have prescription drug coverage through the VA, it’s considered creditable, so you don’t have to enroll in a Part D plan (no penalty).  However, some Medicare beneficiaries still purchase a Part D prescription drug plan in the event the VA doesn’t cover a particular medication, or if they just want the flexibility to pick up certain drugs at a local pharmacy, rather than the VA.

 

But what about prescription drug coverage through your employer?  Is it creditable? 

Well, that depends.  Each group health plan needs to confirm whether the drug coverage is creditable or non-creditable each year from the insurance carrier.  Some plans are creditable, and some are non-creditable. Your employer is required to communicate this to you at least annually when the group renews health coverage, and at your request.  

 

NOTE: This notice only pertains to prescription drug benefits.  It’s commonly confused with a separate notice provided by employers stating you had creditable “medical” coverage through the employer group health plan.  The medical benefits are not in question here, just the prescription drug side.

 

If your group health plan’s drug benefits are creditable, you can delay Part D enrollment (without penalty) and obtain a Part D prescription drug plan when you need it (i.e. within 63 days of when you lose the group coverage at retirement).

 

If your group health plan’s drug benefits are non-creditable, you can purchase a Part D prescription drug plan during your Initial Enrollment Period to avoid the penalty.  If you don’t purchase a Part D prescription drug plan during your Initial Enrollment Period, the penalty will start to accumulate.  The penalty is assessed and charged only after you actually enroll in a stand-alone Part D plan (or Medicare Advantage plan with Part D benefits).  The penalty is calculated based on the number of months you are late enrolling in Part D.

Here’s an example of how the penalty is calculated in 2019 for a Medicare beneficiary enrolling in a Part D plan 10 months late:

— 2019 Part D National Base Premium = $33.19/mo

— 1% of $33.19 = $0.3319

— Multiply $0.3319 by the number of months you are late enrolling ($0.3319 X 10)

— 2019 Part D penalty = $3.32/mo → rounded to the nearest ten cents → $3.30/mo

 

The penalty is assessed monthly, and also for life!  The constant factor will be that you were 10 months late in this example, but what will change is the Part D national base premium.  That means that as the Part D national base premium increases, so will your Part D penalty.

 

So the big lesson here is you need to either pick up a Part D prescription drug plan when you’re first eligible, or get 100% confirmation that your other prescription drug benefits are creditable.  Because otherwise, you might begin to accumulate a life-long penalty.

 

Our next blog post will describe how to remove a Part D late enrollment penalty when it’s incorrectly being charged in the first place.  Be on the lookout. 

 

We are always here to help you with these kinds of issues.  Actually, we suggest addressing this BEFORE it becomes an issue.  Contact us HERE for help.

 

Reference Links

www.medicare.gov

Part D Late Enrollment Penalty

3 Ways to Avoid the Part D Late Enrollment Penalty

 

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

 

Our “Medicare Doesn’t Cover That” series continues this week with routine vision care.  Along with dental coverage, vision is always a concern when we meet with Medicare beneficiaries.  So does Medicare cover vision services? The answer is…it depends.

Routine Eye Services

If your vision need is blanketed under routine care such as eye exams, Medicare doesn’t cover it (i.e. eye refraction).  The same goes for eyeglasses. If you’re ready for a new pair of glasses or contact lenses, Medicare will not pay for it.  

Medical Eye Services

Now, if you have medical issues with your eyes, your vision services will go through your Medicare Part B (medical/outpatient) benefits like any other Medicare-approved medical service.  This includes, but is not limited to: 

Cataracts – One pair of glasses with standard frames or one set of contact lenses are covered only after a cataract surgery.

Glaucoma – Glaucoma tests are covered once every 12 months if you’re at high risk due to diabetes, family history, etc. 

Macular Degeneration – Certain tests and treatments can be covered by Medicare if you have age-related macular degeneration.

Diabetic Eye Exams – If you have diabetes, these exams are covered once every 12 months.

And remember, “covered” doesn’t mean it’s fully paid for.  It simply means Medicare approves the service. Depending on your insurance coverage, you may have additional out-of-pocket costs for these services in the form of a copay or deductible payment.

Contact us for more information on your specific vision needs. We’ll help you determine if Medicare does (or doesn’t) cover it. 


Reference Links

www.medicare.gov

Eye exams (routine) 

Eyeglasses & Contact Lenses After Cataract Surgery

Glaucoma Tests

Macular Degeneration Tests

Diabetic Eye Exams

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

So you’re at the doctor’s office for a check-up, but something’s amiss.  The doc says you need to start taking a medication to treat the new issue at hand.  What should you do? Do you run to the pharmacy and fill the prescription? Depending on the situation, that may be necessary.  But if it isn’t particularly urgent, we have a few recommendations that can hopefully save you time and money.

#1 – Address your health concern naturally 

This isn’t always the correct route, but the first question you should ask your doctor is, “Could I fix my issue with changes to my eating habits and lifestyle?”  If the doctor agrees this is an appropriate first step, then go for it.  But only with your doctor’s approval. If the issue is more serious, then move on to #2.

#2 – Inquire about alternative prescription drug options 

Doctors have their favorite prescription drugs to address certain issues.  But there is typically more than one medication available to treat each condition.  Your doctor might prescribe a generic drug or a brand name drug. Brand name drugs typically cost more than generics, so you want to be extra careful if you’re prescribed a brand name.

Since your doctor doesn’t know the price of every drug and how your insurance plan covers your particular prescriptions, you need to ask for a few alternative drugs when prescribed a brand name drug.  Because if you don’t, you may be in for a big surprise – and a big bill – when you pick up your prescription at the pharmacy. So don’t accept whatever is prescribed to you, especially when it’s a brand name drug.  Consider a generic drug to save you money…as long as your body responds well to the drug and your doctor is okay with it. 

#3 – Compare drug pricing at GoodRx.com

GoodRx.com has become very popular in the past few years.  GoodRx has cash discount deals for prescriptions at many pharmacy chains.  Sometimes it’s actually less expensive via GoodRx than through your Part D prescription drug plan!  And if that’s the case, here’s what you need to do: Show your pharmacist the GoodRx coupon for the particular drug, which you can print at www.goodrx.com or pull up the GoodRx app on your smartphone.

The discount will be applied and you’ll pay the necessary copay like normal.

Please note, you CANNOT use both GoodRx and your Part D prescription drug plan.  It’s one or the other. If you are buying a few prescriptions through your Part D plan and others through GoodRx, be sure to complete two separate transactions at the pharmacy.

When you’re on Medicare, you need to be a little more resourceful when it comes to your prescription drug costs.  But we’re here to help guide you along the way. Contact us for assistance.

Reference Links

www.medicare.gov

www.goodrx.com

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.

Last week, we walked through how to access your Medicare Claim Number beyond your Medicare card. But what if you lose your Medicare card entirely?  Can you request a new one? Can you print a copy online?  

Yes, you can request a new one AND actually print one too!

A step-by-step video guide is available below, via our YouTube Channel.

How To: Request a New Medicare Card Online (via www.socialsecurity.gov)

Login to your My Social Security online account at either www.ssa.gov or www.socialecurity.gov.  On the home page, there is a right-side Navigation bar (see below).

Click on “Replacement Documents”.  There, you’ll see a place to request a replacement Medicare card.

How To: Print a Copy of Your Medicare Card Online (via www.medicare.gov)

To print your Medicare card, you actually need to log in to a completely different online account on www.medicare.gov.  Once you are logged in, you’ll see a yellowish-orange section that says “Your Medicare Card” (see below).  

Just below it, you’ll want to click on “View or print your Medicare card”.  The next page will prompt you to re-enter your online password. After entering your password, you’ll now see an image of your Medicare card (front and back).  You can either print the card or save it as a PDF document.

Now you can access your Medicare card on demand. We are here to help uncomplicate every step of the Medicare process. Check out our blog page and YouTube Channel for more informative posts or contact us for direct, personalized support. 

Reference Links

www.medicare.gov

Neither Medicare Mindset LLC nor its agents are connected with the Federal Medicare program.