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    SEE more canada levitra buy online generic levitra online for sale about "PRUCOL" immigrant eligibility for Medicaid in this article. "Undocumented" immigrants are, with some exceptions for pregnant women and Child Health Plus, only eligible for "emergency Medicaid."NYS announced the 2020 Income and Resource levels in GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates ) and levels based on the Federal Poverty Level are in GIS 20 MA/02 – 2020 Federal Poverty Levels Here is the 2020 HRA Income and Resources Level Chart Non-MAGI - 2020 Disabled, 65+ or Blind ("DAB" or SSI-Related) and have Medicare MAGI (2020) (<. 65, Does not have Medicare)(OR has Medicare and has dependent child <. 18 or canada levitra buy online <. 19 in school) 138% FPL*** Children <.

    5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $875 (up from $859 canada levitra buy online in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All of the attachments with the various levels are posted here. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?. Which household size canada levitra buy online applies?.

    The rules are complicated. See rules here. On the HRA Medicaid Levels chart - Boxes 1 canada levitra buy online and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers. People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit.

    Box 3 on page 1 is canada levitra buy online Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R. § 435.4 canada levitra buy online. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <.

    Age 1, 154% FPL for children age 1 - 19. CAUTION canada levitra buy online. What is counted as income may not be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, canada levitra buy online based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI).

    There are good changes and bad changes. GOOD. Veteran's benefits, Workers compensation, and gifts canada levitra buy online from family or others no longer count as income. BAD. There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules.

    For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for canada levitra buy online a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid. Here are the 2 basic categories and the rules canada levitra buy online for calculating their household size.

    People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the canada levitra buy online new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp.

    8-10 of the PDF, This PowerPoint by NYLAG on MAGI canada levitra buy online Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size. See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally canada levitra buy online responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility.

    See 18 NYCRR 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid.

    Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income.

    This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange.

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    Heads Up - Changes Coming April 2021 Once again, NYS is changing the way people without Medicare access viagra cialis levitra and vardenafil prescription drugs check that. Since October 2011, most people who do not have Medicare obtained their drugs throug their Medicaid managed care plan. At that time, this drug benefit was "carved into" the Medicaid managed care benefit package. Before that date, people viagra cialis levitra and vardenafil enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans.

    That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 HOW DO MANAGED CARE PLANS DEFINE THE PHARMACY viagra cialis levitra and vardenafil BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies. Under Medicaid managed care. Plan formularies will be comparable viagra cialis levitra and vardenafil to but not the same as the Medicaid formulary.

    Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs. The Pharmacy Benefit will viagra cialis levitra and vardenafil vary by plan. Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan.

    Prescriber Prevails applies in certain viagra cialis levitra and vardenafil drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics. Prescribers will need to demonstrate viagra cialis levitra and vardenafil reasonable profession judgment and supply plans witht requested information and/or clinical documentation. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies.

    The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future. Standardized Prior Autorization (PA) Form -- The Department of Health worked with viagra cialis levitra and vardenafil managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013. Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price. CAN CONSUMERS SWITCH viagra cialis levitra and vardenafil PLANS IN ORDER TO GAIN ACCESS TO DRUGS?.

    Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care. Medicaid managed care enrollees can only leave and join another plan within viagra cialis levitra and vardenafil the first 90 days of joining a health plan. After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause.

    The pharmacy benefit changes are not considered good cause viagra cialis levitra and vardenafil. After the first 12 months of enrollment, Medicaid managed care enrollees can http://www.amisdepasteur.fr/cheap-levitra-online-canada/ switch plans at any time. STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements. If the plan still denies access, consumers can pursue review processes specific to managed care while at the same viagra cialis levitra and vardenafil time pursuing a fair hearing. All plans are required to maintain an internal and external review process for complaints and appeals of service denials.

    Some plans may develop special procedures for drug denials. Information on these procedures should be provided in viagra cialis levitra and vardenafil member handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision. An adverse decision is called a 'FInal Adverse Determination" or FAD. See model Denial FAD Notice viagra cialis levitra and vardenafil and FAD Notice to Reduce, Suspend or Stop Services.

    The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up to 14 days viagra cialis levitra and vardenafil if more information is needed and it is in the enrollee's interest. AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time.

    See more about the changes in Managed Care viagra cialis levitra and vardenafil appeals here. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications. Consumers who viagra cialis levitra and vardenafil experience problems with access to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees.

    Certain drugs/drug categories require the prescribers to obtain prior authorization. These include brand name drugs that have a generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list viagra cialis levitra and vardenafil. The full Medicaid formulary can be searched on the eMedNY website. Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is viagra cialis levitra and vardenafil required for original prescriptions, not refills.

    A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months. Click here for more information on NY's prior authorization process. The New York State Board of viagra cialis levitra and vardenafil Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs.

    Click here to viagra cialis levitra and vardenafil view New York State Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline. 1-888-614-5400 NY State Department of Health's Managed Care Hotline.

    Heads Up - Changes Coming April 2021 Once again, NYS is changing the way people without Medicare access canada levitra buy online prescription drugs. Since October 2011, most people who do not have Medicare obtained their drugs throug their Medicaid managed care plan. At that time, this drug benefit was "carved into" the Medicaid managed care benefit package. Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed canada levitra buy online care plan rules.

    COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 HOW DO MANAGED CARE PLANS DEFINE canada levitra buy online THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies.

    Under Medicaid managed care. Plan formularies will canada levitra buy online be comparable to but not the same as the Medicaid formulary. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs.

    The Pharmacy Benefit will vary by plan canada levitra buy online. Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan. Prescriber Prevails applies in canada levitra buy online certain drug classes.

    Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics. Prescribers will canada levitra buy online need to demonstrate reasonable profession judgment and supply plans witht requested information and/or clinical documentation. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies.

    The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future. Standardized Prior Autorization (PA) Form -- The Department of Health worked with managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for canada levitra buy online the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013. Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price.

    CAN CONSUMERS canada levitra buy online SWITCH PLANS IN ORDER TO GAIN ACCESS TO DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care. Medicaid managed care enrollees can only leave and join another plan within the first 90 canada levitra buy online days of joining a health plan.

    After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause. The pharmacy canada levitra buy online benefit changes are not considered good cause. After the first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time.

    STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements. If the plan canada levitra buy online still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing. All plans are required to maintain an internal and external review process for complaints and appeals of service denials. Some plans may develop special procedures for drug denials.

    Information canada levitra buy online on these procedures should be provided in member handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision. An adverse decision is called a 'FInal Adverse Determination" or FAD. See model Denial FAD Notice and FAD Notice to Reduce, canada levitra buy online Suspend or Stop Services.

    The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more information is needed and it is in the enrollee's interest canada levitra buy online. AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing.

    The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time. See more about the changes in Managed Care appeals here canada levitra buy online. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications.

    Consumers who experience problems with access canada levitra buy online to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees. Certain drugs/drug categories require the prescribers to obtain prior authorization. These include brand name drugs that have a canada levitra buy online generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list.

    The full Medicaid formulary can be searched on the eMedNY website. Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is required for original canada levitra buy online prescriptions, not refills. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months.

    Click here for more information on NY's prior authorization process. The New York State Board of canada levitra buy online Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs.

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    The past http://www.amisdepasteur.fr/generic-levitra-cost/ week has seen an explosion of media commentary about whether children in the UK can levitra be purchased over the counter should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open to vulnerable children and young people, can levitra be purchased over the counter and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools. Viner et al1 produced a rapid systematic review that concludes that school closures have less impact can levitra be purchased over the counter on infection rate and mortality than other social distancing measures.

    Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed to the population of the can levitra be purchased over the counter UK on 10 May by the UK prime minister, Boris Johnson. He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from can levitra be purchased over the counter 1 June.

    There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools. In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They can levitra be purchased over the counter recognise that the opening of schools is a vital part of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision. Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that have not spoken or played with another child their own age can levitra be purchased over the counter for the last two months.

    They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will can levitra be purchased over the counter be the ones who fall further behind if we keep school gates closed. This phased return is in line with what other can levitra be purchased over the counter European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting the government plan and the illogical nature of Williamson’s statement. The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school.

    This has caused concern about the attainment gap, but as Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from more affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools can levitra be purchased over the counter had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit. Is that can levitra be purchased over the counter correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’.

    This provoked can levitra be purchased over the counter a great deal of disquiet. Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to children of developing coronavirus can levitra be purchased over the counter disease. The second is the risk to others of children transmitting coronavirus disease, either while being symptomatic or asymptomatic.

    Here are some of the available evidence.Morbidity can levitra be purchased over the counter and mortality in children from coronavirus diseaseChildren appear to be less likely to acquire coronavirus disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications). Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to can levitra be purchased over the counter critical care was 2.2% of confirmed cases (7.2% of admitted children). Death was reported in 15 can levitra be purchased over the counter cases (0.18%).

    This adds to other evidence suggesting that children are at a relatively low risk from the virus, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the virus.15There are concerns that children who have been infected with the virus can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for COVID-19, and in the absence of effective community testing it will be impossible to know if they are carrying the virus. Children also can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the infection.Arav can levitra be purchased over the counter et al18 found that the contact route was much more important than the airborne route, which they concluded had a negligible contribution. They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of infection suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with seems to be small, and the potential gains for children may outweigh can levitra be purchased over the counter them.

    There is a big proviso with this however, and that is that the overall incidence of COVID-19 has fallen below specified threshold. This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of infection decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would not risk a second peak.These conditions are open can levitra be purchased over the counter to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy. Decisions about whether to reopen schools are taken can levitra be purchased over the counter on a national level with a distance from personal concerns and fears.

    Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is a difficult path can levitra be purchased over the counter to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation. Parents were being asked to believe that MMR was a safe vaccine in the face of a massive and emotive campaign that promoted can levitra be purchased over the counter the ‘risk’ of having the vaccine above all else.

    This situation can levitra be purchased over the counter is even more complex than that as we have increased access to opinion and difficulty in understanding if or how much that information is biased. It is no wonder that decision-making is difficult. It is likely that evidence will continue to emerge and gradually the choice will become can levitra be purchased over the counter easier to make. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach.

    By working to identify a consensus position, researchers can report findings on a specific question (or set of questions) that are based on the knowledge and experience of experts in their field.However, there are can levitra be purchased over the counter challenges to this approach. For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way that allows them to consider objectively the views can levitra be purchased over the counter of others and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus.

    Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity can levitra be purchased over the counter and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline. First, the overarching approach is based on a series of ‘rounds’, where a set of experts are asked their opinions on a can levitra be purchased over the counter particular issue. The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses.

    Finally, the findings of each round are always shared with the can levitra be purchased over the counter broader group anonymously. This avoids any bias can levitra be purchased over the counter that might result from participants being concerned about their own views being viewed negatively or from their own opinions being biased by personal factors. This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged. For example, a study of can levitra be purchased over the counter human factors that contributed to nursing errors used only two rounds.

    The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could. Analysis of responses resulted in a list of 28 potential reasons—this can levitra be purchased over the counter list was sent back to the same group of experts for the second round, asking them to score each one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies were developed from the findings of a can levitra be purchased over the counter survey of NP beliefs, knowledge and level of implementation of advance care planning.

    Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made can levitra be purchased over the counter based on the original feedback, and a third round was conducted where 15 of the original NP participants confirmed their consensus with the final document. The final document includes four competencies, each with several elements. Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe Delphi technique offers a flexible approach to gathering the views can levitra be purchased over the counter of experts on an area of interest.

    The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups. The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the group are given extra credence.5However, Delphi studies can—by their very nature—be complex and can levitra be purchased over the counter time consuming. The need for participants to complete can levitra be purchased over the counter multiple rounds can lead to high drop-out rates which impacts on validity of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword.

    It provides those taking part with the opportunity to reflect and reconsider their position in response to additional information, which is an important part of nursing can levitra be purchased over the counter practice. Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’. Even with the level of flexibility and reflexivity present in Delphi studies, it is still unlikely that a group of experts will demonstrate 100% agreement can levitra be purchased over the counter on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached.

    This is where there is inconsistency across studies and authors, with the suggested level of consensus ranging from 51% to 100%.2 In addition, it can levitra be purchased over the counter has been identified that in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to the quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the can levitra be purchased over the counter findings of Delphi studies are intrinsically unreliable or invalid. It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts.

    It allows for reflection among participants, who are able to nuance and reconsider can levitra be purchased over the counter their opinion based on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies. It is important to try and prevent participants from simply resorting can levitra be purchased over the counter to agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

    The past http://www.amisdepasteur.fr/levitra-uk-buy/ week has seen an explosion of media commentary about canada levitra buy online whether children in the UK should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open canada levitra buy online to vulnerable children and young people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools. Viner et al1 produced a canada levitra buy online rapid systematic review that concludes that school closures have less impact on infection rate and mortality than other social distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’.

    This was conveyed to the population of the UK on canada levitra buy online 10 May by the UK prime minister, Boris Johnson. He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken canada levitra buy online by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools. In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a canada levitra buy online vital part of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision.

    Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that have not spoken or played with another child their own canada levitra buy online age for the last two months. They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will be the ones canada levitra buy online who fall further behind if we keep school gates closed. This phased return is in line with what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting the government canada levitra buy online plan and the illogical nature of Williamson’s statement.

    The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school. This has caused concern about the attainment gap, but as Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from more affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools had canada levitra buy online reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit. Is that canada levitra buy online correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’.

    This provoked a great deal of canada levitra buy online disquiet. Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to children of developing canada levitra buy online coronavirus disease. The second is the risk to others of children transmitting coronavirus disease, either while being symptomatic or asymptomatic. Here are some of the available evidence.Morbidity and mortality in children from coronavirus diseaseChildren appear to be less likely to acquire coronavirus disease in various nations.9–11 Barton et al12 found that canada levitra buy online children account for 1.9% of confirmed cases (data collected from government websites and publications).

    Of these 8113 paediatric cases, 14% required hospital admission. The admission canada levitra buy online rate to critical care was 2.2% of confirmed cases (7.2% of admitted children). Death was reported in 15 cases canada levitra buy online (0.18%). This adds to other evidence suggesting that children are at a relatively low risk from the virus, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the virus.15There are concerns that children who have been infected with the virus can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for COVID-19, and in the absence of effective community testing it will be impossible to know if they are carrying the virus. Children also canada levitra buy online can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the infection.Arav et al18 found that the contact route was much more important than the airborne route, which they concluded had a negligible contribution.

    They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of infection suggest that the child was unlikely to be the index case.The canada levitra buy online riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with seems to be small, and the potential gains for children may outweigh them. There is a big proviso with this however, and that is that the overall incidence of COVID-19 has fallen below specified threshold. This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of infection decreasing to manageable levels.Ensuring canada levitra buy online that personal protective equipment supply can meet demand.Being confident that any adjustments would not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy.

    Decisions about whether to reopen schools are taken on a national level with a canada levitra buy online distance from personal concerns and fears. Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is a canada levitra buy online difficult path to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation. Parents were being asked to believe that MMR was a safe vaccine in the face of a massive and emotive campaign that promoted the ‘risk’ of having the vaccine above all canada levitra buy online else.

    This situation is even more complex than that as we have increased access to opinion and canada levitra buy online difficulty in understanding if or how much that information is levitra 20mg coupon biased. It is no wonder that decision-making is difficult. It is likely that evidence will continue to emerge and gradually the choice will become easier to make canada levitra buy online. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach. By working to identify a consensus position, researchers can report findings on a specific question canada levitra buy online (or set of questions) that are based on the knowledge and experience of experts in their field.However, there are challenges to this approach.

    For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way that allows canada levitra buy online them to consider objectively the views of others and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus. Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the gradual formation of canada levitra buy online a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline.

    First, the overarching approach is based on a series of ‘rounds’, where a set canada levitra buy online of experts are asked their opinions on a particular issue. The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses. Finally, the findings of each round are always shared with the canada levitra buy online broader group anonymously. This avoids any bias that might result from participants being concerned about canada levitra buy online their own views being viewed negatively or from their own opinions being biased by personal factors. This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged.

    For example, canada levitra buy online a study of human factors that contributed to nursing errors used only two rounds. The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could. Analysis of responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts for the second round, asking them to score each one canada levitra buy online for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies canada levitra buy online were developed from the findings of a survey of NP beliefs, knowledge and level of implementation of advance care planning.

    Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made based on the canada levitra buy online original feedback, and a third round was conducted where 15 of the original NP participants confirmed their consensus with the final document. The final document includes four competencies, each with several elements. Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses canada levitra buy online of Delphi studiesThe Delphi technique offers a flexible approach to gathering the views of experts on an area of interest. The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups.

    The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or canada levitra buy online high-profile members of the group are given extra credence.5However, Delphi studies can—by their very nature—be complex and time consuming. The need for participants to complete multiple rounds can lead to high drop-out rates which canada levitra buy online impacts on validity of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword. It provides those canada levitra buy online taking part with the opportunity to reflect and reconsider their position in response to additional information, which is an important part of nursing practice. Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’.

    Even with the level of flexibility and reflexivity present in Delphi studies, it is still unlikely that a group of experts will demonstrate 100% agreement on issues canada levitra buy online. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached. This is where there is inconsistency across studies and authors, with the suggested level of consensus ranging from 51% canada levitra buy online to 100%.2 In addition, it has been identified that in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to the quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically canada levitra buy online unreliable or invalid.

    It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts. It allows for reflection among participants, who are able to canada levitra buy online nuance and reconsider their opinion based on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies. It is important to try and canada levitra buy online prevent participants from simply resorting to agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

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    John Rawls begins a Theory of Justice with the observation that 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each http://www.amisdepasteur.fr/order-generic-levitra/ person possesses an inviolability founded where is better to buy levitra on justice that even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment and many other where is better to buy levitra changes to the everyday behaviour of persons. The justice issues it raises are diverse, profound and will demand our attention for some time.

    How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of where is better to buy levitra their application to COVID-19 triage situations. Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary of Defense Robert McNamara used enemy body counts as a measure of military success during the Vietnam war where is better to buy levitra.

    So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so where is better to buy levitra they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between the different forms of procedural fairness. While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p.

    85) there is little where is better to buy levitra prospect of that. As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should work toward a transparent and fair process, what Rawls would describe as imperfect procedural justice (p where is better to buy levitra.

    85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85).

    Their proposal is to triage patients into three broad categories. High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19.

    They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU. Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues.

    Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding.

    Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus. Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles.

    They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19. These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests.

    They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means. They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other.

    These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly. In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access.

    However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020.

    Central to these disucssions were two assumptions. First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU.

    In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question. Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines.

    ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient.

    People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission. The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups.

    The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups. This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in COVID-19 infection.

    Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears. Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it. Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases.

    Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

    The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate.

    This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die. Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation. Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19.

    In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage. Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds.

    First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits. For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups.

    In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care.

    This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas. Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation.

    Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people). There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team.

    Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources.

    These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context. See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests.

    Patients may be isolated in hospital for several weeks. To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity.

    However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers. Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear.

    An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis. This suggests the need for COVID-19-specific ACPs.

    Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex.

    Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients. But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients.

    And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature. Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19.

    Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..

    John Rawls begins a Theory of Justice with the canada levitra buy online observation that 'Justice http://www.amisdepasteur.fr/levitra-where-can-i-buy/ is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right canada levitra buy online to refuse medical treatment and many other changes to the everyday behaviour of persons. The justice issues it raises are diverse, profound and will demand our attention for some time. How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to canada levitra buy online treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations.

    Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary of Defense Robert McNamara used enemy body counts as a canada levitra buy online measure of military success during the Vietnam war. So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction between procedural and outcome consistency, which is canada levitra buy online important, and hints at distinctions Rawls drew between the different forms of procedural fairness.

    While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p. 85) there is little prospect of that canada levitra buy online. As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should work toward a transparent and fair process, what canada levitra buy online Rawls would describe as imperfect procedural justice (p.

    85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85). Their proposal is to triage patients into three broad categories.

    High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19. They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU.

    Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues. Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding.

    Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus. Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles. They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19.

    These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests. They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means.

    They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly. In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access.

    However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020. Central to these disucssions were two assumptions.

    First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU. In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question.

    Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines. ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient.

    People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission. The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups. The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups.

    This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from http://www.amisdepasteur.fr/where-is-better-to-buy-levitra/ lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in COVID-19 infection. Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears. Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it.

    Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases. Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

    The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate. This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die.

    Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation. Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19. In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage.

    Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds. First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits. For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups.

    In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas.

    Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation. Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people).

    There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team. Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources.

    These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context. See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests. Patients may be isolated in hospital for several weeks.

    To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity. However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers.

    Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear. An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis. This suggests the need for COVID-19-specific ACPs.

    Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex. Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients.

    But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients. And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature.

    Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19. Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..

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    Lady Gaga, for example, tells levitra low price in the Netflix documentary “Five Foot Two,” how she powers through on “bad pain days” with a bevy of physicians at her side, pumping her body with corticosteroids before performances. But it can take years to get where she is. Labyrinthine corridors of pain management clinics, at any given time, teem with FMS sufferers who hunt for solidarity amongst strangers as they ask one another, “Do you also…?. ” and “what do you do levitra low price for the…?. ” and “I’m tired of being disbelieved.”Yet, even as FMS continues to be a mystery to medical practitioners around the world, recent research has slowly started to shed light on some of its major symptoms — offering new hope to the millions who suffer from it.

    Clues in the GutAmir Minerbi, a specialized pain physician levitra low price at the Alan Edwards Pain Management Unit at McGill University, says he treats many individuals affected by fibromyalgia. And his patients are frustrated. “They share how long it takes to get diagnosed, how ineffective many of our treatment modalities are, how difficult it is for others to understand what they are going through — friends, family and even medical personnel,” Minerbi says. In a June 2019 study in the journal Pain, Minerbi and colleagues found that compared to healthy individuals, patients with fibromyalgia had a different composition of gut microbes levitra low price. “We used this correlation to teach a computer to classify patients from controls, and reached reasonably good accuracy,” says Minerbi.

    While the demonstration so far doesn’t confirm that the absence or presence of certain bacteria causes fibromyalgia, the team is keen to build on the study to search for a causal relationship. Minerbi says that the hope is to “be able not only to make faster, more accurate diagnoses of fibromyalgia, but also to treat it by manipulating the microbiome.”This improved understanding could one day lead to the creation of new diagnostic tools, levitra low price the researchers concluded in their study. Gut disturbances aren’t the only symptoms that have received recent attention in relation to FMS. This year, researchers also studied the chronic condition’s overlap with mental levitra low price health.High RiskIn June 2020, a study in the journal Arthritis Care &. Research examined the connection between self-harm and severe rheumatological conditions.

    The group of scientists, led by epidemiologist James Prior at Keele University in the UK found that, of all the conditions studied, self-harm was most prevalent among patients with fibromyalgia — even more than conditions like rheumatoid arthritis or osteoarthritis. Fibromyalgia sufferers were also found to have greater incidence of depression and mental health issues than patients with levitra low price the other arthritic conditions studied. Prior says the link between fibromyalgia and depression was unearthed out of medical records of patients, who have their conditions listed on the UK’s primary care database as soon as they visit a primary care provider. This makes sense, given that anti-depressants are a recommended treatment for fibromyalgia symptoms.“We were certainly pleased that our work has highlighted that healthcare professionals need to be aware of the impact that this invisible condition has on the mental health of patients with rheumatological conditions, especially fibromyalgia,” says Prior.Mental health is indeed an important factor to look out for in FMS, since it can both cause and be the cause of other levitra low price symptoms. Sexual dysfunction, for instance, is an FMS symptom that rarely gets attention — even though it, too, can lead to mental health issues.

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    I cheated on one doctor with the next, experimenting with one’s test and then another’s treatment, like physician’s roulette, but nothing worked. And then, one day, a wizened rheumatologist squeezed mounds of my flesh between the tips of his fingers and hmmed and ahhed canada levitra buy online before ruling me a survivor of the chronic pain syndrome, fibromyalgia. As it turns out, I’m one in a vast pool of fibromyalgia syndrome (FMS) sufferers.

    The condition affects 10 million people just in the U.S., and an estimated 80 to 90 percent of all diagnosed patients in the world are women. But the jury’s been canada levitra buy online out for decades on what causes it. Conjectures vary from family history of rheumatoid illnesses to childhood trauma and severe physical or emotional stress.

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    Lady Gaga, for example, tells in the Netflix documentary canada levitra buy online “Five Foot Two,” how she powers through on “bad pain days” with a bevy of physicians at her side, pumping her body with corticosteroids before performances. But it can take years to get where she is. Labyrinthine corridors of pain management clinics, at any given time, teem with FMS sufferers who hunt for solidarity amongst strangers as they ask one another, “Do you also…?.

    ” and “what canada levitra buy online do you do for the…?. ” and “I’m tired of being disbelieved.”Yet, even as FMS continues to be a mystery to medical practitioners around the world, recent research has slowly started to shed light on some of its major symptoms — offering new hope to the millions who suffer from it. Clues in the GutAmir Minerbi, a specialized pain physician at the Alan Edwards Pain Management Unit at McGill University, says he treats many individuals canada levitra buy online affected by fibromyalgia.

    And his patients are frustrated. “They share how long it takes to get diagnosed, how ineffective many of our treatment modalities are, how difficult it is for others to understand what they are going through — friends, family and even medical personnel,” Minerbi says. In a June 2019 study in the journal Pain, Minerbi and colleagues found that compared to healthy individuals, patients with fibromyalgia had a different composition of canada levitra buy online gut microbes.

    “We used this correlation to teach a computer to classify patients from controls, and reached reasonably good accuracy,” says Minerbi. While the demonstration so far doesn’t confirm that the absence or presence of certain bacteria causes fibromyalgia, the team is keen to build on the study to search for a causal relationship. Minerbi says that the hope is to “be able not only to make faster, more accurate diagnoses of fibromyalgia, but also to treat it by manipulating the microbiome.”This improved understanding could one day lead to canada levitra buy online the creation of new diagnostic tools, the researchers concluded in their study.

    Gut disturbances aren’t the only symptoms that have received recent attention in relation to FMS. This year, researchers also studied the chronic condition’s canada levitra buy online overlap with mental health.High RiskIn June 2020, a study in the journal Arthritis Care &. Research examined the connection between self-harm and severe rheumatological conditions.

    The group of scientists, led by epidemiologist James Prior at Keele University in the UK found that, of all the conditions studied, self-harm was most prevalent among patients with fibromyalgia — even more than conditions like rheumatoid arthritis or osteoarthritis. Fibromyalgia sufferers were also found to have greater incidence of depression and mental health issues than patients with canada levitra buy online the other arthritic conditions studied. Prior says the link between fibromyalgia and depression was unearthed out of medical records of patients, who have their conditions listed on the UK’s primary care database as soon as they visit a primary care provider.

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    A New Kind of Sex LifeSeveral studies over canada levitra buy online the years have recorded the loss of libido and sexual dysfunction among patients with fibromyalgia. What should comfort both FMS patientsand their partners, though, is the understanding developing in this arena. Research is examining how women on anti-depressants can face loss of arousal, vaginal lubrication and apathy to sex — and how their long-term sexual partners are working with them to find a solution.

    A study published in November 2019 in PLOS ONE, led by Patricia Romero-Alcalá at the University of canada levitra buy online Almeria in Spain, investigated the changing realities of couples living with fibromyalgia. Although limited in that it looked only at heterosexual relationships, the study is promising in its recognition of sexuality as an important aspect of FMS. Other studies have found a definite association between female sexual dysfunction and fibromyalgia — as well as a possible relationship between canada levitra buy online depression and sexual dysfunction in premenopausal women with the condition.

    The one thing common among them is all, is the evidence for patients’ need for sexological support. Hope for the FutureWhile research is ongoing, a medical breakthrough to treat FMS is still some distance away. Science is still no closer to explaining is what actually causes fibromyalgia and how one can map its probable development in the next generation.Besides concrete canada levitra buy online data, what FMS sufferers need in general is empathy.

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    Section 1 how to buy levitra in usa. Identifying Stress &. Trauma1.1 how to buy levitra in usa Sussing Out Stress by Hermann Englert 1.2 Treating a Toxin to Learning by Clancy Blair 1.3 The Trauma after the Storm by Anna Harwood Section 2.

    Effects on the Body &. Immune System 2.1 The Danger of Stress by Melinda Wenner 2.2 Fact or Fiction?. Stress Causes Gray Hair by how to buy levitra in usa Coco Ballantyne 2.3 Female Stress.

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    by Bret Stetka 5.5 Mind of the Meditator by Matthieu Ricard, Antoine Lutz &. Richard J. Davidson Section how to buy levitra in usa 6.

    Resilience. Aftermath 6.1 Ready for Anything by Steven M. Southwick & how to buy levitra in usa.

    Dennis S. Charney 6.2 The Neuroscience of True Grit by Gary Stix 6.3 The Coronavirus and Post-Traumatic Growth by Steve Taylor 6.4 COVID-19. The Biggest Psychological Experiment by Lydia DenworthIn response how to buy levitra in usa to the COVID-19 pandemic, members of the Rapid Deployment Vaccine Collaborative (or RaDVaC)—a group composed of scientists and their friends or colleagues—have been self-administering an untested vaccine for SARS-CoV-2 (the virus that causes COVID-19).

    The RaDVaC scientists describe their project as aiming “to reduce risk of harm from SARS-CoV-2, minimally until there is at least one effective commercial vaccine widely available.” Although the project’s white paper includes includes terms and conditions designed to shield the authors from liability, RaDVaC’s self-experimentation raises important legal and ethical questions. Self-experimentation has a fascinating history. In the early 1900s, Walter Reed conducted experiments in Cuba deliberately exposing individuals to yellow fever that included members of the study team how to buy levitra in usa as participants.

    These led to significant public health benefits in confirming that yellow fever was transmitted by mosquitoes, but also resulted in the deaths of several participants. Some Nobel Prize–winning work by scientists was based on self-experimentation that initially was seen as crazy. For instance, in 1984, Barry Marshall swallowed bacteria to prove that how to buy levitra in usa they caused gastritis and peptic ulcers.

    Many cardiac procedures are based on a 1929 experiment by a German doctor who inserted a catheter into his own heart. Perhaps surprisingly, self-experimentation was once how to buy levitra in usa considered an ethical safeguard. The Nuremberg Code, established in response to grossly unethical experiments during World War II, permitted higher risk research if investigators also volunteered to participate, as they had in the earlier yellow fever studies.

    However, the idea that self-experimentation can justify higher research risks was abandoned in later codes of ethics. Not only is self-experimentation legally how to buy levitra in usa and ethically complex, but protections like independent review and informed consent, which are now required by research regulations, may be a better way to protect research participants. Existing regulations for research were not designed to address self-experimentation.

    Laws governing research typically define research as an activity designed to produce generalizable knowledge, which does not cover experimentation that is badly designed, unlikely to produce useful data, and merely aiming to protect a small group of people. In addition, how to buy levitra in usa the U.S. Common Rule governs federally funded research, and RaDVaC is not using any federal funding.

    However, Harvard is covered by a “federalwide assurance” under which the institution has agreed that all research it conducts will abide by the regulations (regardless of funding source). If studies of immune responses involving how to buy levitra in usa self-experimentation are planned in George Church’s laboratory at Harvard, as has been reported, this undoubtedly requires approval by an Institutional Review Board, which would provide some oversight of this self-experimentation. If results are to be published in a peer-reviewed journal, moreover, most, if not all, journals would require assurance of regulatory review and oversight.

    The U.S. Food and how to buy levitra in usa Drug Administration has similar power to regulate research, and, perhaps more relevant for our purposes, “drugs” (including human biological materials and biologics)—even if they are not distributed for profit. The RaDVaC project uses biological materials—more specifically, small chains of amino acids from key SARS-CoV-2 proteins—and therefore may fall under the FDA’s jurisdiction.

    While the FDA has not traditionally exercised this authority to regulate the analogous practice of small scale, do-it-yourself biohacking, it retains the power to do so in the future. Finally, if people were harmed by taking this vaccine, they could also sue RaDVaC, how to buy levitra in usa but the disclaimers in the white paper are carefully designed to avoid liability. Even if the law doesn’t adequately address this behavior, it may be ethically problematic—including because it could be a waste of scientific expertise and research effort.

    If RaDVaC intends to produce generalizable knowledge about this vaccine, unsystematic self-experimentation is unlikely to produce useful information. For example, self-experimentation can lead to biased results if researchers overestimate the chance that the vaccine how to buy levitra in usa works, or fail to report side effects. Randomized controlled trials, by contrast, are typically designed with researchers being blinded to who receives the intervention or the placebo.

    Beyond self-experimentation, friends, staff members, and family members of the scientists involved are taking this vaccine based on these expert’s recommendations, which could lead to two potential misconceptions. First, people taking the vaccine might overestimate the likelihood that they are protected how to buy levitra in usa from SARS-CoV-2 and change their behavior. If some individuals falsely believe they are protected, they might engage in riskier behavior that could cause harm to themselves and others.

    A second misconception is the idea that this is research that could benefit others. The same data analyst seemed how to buy levitra in usa to believe this when he added “my continued existence through this pandemic will be a useful data set.” Yet the RaDVaC project could not produce useful data in the same way as standard, well-designed vaccine trials, for example, because it is unclear whether individuals receiving the vaccine are thoroughly evaluated or monitored, and there does not appear to be a control group. Even if everyone involved with this project fully understands what they are getting into, however, there are also questions about expertise and privilege.

    Senior scientists benefit from many layers of privilege. Investment in their education, expertise in specialized areas, and access to information how to buy levitra in usa or materials. Arguably, these privileges come with a responsibility to use expertise for the benefit of society.

    If the RaDVaC vaccine is potentially beneficial, then it is how to buy levitra in usa tragic not to test it in a rigorously designed study. Indeed, uncontrolled self-experimentation is part of a larger problem in the COVID-19 pandemic. Panic about the virus has led to the widespread use of interventions outside of well-designed clinical trials.

    Without such trials, we how to buy levitra in usa remain in the dark about which interventions offer net benefits or net harms. Insofar as the scientists involved have expertise in vaccine research, they should either reform the RaDVaC project or lend their expertise to serious projects. On the other hand, if scientists don’t have relevant expertise, their overconfidence at their ability to work outside of their wheelhouse may be harmful.

    Earlier this week, Steven Salzberg, a computational biologist, called for experimental COVID-19 vaccines to be rolled out before the results how to buy levitra in usa of phase III testing. An op-ed denouncing his misinformed view was published the next day, and Salzberg reversed his position immediately. Similarly, some of the named members of the RaDVaC project have expertise in genetics, neuroscience, and anti-aging research.

    Their time might be better spent on projects in these fields, which will still be important when this how to buy levitra in usa pandemic is finally over. Rather than trying everything but the kitchen sink against COVID-19, it would be wiser to focus our collective efforts on prioritizing the most promising interventions and testing them in rigorous research, as has been done for some treatments for COVID-19. RaDVaC’s scientists should be encouraged to collaborate on systematic COVID-19 vaccine testing if they have relevant expertise, and to do other valuable things with their time if not.Not far from the famously multihued architecture of Bilbao in northern Spain, an underground world boasts its own vibrant display of color.

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    Scientists suggest, in an article published online in April in Quaternary International, how to buy levitra in usa that Goikoetxe Cave's speleothems record environmental conditions such as rainfall.The wildfire season is off to a roaring start. The hot summer is worsening drought and drying out vegetation—an unfortunately ideal environment for wildfires to rage. But that’s just one consequence of global warming.

    It’s also leading to how to buy levitra in usa flooding, torrential rainstorms and heat-related deaths. In fact, the climate crisis has led to a widespread public health crisis. And as an ear, nose and throat physician, I see the effects more and more often.

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    September 2019 was how to buy levitra in usa the hottest on record. January 2020 was the hottest on record. May 2020 was the hottest on record.

    This is not how to buy levitra in usa a coincidence. It is a pattern. Carbon dioxide, an important greenhouse gas contributing to global warming, has increased by 9 percent since 2005 and by 31 percent since 1950.

    A U.N how to buy levitra in usa. Intergovernmental Panel on Climate Change special report pointed out that the world has already warmed about one degree Celsius from pre-industrial levels. It stressed the urgency to act to limit warming to 1.5 degrees, and that how to buy levitra in usa a two-degree increase will lead to unprecedented extreme heat, water scarcity and food shortages around the globe.

    Heat affects every part of our body. It can lead to heat exhaustion, heat stroke, anxiety, impaired cognitive function and even premature death from heart and lung disease. Across the country, the health concerns of the climate crisis are increasingly being recognized, how to buy levitra in usa pushing thousands of medical providers—doctors, nurses, pharmacists, therapists, medical students—to become advocates for change.

    In my own practice, I explain to patients how the climate crisis affects their health. For example, apart from contributing to global warming, rising carbon dioxide levels increase the amount of pollen that plants produce as a consequence of higher rates of photosynthesis. This rise in pollen levels can lead to worsening allergy how to buy levitra in usa symptoms.

    Another example is fine particulate matter (known as PM2.5) associated with air pollution, much of it linked to the burning of fossil fuels that help drive the warming. When we breathe in these particles, they travel down the airway and settle in the tiny air sacs called alveoli of the lungs, causing inflammation and potentially worsening asthma symptoms. The explanations are simple, but the health risks are widespread how to buy levitra in usa and complex.

    Ground-level ozone pollution, which is worse in hotter weather, can also harm people with asthma and other respiratory diseases. And that harm falls disproportionately on the poor. Wealthier people living in North America have a per capita carbon footprint that is 25 percent higher than those of lower-income residents, with some affluent suburbs producing emissions 15 times higher how to buy levitra in usa than nearby neighborhoods.

    These carbon emissions contribute to global warming, and the subsequent health consequences are felt far beyond the neighborhood that produces them. Older adults, children, low-income communities and communities of color are less resilient on average to the health impacts of climate change. The climate crisis is how to buy levitra in usa thus leading to a disproportionate public health crisis—and worse, it is a threat multiplier.

    At a time when many Americans are economically challenged, continued heat waves and the higher energy bills they trigger threaten access to water and energy security. The economic benefits of a low-carbon economy are clear. Estimates suggest that without climate investments, the United States will face economic damage from climate change equivalent to 1–3 percent of GDP per year by 2100.

    The majority of Americans think global warming is happening. The climate crisis has unfairly been labeled as political, when in fact, people recognize that something needs to be done about it. Even for those who are seemingly unaffected, there is increasing global recognition that the safeguards of living in a protected community and affording expert medical care will eventually fail if global warming continues unchecked.

    Unfortunately, there will be no vaccine in six months or a year for the climate crisis. The only treatment is collective climate action in the present. Climate action is required of our elected leaders, and we must mandate it of ourselves.

    It can be as simple as educating family and friends, while making sustainable shopping and traveling choices. It includes eating less meat, unplugging electronics and raising a voice against the fossil fuel industry. With a rise in demand for absentee ballots for the election this November, it is crucial to request mail-in ballots right away to make sure our voices are heard.

    The United States is the second largest emitter of greenhouse gases, and we must vote for green policy. Legislative action and policy change work, as evidenced by the Clean Air Act and its subsequent amendments, which are projected to save 230,000 lives in 2020. The climate crisis is a public health issue, and we must start healing the planet in order to heal each other.

    Fighting against the climate crisis is one of the most patriotic things we can do right now. It will protect our health and the health of our neighbors across the country and the globe, and will allow all of us to live on this planet, the only home we have..

    Section 1 canada levitra buy online http://www.amisdepasteur.fr/levitra-where-can-i-buy/. Identifying Stress &. Trauma1.1 Sussing Out Stress by Hermann Englert 1.2 Treating a Toxin to Learning by Clancy Blair 1.3 The Trauma after the Storm by Anna Harwood Section 2 canada levitra buy online. Effects on the Body &.

    Immune System 2.1 The Danger of Stress by Melinda Wenner 2.2 Fact or Fiction?. Stress Causes Gray Hair canada levitra buy online by Coco Ballantyne 2.3 Female Stress. A Faster, Stronger Response by Debra A. Bangasser 2.4 Fight or Flight May Be in Our Bones by Diana Kwon Section 3.

    Effects on the canada levitra buy online Mind &. Brain 3.1 This Is Your Brain in Meltdown by Amy Arnsten, Carolyn M. Mazure &. Rajita Sinha 3.2 Strain on the canada levitra buy online Brain by Brian Mossop 3.3 Why Can't Christine Blasey Ford Remember How She Got Home?.

    by Jim Hopper 3.4 Language Patterns Reveal Body’s Hidden Response to Stress by Jo Marchant Section 4. Burnout 4.1 Why Aren’t We Talking About Burnout?. by Krystal D'Costa canada levitra buy online 4.2 Conquering Burnout by Michael P. Leiter &.

    Christina Maslach 4.3 Frontline Trauma by Jillian Mock Section 5. Stress Management 5.1 Fight the Frazzled Mind by Robert Epstein 5.2 How I Broke the Cycle of Stress by Ashten Duncan 5.3 The Essence of Optimism by Elaine canada levitra buy online Fox 5.4 Changing Our DNA through Mind Control?. by Bret Stetka 5.5 Mind of the Meditator by Matthieu Ricard, Antoine Lutz &. Richard J.

    Davidson Section canada levitra buy online 6. Resilience. Aftermath 6.1 Ready for Anything by Steven M. Southwick & canada levitra buy online.

    Dennis S. Charney 6.2 The Neuroscience of True Grit by Gary Stix 6.3 The Coronavirus and Post-Traumatic Growth by Steve Taylor 6.4 COVID-19. The Biggest Psychological Experiment by Lydia DenworthIn canada levitra buy online response to the COVID-19 pandemic, members of the Rapid Deployment Vaccine Collaborative (or RaDVaC)—a group composed of scientists and their friends or colleagues—have been self-administering an untested vaccine for SARS-CoV-2 (the virus that causes COVID-19). The RaDVaC scientists describe their project as aiming “to reduce risk of harm from SARS-CoV-2, minimally until there is at least one effective commercial vaccine widely available.” Although the project’s white paper includes includes terms and conditions designed to shield the authors from liability, RaDVaC’s self-experimentation raises important legal and ethical questions.

    Self-experimentation has a fascinating history. In the early 1900s, Walter Reed conducted experiments in Cuba deliberately exposing individuals to yellow fever that included members of the canada levitra buy online study team as participants. These led to significant public health benefits in confirming that yellow fever was transmitted by mosquitoes, but also resulted in the deaths of several participants. Some Nobel Prize–winning work by scientists was based on self-experimentation that initially was seen as crazy.

    For instance, in 1984, Barry Marshall swallowed bacteria to prove that they caused gastritis and canada levitra buy online peptic ulcers. Many cardiac procedures are based on a 1929 experiment by a German doctor who inserted a catheter into his own heart. Perhaps surprisingly, self-experimentation was once considered canada levitra buy online an ethical safeguard. The Nuremberg Code, established in response to grossly unethical experiments during World War II, permitted higher risk research if investigators also volunteered to participate, as they had in the earlier yellow fever studies.

    However, the idea that self-experimentation can justify higher research risks was abandoned in later codes of ethics. Not only is self-experimentation legally and ethically complex, but protections like independent review and informed consent, which are now required by research regulations, may be a canada levitra buy online better way to protect research participants. Existing regulations for research were not designed to address self-experimentation. Laws governing research typically define research as an activity designed to produce generalizable knowledge, which does not cover experimentation that is badly designed, unlikely to produce useful data, and merely aiming to protect a small group of people.

    In addition, canada levitra buy online the U.S. Common Rule governs federally funded research, and RaDVaC is not using any federal funding. However, Harvard is covered by a “federalwide assurance” under which the institution has agreed that all research it conducts will abide by the regulations (regardless of funding source). If studies of immune responses involving self-experimentation are planned in George Church’s laboratory at Harvard, as has been reported, this undoubtedly requires approval by an Institutional Review Board, canada levitra buy online which would provide some oversight of this self-experimentation.

    If results are to be published in a peer-reviewed journal, moreover, most, if not all, journals would require assurance of regulatory review and oversight. The U.S. Food and Drug Administration has similar power to regulate research, canada levitra buy online and, perhaps more relevant for our purposes, “drugs” (including human biological materials and biologics)—even if they are not distributed for profit. The RaDVaC project uses biological materials—more specifically, small chains of amino acids from key SARS-CoV-2 proteins—and therefore may fall under the FDA’s jurisdiction.

    While the FDA has not traditionally exercised this authority to regulate the analogous practice of small scale, do-it-yourself biohacking, it retains the power to do so in the future. Finally, if people were harmed by taking this vaccine, they could also sue RaDVaC, but the disclaimers in the canada levitra buy online white paper are carefully designed to avoid liability. Even if the law doesn’t adequately address this behavior, it may be ethically problematic—including because it could be a waste of scientific expertise and research effort. If RaDVaC intends to produce generalizable knowledge about this vaccine, unsystematic self-experimentation is unlikely to produce useful information.

    For example, canada levitra buy online self-experimentation can lead to biased results if researchers overestimate the chance that the vaccine works, or fail to report side effects. Randomized controlled trials, by contrast, are typically designed with researchers being blinded to who receives the intervention or the placebo. Beyond self-experimentation, friends, staff members, and family members of the scientists involved are taking this vaccine based on these expert’s recommendations, which could lead to two potential misconceptions. First, people taking the vaccine might overestimate the likelihood that they are protected from SARS-CoV-2 and change canada levitra buy online their behavior.

    If some individuals falsely believe they are protected, they might engage in riskier behavior that could cause harm to themselves and others. A second misconception is the idea that this is research that could benefit others. The same data analyst seemed to believe this when he added “my continued existence through this pandemic will be a useful data set.” Yet the RaDVaC project could not produce useful data in the same way as standard, well-designed vaccine trials, for example, because it is unclear whether individuals receiving the vaccine are thoroughly evaluated or monitored, and there does not appear canada levitra buy online to be a control group. Even if everyone involved with this project fully understands what they are getting into, however, there are also questions about expertise and privilege.

    Senior scientists benefit from many layers of privilege. Investment in their canada levitra buy online education, expertise in specialized areas, and access to information or materials. Arguably, these privileges come with a responsibility to use expertise for the benefit of society. If the canada levitra buy online RaDVaC vaccine is potentially beneficial, then it is tragic not to test it in a rigorously designed study.

    Indeed, uncontrolled self-experimentation is part of i thought about this a larger problem in the COVID-19 pandemic. Panic about the virus has led to the widespread use of interventions outside of well-designed clinical trials. Without such canada levitra buy online trials, we remain in the dark about which interventions offer net benefits or net harms. Insofar as the scientists involved have expertise in vaccine research, they should either reform the RaDVaC project or lend their expertise to serious projects.

    On the other hand, if scientists don’t have relevant expertise, their overconfidence at their ability to work outside of their wheelhouse may be harmful. Earlier this week, Steven Salzberg, a computational biologist, called for experimental COVID-19 canada levitra buy online vaccines to be rolled out before the results of phase III testing. An op-ed denouncing his misinformed view was published the next day, and Salzberg reversed his position immediately. Similarly, some of the named members of the RaDVaC project have expertise in genetics, neuroscience, and anti-aging research.

    Their time might be better spent on projects in these fields, which will still be important when this pandemic is finally over canada levitra buy online. Rather than trying everything but the kitchen sink against COVID-19, it would be wiser to focus our collective efforts on prioritizing the most promising interventions and testing them in rigorous research, as has been done for some treatments for COVID-19. RaDVaC’s scientists should be encouraged to collaborate on systematic COVID-19 vaccine testing if they have relevant expertise, and to do other valuable things with their time if not.Not far from the famously multihued architecture of Bilbao in northern Spain, an underground world boasts its own vibrant display of color. The stalagmites and stalactites of Goikoetxe Cave are canada levitra buy online not just the usual white.

    Many range from honey to deep red. New research shows that these formations, known generally as speleothems, get their red color from organic compounds leached from soil and transported by water. Scientists suggest, in an article published online in April in canada levitra buy online Quaternary International, that Goikoetxe Cave's speleothems record environmental conditions such as rainfall.The wildfire season is off to a roaring start. The hot summer is worsening drought and drying out vegetation—an unfortunately ideal environment for wildfires to rage.

    But that’s just one consequence of global warming. It’s also leading to canada levitra buy online flooding, torrential rainstorms and heat-related deaths. In fact, the climate crisis has led to a widespread public health crisis. And as an ear, nose and throat physician, I see the effects more and more often.

    I vividly canada levitra buy online remember a patient who came in late for her appointment during a July heat wave. When I walked in, she said, “I’m so sorry I’m late, I was up all night walking my grandbaby around the train station.” Without air conditioning at home, the child was sweating through her clothes in the heat of the night, putting her at risk for dehydration. July 2019 was the hottest July on record. September 2019 canada levitra buy online was the hottest on record.

    January 2020 was the hottest on record. May 2020 was the hottest on record. This is canada levitra buy online not a coincidence. It is a pattern.

    Carbon dioxide, an important greenhouse gas contributing to global warming, has increased by 9 percent since 2005 and by 31 percent since 1950. A U.N canada levitra buy online. Intergovernmental Panel on Climate Change special report pointed out that the world has already warmed about one degree Celsius from pre-industrial levels. It stressed the urgency to act to limit warming to 1.5 degrees, and that a two-degree canada levitra buy online increase will lead to unprecedented extreme heat, water scarcity and food shortages around the globe.

    Heat affects every part of our body. It can lead to heat exhaustion, heat stroke, anxiety, impaired cognitive function and even premature death from heart and lung disease. Across the country, the health concerns of the climate crisis are increasingly being canada levitra buy online recognized, pushing thousands of medical providers—doctors, nurses, pharmacists, therapists, medical students—to become advocates for change. In my own practice, I explain to patients how the climate crisis affects their health.

    For example, apart from contributing to global warming, rising carbon dioxide levels increase the amount of pollen that plants produce as a consequence of higher rates of photosynthesis. This rise in pollen levels can lead to worsening allergy canada levitra buy online symptoms. Another example is fine particulate matter (known as PM2.5) associated with air pollution, much of it linked to the burning of fossil fuels that help drive the warming. When we breathe in these particles, they travel down the airway and settle in the tiny air sacs called alveoli of the lungs, causing inflammation and potentially worsening asthma symptoms.

    The explanations are simple, but the health risks are canada levitra buy online widespread and complex. Ground-level ozone pollution, which is worse in hotter weather, can also harm people with asthma and other respiratory diseases. And that harm falls disproportionately on the poor. Wealthier people living in North America have a per capita carbon footprint that canada levitra buy online is 25 percent higher than those of lower-income residents, with some affluent suburbs producing emissions 15 times higher than nearby neighborhoods.

    These carbon emissions contribute to global warming, and the subsequent health consequences are felt far beyond the neighborhood that produces them. Older adults, children, low-income communities and communities of color are less resilient on average to the health impacts of climate change. The climate crisis is canada levitra buy online thus leading to a disproportionate public health crisis—and worse, it is a threat multiplier. At a time when many Americans are economically challenged, continued heat waves and the higher energy bills they trigger threaten access to water and energy security.

    The economic benefits of a low-carbon economy are clear. Estimates suggest that without climate investments, the United States will face economic damage canada levitra buy online from climate change equivalent to 1–3 percent of GDP per year by 2100. The majority of Americans think global warming is happening. The climate crisis has unfairly been labeled as political, when in fact, people recognize that something needs to be done about it.

    Even for those who are seemingly unaffected, there is increasing global recognition that the safeguards of living in a protected community and affording expert medical care will eventually fail if global warming continues unchecked. Unfortunately, there will be no vaccine in six months or a year for the climate crisis. The only treatment is collective climate action in the present. Climate action is required of our elected leaders, and we must mandate it of ourselves.

    It can be as simple as educating family and friends, while making sustainable shopping and traveling choices. It includes eating less meat, unplugging electronics and raising a voice against the fossil fuel industry. With a rise in demand for absentee ballots for the election this November, it is crucial to request mail-in ballots right away to make sure our voices are heard. The United States is the second largest emitter of greenhouse gases, and we must vote for green policy.

    Legislative action and policy change work, as evidenced by the Clean Air Act and its subsequent amendments, which are projected to save 230,000 lives in 2020. The climate crisis is a public health issue, and we must start healing the planet in order to heal each other. Fighting against the climate crisis is one of the most patriotic things we can do right now. It will protect our health and the health of our neighbors across the country and the globe, and will allow all of us to live on this planet, the only home we have..

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    €œWe demonstrate that even under extreme antidepressant levitra conditions, SARS-CoV-2 virus is unable to replicate in these mosquitoes and therefore cannot be transmitted to people even in the unlikely event that a mosquito fed upon a viremic host,” researchers stated.“Although we do not know the duration of virus infectivity on contaminated surfaces, mechanical transmission by (mosquitoes) seems highly unlikely, and even if not impossible, would result in very few, if any human infections, and not be epidemiologically relevant.” Click here to sign up for Daily Voice's free daily emails and news alerts..

    While COVID-19 can spread in a number of ways, mosquitoes and ticks are not canada levitra buy online among them, the U.S. Centers for Disease Control and Prevention (CDC) is now saying.There is no data to suggest that COVID is spread by either mosquitoes or canada levitra buy online ticks, and is more likely to be spread from person to person through droplets when they talk, cough, or sneeze.According to the World Health Organization, to date, there is no evidence to suggest that the virus could be transmitted by the insects.“The new coronavirus is a respiratory virus which spreads primarily through droplets generated by an infected person,” the WHO noted. €œTo protect yourself, clean your hands frequently with an alcohol-based hand rub or wash them with soap and water.“Also avoid close contact with anyone who is coughing and sneezing.” A new study out of Kansas State University found that “three widely distributed species of mosquito, which canada levitra buy online represent the two most significant genera of the insect that infect people, were tested, and it was determined that the virus cannot spread through them.

    €œWe demonstrate that even under extreme conditions, SARS-CoV-2 virus is unable to canada levitra buy online replicate in these mosquitoes and therefore cannot be transmitted to people even in the unlikely event that a mosquito fed upon a viremic host,” researchers stated.“Although we do not know the duration of virus infectivity on contaminated surfaces, mechanical transmission by (mosquitoes) seems highly unlikely, and even if not impossible, would result in very few, if any human infections, and not be epidemiologically relevant.” Click here to sign up for Daily Voice's free daily emails and news alerts..

    Cialis levitra viagra diferencias

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    INCOME LIMITS generic levitra tablets and RULES Each of the three cialis levitra viagra diferencias MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below. NOTE cialis levitra viagra diferencias.

    There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use cialis levitra viagra diferencias the new FPLs and go ahead and factor in any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.

    367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &.

    Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc.

    For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher.

    The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2. See DAB Household Size Chart.

    Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare.

    His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010.

    This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP.

    In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). 3. The Three Medicare Savings Programs - what are they and how are they different?.

    1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations.

    Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible. ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center).

    2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.

    3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.

    However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both.

    It is their choice. DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB.

    4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable.

    They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit.

    People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application.

    Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb.

    18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP).

    Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP.

    AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55.

    Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs.

    See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium.

    Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?.

    The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification.

    Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits.

    See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment.

    See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP.

    Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033).

    Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason.

    SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application.

    As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D.

    Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid.

    See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address. See the application form for other instructions.

    One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person.

    Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district.

    The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare.

    IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare.

    People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP.

    08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016.

    He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund.

    This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP.

    (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply.

    The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center).

    This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as.

    SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period.

    (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check.

    SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!. !.

    !. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?. ​The answer is different for the 3 MSP programs.

    QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year.

    7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations.

    First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance.

    Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.THE PROBLEM. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations.

    Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER.

    QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service.

    However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them.

    These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here.

    See pp. 53, 86. 1. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?.

    "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?.

    If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C.

    § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?.

    The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans.

    The answer also differs based on the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down.

    For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020.

    For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down.

    In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage.

    If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate.

    ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is.

    This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd. 1(d)(iv), added 2016.

    EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules. The Medicare rate for Mary's specialist visit is $185.

    The Medicaid rate for the same service is $120. Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50.

    The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148).

    For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. . 4.

    May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C.

    § 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.

    This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.

    QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals.

    See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue.

    If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN.

    The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services.

    CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb.

    2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card dos not indicate QMB eligibility.

    Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly.

    6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

    16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice. Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26.

    2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372. Medicare Advantage members should complain to their Medicare Advantage plan.

    In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs. Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans. Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs.

    Links to their webinars and other resources is at this link. Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author. Cathy Roberts.

    Author. Geoffrey Hale This article was authored by the Empire Justice Center.Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in QMB receive additional subsidies for Medicare costs.

    See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y. Soc. Serv.

    L. § 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A.

    Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?.

    4. FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &.

    Applications for People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1.

    NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?.

    YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

    Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA 027.

    Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down.

    2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below.

    NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA.

    See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv.

    L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include.

    (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted).

    * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart.

    As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2.

    See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month.

    He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO.

    DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?.

    Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). 3.

    The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits.

    Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

    ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only.

    SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only.

    QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid.

    They cannot be in both. It is their choice. DOH MRG p. 19.

    In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1.

    Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL.

    However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients.

    The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03.

    Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center.

    If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life..

    Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3.

    No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010.

    The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP.

    Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?.

    And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods.

    Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar.

    A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply.

    The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below.

    WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid.

    (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP.

    Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note.

    The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district.

    (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available).

    Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address.

    See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1.

    Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare.

    To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

    IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test.

    For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down.

    If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE.

    Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check.

    He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district.

    Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown.

    MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium.

    See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment.

    The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums.

    In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid.

    The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check. SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!.

    !. !. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?.

    ​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year.

    No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance.

    However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider.

    But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.THE PROBLEM. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB).

    His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay.

    Read below to find out -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all.

    This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries.

    Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections.

    Download the 2020 Medicare Handbook here. See pp. 53, 86. 1.

    To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2.

    How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining.

    42 U.S.C. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3.

    For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further.

    The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down.

    Payments are reduced if the beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here.

    Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible.

    If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature.

    Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage. If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate.

    Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd.

    1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd.

    1(d)(iv), added 2016. EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules.

    The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan).

    Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37.

    Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. .

    4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997.

    42 U.S.C. § 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider.

    If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at.

    CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018.

    CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB.

    It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

    Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here.

    They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed.

    Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays.

    Unfortunately, the Medicaid card dos not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney.

    The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer.

    See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice.

    Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26. 2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372.

    Medicare Advantage members should complain to their Medicare Advantage plan. In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs. Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans.

    Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link. Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author.

    Applications for canada levitra buy online People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - canada levitra buy online How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1.

    NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A canada levitra buy online. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?.

    YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A canada levitra buy online Buy-In” YES YES Pays Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

    Yes canada levitra buy online - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See canada levitra buy online GIS 07 MA 027.

    Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between canada levitra buy online QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down.

    2. INCOME LIMITS and RULES Each canada levitra buy online of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below.

    NOTE canada levitra buy online. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and canada levitra buy online go ahead and factor in any COLA.

    See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv.

    L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include.

    (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted).

    * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart.

    As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2.

    See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month.

    He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO.

    DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?.

    Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). 3.

    The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits.

    Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

    ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only.

    SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only.

    QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid.

    They cannot be in both. It is their choice. DOH MRG p. 19.

    In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1.

    Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL.

    However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients.

    The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03.

    Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center.

    If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life..

    Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3.

    No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010.

    The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP.

    Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?.

    And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods.

    Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar.

    A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply.

    The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below.

    WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid.

    (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP.

    Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note.

    The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district.

    (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available).

    Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address.

    See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1.

    Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare.

    To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

    IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test.

    For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down.

    If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE.

    Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check.

    He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district.

    Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown.

    MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium.

    See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment.

    The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums.

    In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid.

    The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check. SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!.

    !. !. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?.

    ​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year.

    No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance.

    However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider.

    But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.THE PROBLEM. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB).

    His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay.

    Read below to find out -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all.

    This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries.

    Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections.

    Download the 2020 Medicare Handbook here. See pp. 53, 86. 1.

    To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2.

    How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining.

    42 U.S.C. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3.

    For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further.

    The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down.

    Payments are reduced if the beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here.

    Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible.

    If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature.

    Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage. If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate.

    Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd.

    1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd.

    1(d)(iv), added 2016. EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules.

    The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan).

    Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37.

    Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. .

    4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997.

    42 U.S.C. § 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider.

    If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at.

    CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018.

    CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB.

    It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

    Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here.

    They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed.

    Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays.

    Unfortunately, the Medicaid card dos not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney.

    The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer.

    See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice.

    Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26. 2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372.

    Medicare Advantage members should complain to their Medicare Advantage plan. In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs. Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans.

    Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link. Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author.

    Cathy Roberts. Author. Geoffrey Hale This article was authored by the Empire Justice Center.Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below.

    Those in QMB receive additional subsidies for Medicare costs. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y. Soc.

    Serv. L. § 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1.

    No Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3.

    The Three MSP Programs - What are they and how are they Different?. 4. FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5.

    Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7.

    What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A.

    SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &. B deductibles &.

    Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application).

    See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid.

    Cannot have both, not even Medicaid with a spend-down. 2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL).

    2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below. NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment).

    Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc.

    Serv. L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded.

    The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS.

    * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted.

    You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO.

    18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE.

    Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit.

    In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP.

    When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties).

    3. The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB).

    The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive.

    The program’s benefits will begin the month after the month in which your client is found eligible. ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB).

    For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1).

    For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage.

    Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both. It is their choice. DOH MRG p.

    19. In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST).

    Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year.

    The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy.

    Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application.

    The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability.

    An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties...

    For life.. Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer.

    Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits.

    Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4.

    SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections.

    Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification.

    New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit.

    It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare.

    Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP.

    See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B.

    Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing.

    Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive.

    Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program.

    Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev.

    8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &.

    Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time.

    If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan.

    GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification.

    NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02.

    Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit.

    Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility.

    EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016.

    Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan.

    See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19).

    Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6.

    Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013.

    In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program.

    Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7.

    What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check. SSA also refunds any amounts owed to the recipient. (Note.

    This process can take awhile!. !. !. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS).

    ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?. ​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application.

    QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing.

    QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid.

    Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.THE PROBLEM.

    Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay.

    Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider.

    Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers.

    Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights.

    The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here. See pp. 53, 86.

    1. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance.

    2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care).

    Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan.

    3. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov.

    Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay.

    Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200).

    See more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198.

    Medicaid pays the entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below.

    This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage. If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20.

    If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32).

    SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them.

    SSL 367-a, subd. 1(d)(iv), added 2016. EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate.

    ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules. The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since 2016).

    Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients.

    Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget.

    . 4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No.

    Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C. § 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance.

    This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments.

    This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.

    Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?.

    It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

    16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider.

    Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability.

    These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid.

    The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card dos not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB.

    See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney.

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