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Start Preamble Department buy viagra online without a prescription of Veterans Affairs. Proposed rule. The Department of Veterans Affairs (VA) proposes to amend its medical regulations that buy viagra online without a prescription govern the VA health care professionals who practice health care via telehealth.

This proposed rule would implement the authorities of the VA MISSION Act of 2018 and the William M. (Mac) Thornberry buy viagra online without a prescription National Defense Authorization Act for Fiscal Year 2021. Comments must be received on or before October 24, 2022.

Comments buy viagra online without a prescription may be submitted through www.Regulations.gov. Comments should indicate that they are submitted in response to [“RIN 2900-AQ59—Health Care Professionals Practicing Via Telehealth.”] Comments received will be available at regulations.gov for public viewing, inspection or copies. Start Further Info Kevin Galpin, MD, Executive buy viagra online without a prescription Director Telehealth Services, Veterans Health Administration Office of Connected Care, 810 Vermont Avenue NW, Washington, DC 20420.

(404) 771-8794. (This is not buy viagra online without a prescription a toll-free number.) Kevin.Galpin@va.gov. End Further Info End Preamble Start Supplemental Information On June 6, 2018, section 151 of Public Law 115-182, the John S.

McCain III, buy viagra online without a prescription Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, or the VA MISSION Act of 2018, amended buy viagra online without a prescription title 38 of the United States Code (U.S.C.) by adding a new section 1730C, titled Licensure of health care professionals providing treatment via telemedicine.

On June 11, 2018, a final rule VA published in May 2018, 83 FR 21897, titled Authority of Health Care Providers to Practice Telehealth (RIN 2900-AQ06), became effective. This regulation, which established 38 CFR 17.417, grants VA health care providers the ability buy viagra online without a prescription to provide telehealth services within their scope of practice, functional statement, and/or in accordance with privileges granted to them by VA, in any location, within any State, irrespective of the State or location within a State where the health care provider or the beneficiary is physically located. Congress was aware VA was promulgating this regulation and sought to codify VA's telehealth authority through legislation.

See H.R buy viagra online without a prescription. Rep. No.

115-671, Part I, at 13-14. Congress passed the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 (2021 NDAA), which further amended the definition of health care professional by including post graduate health care employees and health professions trainees.

See Public Law 116-283, sec. 9101, January 2, 2021. Given the enactment of these laws, we are updating our regulations to implement the new statutory authority.

Section 1730C provides a definition of covered health care professionals that differs from the definition of health care provider under § 17.417(a). We propose this regulation to make these definitions consistent. Section 1730C(b)(1)(A) defines a covered health care professional to include those VA employees appointed under 38 U.S.C.

7306, 7401, 7405, 7406, 7408 and title 5 of the U.S. Code. Section 17.417(a) defined a health care provider as an individual who is appointed to an occupation in the Veterans Health Administration that is listed in or authorized under 38 U.S.C.

7401(1) or (3). To maintain consistency between 38 U.S.C. 1730C and § 17.417, VA is proposing to amend the definition of health care provider to instead refer to health care professionals.

We would also renumber the definition in § 17.417 for clarity. VA proposes to add in § 17.417(a)(2)(i) that a health care professional would include those individuals who are appointed under 38 U.S.C. 7306, 7401, 7405, 7406, 7408, and title 5 of the U.S.

Code. VA is further proposing to amend the definition of health care professional to be consistent with section 1730C(b)(1)(C) in proposed § 17.417(a)(2)(ii) to state that VA health care professionals would be required to adhere to all standards for quality relating to the provision of health care in accordance with applicable VA policies. We note that while the statute uses the phrase provision of medicine, we propose to use the phrase provision of health care because we understand these terms to be equivalent and because the term health care is used more frequently in VA's regulations than medicine.

Consistent with current § 17.417, we would state in proposed § 17.417(a)(2)(iii) that VA-contracted health care professionals remain excluded from the definition of health care professional. We maintain this exclusion because contracted health care professionals and community care professionals are not appointed under 38 U.S.C. 7306, 7401, 7405, 7406, 7408, or title 5, U.S.

Code. We would also state in proposed § 17.417(a)(2)(iv)(A) that the health care professional is qualified to provide health care based on having an active, current, full, and unrestricted license, registration, certification, or satisfy another State requirement in a State to practice the health care profession of the health care professional. This language is similar to the language in section 1730C(b)(1)(D)(i).

Proposed § 17.417(a)(2)(iv)(B) would include those health care professions listed under 38 U.S.C. 7402(b)(14) that, although they may not be required to be licensed, registered or certified in their health care profession, may be required to satisfy another State requirement in a State that might limit them to practice telehealth. This additional provision Start Printed Page 51626 would recognize such qualifications as prescribed by the Secretary for those health care professions listed under 38 U.S.C.

7402(b)(14). This amendment is consistent with section 1730C(b)(1)(D)(2). Additionally, the proposed updates to the regulation are permitted pursuant to three general statutory provisions that permit VA to authorize health care practices by health care professionals at VA.

38 U.S.C. 303, 38 U.S.C. 7401, and 38 U.S.C.

7403(a)(1). Proposed § 17.417(a)(2)(iv)(C) would be consistent with section 1730C(b)(1)(B) and state that a health care professional is an employee otherwise authorized by the Secretary to provide health care services. The statutory authorities under 38 U.S.C.

303, 7401, and 7403(a)(1) also permit the VA Secretary to authorize VA health care professionals, including health professions trainees, other health care professionals, and those listed in the proposed regulation, to engage in telehealth. In addition, the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 amended section 1730C to expressly identify such persons within its statutory authority.

We note that section 1730C uses the term postgraduate health care employee. However, we would instead use the term health care professional to maintain consistency in terminology with other regulations. See § 17.419.

We would, therefore, state in proposed § 17.417(a)(2)(iv)(D) that a health care professional would also include those individuals who are under the clinical supervision of a health care professional that meets the requirements of paragraphs (a)(2)(iv)(A) through (C) of this section and is either a health professions trainee or a health care employee. Health professions trainees work in an apprenticeship model with VA-employed health care professionals as part of their training programs and are not required to have a license, registration, certification, or other State requirement. Health professions trainees are appointed under 38 U.S.C.

7405 or 7406. Section 1730C(b)(3) authorizes trainees to provide health care via telehealth and as such, we would state in § 17.417(a)(2)(iv)(D)( 1) that such trainee must be a health professions trainee appointed under 38 U.S.C 7405 or 38 U.S.C 7406 participating in clinical or research training under supervision to satisfy program or degree requirements. Similarly, section 1730C(b)(2) includes health care employees who are appointed under title 5, U.S.

Code, 38 U.S.C. 7401(1), (3), or 38 U.S.C. 7405 for any category of personnel described in 38 U.S.C.

7401(1) or (3). Health care employees must obtain full and unrestricted licensure, registration, or certification or meet the qualification standards as defined by the Secretary within the specified time frame. We would state these requirements in § 17.417(a)(2)(iv)(D)( 2).

We propose to amend § 17.417(b)(1) for clarity. We would clarify the first part of the first sentence of § 17.417(b)(1), which would now be numbered as § 17.417(b)(1), by stating that when a State law, license, registration, certification, or other State requirement is inconsistent with this section, the health care professional is required to abide by their Federal duties and requirements. We would make this clarification because without a broad, clear statement about which standards a health care professional should follow when State requirements are inconsistent with VA requirements for a health care professional's practice via telehealth, such State requirements would create ambiguity for VA health care professionals, thereby delaying telehealth service delivery, and preventing VA from training and overseeing VA health care professionals based on a single, consistent standard.

This change would also be consistent with the statute governing licensure requirements of VA health care professionals' practice via telehealth. See 38 U.S.C. 1730C(d)(1).

One example is if VA requires verbal consent for telehealth but a State required written consent, the VA health care professional would only be required to obtain verbal consent. Alternatively, if State law did not require obtaining consent at all, but VA policy required verbal consent, the VA health care professional would still be required to obtain verbal consent. Another example is when a State has a specific training requirement for a health care professional for telehealth.

We note that VA has specific training requirements for health care professionals who practice via telehealth that do not include each State's specific training or telehealth requirements. The VA health care professional must comply with VA's training requirement in order to practice via VA's telehealth program. In all instances, VA policy would establish requirements for quality and processes that would be met in all cases, but VA health care professionals would not be required to take additional steps or actions beyond those established in VA policy to comply with State law requirements.

We propose to add a new § 17.417(b)(2), which would restate the second part of the first sentence of current § 17.417(b)(1). However, we would clearly state that in order for the health care professional to be covered under this section, such professional must be practicing within the scope of their Federal duties. The provision of telehealth outside of the scope of the health care professional's Federal duties would not be covered by this rulemaking.

We would, therefore, state in proposed § 17.417(b)(2) that VA health care professionals may practice their health care profession within the scope of their Federal duties in any State irrespective of the State or location within a State where the health care professional or the beneficiary is physically located, if the health care professional is using telehealth to provide health care to a beneficiary. We propose to add a new § 17.417(b)(3) to restate the second sentence of current § 17.417(b)(1), but would add that the practice is limited by the Controlled Substances Act and its implementing regulations. Proposed § 17.417(b)(3) would state that health care professionals' practice is subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C.

801, et seq. And implementing regulations at 21 CFR part 1300 on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law, regulation, and policy. Section 1730C provides VA's authority to establish the scope of practice for health care professionals who practice telehealth.

Section 1730C(d)(1) provides that federal law shall supersede any provisions of the law of any State to the extent that such provisions of State law are inconsistent with it. States are, therefore, prevented from interfering with the exercise of VA duties by imposing requirements that are inconsistent with federal duties and requirements of health care professionals who practice within the scope of their VA employment. While there is a general requirement that a Federal employee be licensed, registered, or certified by a State, a line must be drawn between reasonable and established rules of practice, which are understood to be incorporated by reference by Federal statutes requiring Federal employees to carry licenses, and rules that would penalize or otherwise interfere with the performance of authorized federal duties.

See State Bar Disciplinary Rules as Applied to Federal Government Attorneys, 9 Op. O.L.C. 71, 72-73 (1985) (quotations omitted).

A State's licensure laws or rules that would prevent a VA health care Start Printed Page 51627 professional from engaging in telehealth would fall into the latter category and therefore could be preempted. Given our statutory authority under section 1730C, which supersedes any provisions of State law to the extent that such provision of State law are inconsistent with a VA health care professional's practice via telehealth, we propose to remove the last part of the last sentence in § 17.417(b)(1). We propose to add a new § 17.417(b)(4), which would restate § 17.417(b)(2) with changes described herein.

We are clarifying current § 17.417(b)(4)(iii) and (iv). The current language is not clear as to where the health care professional or the beneficiary is located. Proposed paragraph § 17.417(b)(4) (iii) would now state the health care professional is delivering services while the professional is located in a State other than the health care professional's State of licensure, registration, or certification.

Proposed § 17.417(b)(4)(iv) would now state the health care professional is delivering services while the professional is either on or outside VA property. We propose to clarify current § 17.417(b)(2)(v) to be inclusive of all beneficiaries. We note that all beneficiaries do not identify as she or he.

We would, therefore, amend § 17.417(b)(2)(v) to state the beneficiary is receiving services while the beneficiary is located either on or outside VA property. Current § 17.417(b)(2)(vi) states that situations where a health care provider's VA practice of telehealth may be inconsistent with a State law, or State license, registration, or certification, or other requirement include when the beneficiary has or has not previously been assessed, in person, by the health care provider. We propose to eliminate the term “has” as it refers to having been previously assessed in person.

Some States require that a patient be first assessed in person prior to being provided health care via telehealth. Therefore, this part of the provision would not be inconsistent with some State requirements. Proposed § 17.417(b)(4)(vi) would only provide for situations that would be inconsistent with State law or State license, registration, certification, or other requirements related to telehealth, which includes when the beneficiary has not been previously assessed, in person, by the health care professional.

The proposed change would also be consistent with section 1730C(d)(1). We propose to add a new § 17.417(b)(4)(vii), which would provide another example of a situation where a State license, registration, certification, or other State requirement may be inconsistent or conflict with VA policy. One example would be where a beneficiary has not provided VA with a signed written consent in order to receive health care via telehealth.

This example is added because some States do not allow a health care professional to provide telehealth services to a beneficiary unless the beneficiary has signed a written consent form. VA regulations only require verbal consent for the provision of telehealth. Requiring signature consent would disadvantage beneficiaries who do not possess the technology or digital skills to complete a remote signature consent prior to their telehealth visits.

This provision would allow for the provision of health care services via telehealth. VA is already bound to informed consent requirements under 38 U.S.C. 7331 as implemented by 38 CFR 17.32.

Section 17.32 of 38 CFR mandates that all patient care furnished under title 38, including health care services via telehealth, shall be carried out with the full and informed consent of the patient or, in appropriate cases, a representative thereof. That consent is not required to be in writing except in the narrow circumstances set forth in 38 CFR 17.32(d)(1). Thus, because 38 U.S.C.

7331 requires, in relevant part, that the Secretary of Veterans Affairs, prescribe regulations to ensure, to the maximum extent practicable, that all VA patient care be carried out only with the full and informed consent of the patient, or in appropriate cases, a representative thereof, and VA has implemented 38 CFR 17.32 establishing the standards for obtaining informed consent from a patient for a medical treatment or a diagnostic or therapeutic procedure, we assert that 38 CFR 17.32, combined with 38 U.S.C. 7331 categorically excludes any State regulation of how VA health care professionals go about obtaining informed consent. We would not restate current § 17.417(b)(2)(vii) because this information is already captured in proposed § 17.417(b)(1).

Finally, we propose to revise the list of authorities cited for § 17.417 to include section 1730C. We note that all prior authorities cited by this regulation would continue to apply and could protect VA health care professionals practicing telehealth in situations not covered by section 1730C. For example, section 1730C only protects VA health care professionals providing treatment to individuals under chapter 17 of title 38, U.S.C.

VA provides treatment to servicemembers and other beneficiaries of the Department of Defense who are not eligible for VA health care under chapter 17 pursuant to sharing agreements entered into under section 8111 in chapter 81 of title 38, U.S.C. VA's general authority on which its original regulations were premised, 38 U.S.C. 303, 7401, and 7403(a)(1), would continue to cover VA health care professionals furnishing health care not otherwise covered by section 1730C.

We propose to also include 38 U.S.C. 7306, 7405, 7406, and 7408. These new authorities cover individuals who would now be included as health care professionals under the proposed definition in § 17.417(a)(2).

In addition, we would also include 38 U.S.C. 7331, which would cover the informed consent as previously stated in this rulemaking. The statutory authority for § 17.417 would now be 38 U.S.C.

1701 (note), 1709A, 1712A (note), 1722B, 1730C, 7301, 7306, 7330A, 7331, 7401-7403, 7405, 7406, 7408. Executive Order 13132 provides the requirements for preemption of State law when it is implicated in rulemaking. Where a Federal statute does not expressly preempt State law, agencies shall construe any authorization in the statute for the issuance of regulations as authorizing preemption of State law by rulemaking only when the exercise of State authority directly conflicts with the exercise of Federal authority or there is clear evidence to conclude that the Congress intended the agency to have the authority to preempt State law.

Through this rulemaking process, we can preempt any State law or action that conflicts with the exercise of Federal duties in providing health care via telehealth to VA beneficiaries. In addition, any regulatory preemption of State law must be restricted to the minimum level necessary to achieve the objectives of the statute pursuant to the regulations that are promulgated. In this rulemaking, State licensure, registration, and certification laws, rules, regulations, or other State requirements are preempted only to the extent such State laws are inconsistent with the VA health care professionals' practicing health care via telehealth while acting within the scope of their VA employment.

VA also has statutory authority under 38 U.S.C. 1730C to preempt State law. Therefore, we believe that the rulemaking is restricted to the minimum level necessary to achieve the objectives of the Federal statute.

The Executive Order also requires an agency that is publishing a regulation Start Printed Page 51628 that preempts State law to follow certain procedures. These procedures include. The agency consult with, to the extent practicable, the appropriate State and local officials in an effort to avoid conflicts between State law and federally protected interests.

And the agency provide all affected State and local officials notice and an opportunity for appropriate participation in the proceedings. Because this proposed rule would preempt certain State laws, VA consulted with State officials in compliance with sections 4(d) and (e), as well as section 6(c) of Executive Order 13132. On August 21, 2019, VA sent a letter to the following.

National Association of Boards of Pharmacy (NABP), Association of State and Provincial Psychology Boards, National Governors Association, American Academy of Physicians Assistants (AAPA), National Council of State Boards of Nursing (NCSBN), National Association of State Directors of Veterans Affairs, Association of Social Work Boards (ASWB), and the Federation of State Medical Boards to state VA's intent to amend the current regulations that allow VA health care professionals to practice telehealth. We received 11 comments from the State officials. We received three comments fully supporting the rule.

The AAPA supported the objective of the proposed amendment to ensure qualified health care professionals, including trainees, employed by VA, provide veterans with the same high level of care and access to care no matter where a beneficiary or health care provider is located at the time health care is provided. AAPA also appreciated VA proposing to modify the telehealth regulation to add clarity so that, in situations where VA rules governing the practice of telehealth are in conflict with State laws or State license, registration, or certification requirements, the health care professional practicing telehealth at VA is required to adhere to VA policy or standards and is not at risk of losing their State license. AAPA stated that it supports the efforts VA is undertaking to improve the delivery of care for our nation's veterans and stands ready to assist VA in meeting its challenge to provide veterans with timely access to high quality medical care.

NABP supported expanding health care delivery by means of telehealth, specifically telepharmacy, and recognizes that telehealth can provide patients with quality health care that they may not otherwise receive or have difficulty accessing. The Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy (Model Act) provides model regulatory language for NABP's member boards. Pursuant to the recommendation of NABP's Task Force on the Regulation of Telepharmacy Practice, the Model Act was amended to include the practice of telepharmacy.

The State boards of pharmacy also recognize the important benefits of telehealth services to the public. According to information provided to NABP from the State boards of pharmacy, approximately 40 States allow the practice of telepharmacy in some manner. NABP stated that it would communicate VA's intention to expand health care to veterans through telemedicine, encourage the State boards of pharmacy to review existing pharmacy laws and rules for hinderances to implementation of telemedicine services to veterans, and encourage the boards to make amendments to State laws and rules to facilitate telehealth access to veterans.

NABP stated that the practice of telehealth, specifically telemedicine, between a health care provider and a veteran receiving care through the Veterans Health Administration is not typically subject to State regulatory oversight. One scenario that NABP wished to highlight is the legitimacy of controlled substance (CS) prescriptions that are issued by means of telecommunications that do not involve an initial face-to-face encounter for an exam/assessment, but are otherwise valid prescriptions under the Controlled Substances Act. If a CS prescription is issued via telemedicine without a face-to-face encounter and a veteran seeks the services of a community pharmacy to meet his or her immediate need, the community pharmacists may not be authorized to dispense the CS according to certain State pharmacy laws.

Therefore, NABP stated it would communicate to the State boards of pharmacy about VA's telehealth initiative to help bridge the gap between the need for health care and veterans' access to it. We received a comment from the Association of State and Provincial Psychology Boards (ASPPB). Based on a review of the information shared within the recent VA correspondences to ASPPB and ASPPB's knowledge of the strong training programs that occur throughout the nation under the authority of the VA, the ASPPB stated that they have no comments to refute the proposed upcoming changes to VA regulatory language on VA's proposed plans to amend its regulations to remove barriers and accelerate access to telehealth for veterans.

The other comments received were mostly in favor of the rule, however, the commenters expressed concern surrounding the addition of trainees as health care professionals who would be allowed to practice telehealth within the scope of their VA duties. The comments are as follows. The ASWB requested a clarification of the definition of trainee.

The ASWB asked if the term trainee included social work students in field placement only or if trainees included master of social work graduates under clinical supervision working towards licensure. The ASWB added that in both of these scenarios, the trainees would be bound to adhere to VA policies and procedures in addition to school policies as students and State policies while working towards their State licensure. The ASWB also stated that it requires a licensed social worker to obtain a State license in the State where the client is located as well as the State where the health care provider is located.

The ASWB understands that VA has secure, advanced, and supervised telehealth infrastructure in place that protects the health care professional and client and is able to provide support services while the health care professional is practicing in a VA medical facility. However, the ASWB believes that this may not be the case in circumstances where the health care professional is practicing telehealth outside a VA medical facility. Social work regulators believe that by requiring a social worker to obtain a license in each jurisdiction where practice occurs, the client is better protected.

The ASWB emphasized that jurisdictional boards have the power to investigate any complaints made against licensed social workers employed in VA and that VA's full cooperation with the investigation and enforcement related to licenses is needed for true protection of the public. In response to ASWB's concerns, we note that VA has the statutory authority under 38 U.S.C. 1730C(d)(1) to preempt any provisions of the law of any State to the extent that such provisions of State law are inconsistent with this section.

In addition, VA has already established in 38 CFR 17.417 that this section preempts conflicting State laws relating to the practice of health care providers when such health care providers are practicing telehealth within the scope of their VA employment. As such, VA has the authority to allow social workers to practice health care via telehealth. Also, the qualifications of a VA social worker are stated in 38 U.S.C.

7402(b)(9), which include that the social worker must hold a master's degree in social work from a college or university approved by the Start Printed Page 51629 Secretary and be licensed or certified to independently practice social work in a State. With regards to social worker trainees, VA never intended that these trainees work without the supervision of an otherwise licensed social worker. The trainees will be supervised while practicing health care via telehealth.

We appreciate the commenter's recognition of the quality of the VA telehealth program and that VA maintains a secure, advanced, and supervised telehealth infrastructure irrespective of the veterans or health care professional's location when delivering VA. The NCSBN expressed concern regarding the expansion of telehealth privileges to nurse assistants and other assistive personnel as outlined in 38 U.S.C. 7401.

Nurse assistants and other assistive personnel do not have a national governing body, leaving the regulation of these occupations to the individual States. The majority of States do not license the occupation and have widely inconsistent standards for certification. There is no national database for agencies to report disciplinary actions for many assistive personnel roles, creating a public protection issue for these for patients receiving care across State lines.

NCBSN provided the following example. If VA fired a nurse assistant following an interstate telehealth interaction, there is no infrastructure by which those States can communicate nationally to ensure that appropriate disciplinary action is taken against the provider's licensure/certification across the country. Therefore, it would be possible that the provider could continue to practice in a different system and State without suffering any consequences.

Additionally, NCSBN did not support allowing unlicensed or pre-licensure nurses to provide telehealth services as would be allowable for temporary full-time appointments under 38 U.S.C 7405. Boards of Nursing (BONs) do not have authority to discipline pre-licensure nurses, as they do not have an active license. Furthermore, BONs are unable to determine a nurse's competency without the completion and passage of the National Council Licensure Examination.

Without a license, a nurse cannot be held accountable for a mistake by a BON, because there is no means to report them to a BON if an adverse event takes place. This also means there is no recourse for the patient if they are harmed. By allowing pre-licensure nurses to deliver telehealth services, VA would be exposing patients and nurses in the process of seeking licensure to great risk.

Further, NCSBN stated that section 1730C(b)(1) defines a covered health professional as not only an employee of the Department appointed under the authority under section 7306, 7405, 7406, or 7408 of this title or title 5, but also a health care professional who has “an active, current, full and unrestricted license, registration and certification in a State to practice the health care profession of the health care professional.” NCSBN stated that while 38 U.S.C. 7405 includes unlicensed or pre-licensure individuals, it believed section 1730C explicitly states that in order to practice telemedicine, a provider must have an active license. NCSBN stated its firm belief that nurses should be fully licensed before practicing to ensure that they provide safe, competent care and retain the public protection mechanisms that allows VA to report disciplinary actions to the appropriate State licensing boards.

VA recognizes that 38 U.S.C. 1730C(b)(1)(D)(i) states that a covered health care professional must have an active, current, full, and unrestricted license, registration, or certification in a State to practice the health care profession of the health care professional. However, 38 U.S.C.

1730C was updated by the 2021 NDAA and section 1730C(b)(2) and (b)(3) now includes those individuals who are trainees and post graduate employees appointed under 38 U.S.C. 7405 and 7406. In addition, VA requires supervision of trainees pre-licensed nurses by a qualified health care professional who meet the requirement of stated in section 1730C(b)(1).

VA also continuously monitors all health care professionals, including trainees, and has procedures in place to report any adverse action to the appropriate State licensing board. VA received several comments regarding trainees. The commenters from the Virginia Board of Medicine, Federation of State Medical Boards, Kansas State Board of Healing Arts, and the Wisconsin Medical Examining Board stated that to ensure consistency in the quality of care between veterans and the general public, trainees should not be allowed to practice telehealth without supervision and that only such trainees that possessed full and unrestricted licenses should practice health care via telehealth.

The commenters added that the care that is provided by VA must be of the highest quality, meaning from physicians who have been trained to practice independently, have proven their knowledge, clinical acumen, and skills, or, if not, are under the supervision of another physician who has. A commenter added that the proposed rule to amend the definition of health care provider to include trainees and authorize trainees to provide health care or telemedicine would mean that a trainee could practice independently via telemedicine or independently provide other health care without supervision, in violation of their license and with the risks of providing less than optimal care and potentially putting patients' lives at risk. They further stated that the proposed rule fails to recognize not only that States differ in qualifications to get a training license but also that these trainees differ in their knowledge and capabilities.

In addition, a commenter argued that assigning a person with a trainee license to provide telemedicine or other health care is contrary to the VA mission and core value of excellence. Finally, they concluded that expanding the definition of health care provider to include trainees and asserting that where State law is inconsistent with VA practice the VA standards will prevail or supersede State law will promote lower standards of care for veterans. In response to the comments about trainees and postgraduate employees practicing independently through telehealth, this rulemaking would not allow these individuals to practice without clinical supervision.

In fact, this rulemaking explicitly requires that trainees and postgraduate employees only participate in telehealth under clinical supervision by an employee who is licensed, registered, or certified by a State, or under clinical supervision by an employee who otherwise meets qualifications as defined by the Secretary. To be covered by the authorization to practice telehealth in 38 U.S.C. 1730C(b), a VA health care professional must have an active, current, full, and unrestricted license, registration, or certification in a State to practice the health care profession of the health care professional or, with respect to a health care profession listed under section 7402(b) of Title 38, have qualifications for such profession as set forth by the secretary.

Trainees and postgraduate employees are expressly authorized to participate in telehealth in the 2021 NDAA updates to 38 U.S.C. 1730C, but only under the supervision of one of these health care professionals. Additionally, the VA Secretary has statutory authority independent of 38 U.S.C.

1730C to permit the authorization of health care practices by health care professionals at VA pursuant to 38 U.S.C. 303, 501, and 7403. Start Printed Page 51630 Thus the VA Secretary has the authority to authorize by regulation the practice of telehealth by the VA health care professionals listed in 38 U.S.C.

7401 and by VA health care professional trainees appointed under 38 U.S.C. 7405 or 7406. We also received a comment from the National Board for Certification in Occupational Therapy and another from the Federation of State Boards of Physical Therapy, however, these comments were received outside the 30-day comment period.

These commenters may submit a comment during the rulemaking's notice and comment period. We received a response from the National Association of State Directors of Veterans Affairs, however, we consider these comments outside the scope of this rulemaking and do not make any changes based on these comments. Paperwork Reduction Act This proposed rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C.

3501-3521). Regulatory Flexibility Act The Secretary hereby certifies that this proposed rule will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612.

The provisions associated with this rulemaking are not processed by any other entities outside of VA. Therefore, pursuant to 5 U.S.C. 605(b), the initial and final regulatory flexibility analysis requirements of 5 U.S.C.

603 and 604 do not apply. Executive Orders 12866, 13563 Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages. Distributive impacts.

And equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. The Office of Information and Regulatory Affairs has determined that this rule is not a significant regulatory action under Executive Order 12866.

The Regulatory Impact Analysis associated with this rulemaking can be found as a supporting document at www.regulations.gov. Unfunded Mandates The Unfunded Mandates Reform Act of 1995, 2 U.S.C. 1532, requires that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year.

This proposed rule will have no such effect on State, local, and tribal governments, or on the private sector. Assistance Listing The Assistance Listing numbers and titles for the programs affected by this document are. 64.007, Blind Rehabilitation Centers.

64.008, Veterans Domiciliary Care. 64.009, Veterans Medical Care Benefits. 64.010, Veterans Nursing Home Care.

64.011, Veterans Dental Care. 64.012, Veterans Prescription Service. 64.013, Veterans Prosthetic Appliances.

64.018, Sharing Specialized Medical Resources. 64.019, Veterans Rehabilitation Alcohol and Drug Dependence. 64.022, Veterans Home Based Primary Care.

64.039, CHAMPVA. 64.040, VHA Inpatient Medicine. 64.041, VHA Outpatient Specialty Care.

64.042, VHA Inpatient Surgery. 64.043, VHA Mental Health Residential. 64.044, VHA Home Care.

64.045, VHA Outpatient Ancillary Services. 64.046, VHA Inpatient Psychiatry. 64.047, VHA Primary Care.

64.048, VHA Mental Health Clinics. 64.049, VHA Community Living Center. And 64.050, VHA Diagnostic Care.

Start List of Subjects End List of Subjects Administrative practice and procedure, Alcohol abuse, Alcoholism, Claims, Day care, Dental health, Drug abuse, Foreign relations, Government contracts, Grant programs-health, Grant programs-veterans, Health care, Health facilities, Health professions, Health records, Homeless, Medical and dental schools, Medical devices, Medical research, Mental health programs, Nursing homes, Reporting and recordkeeping requirements, Scholarships and fellowships, Travel and transportation expenses, Veterans. Signing Authority Denis McDonough, Secretary of Veterans Affairs, approved this document on July 21, 2022, and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Start Signature Consuela Benjamin, Regulations Development Coordinator, Office of Regulation Policy &.

Management, Office of General Counsel, Department of Veterans Affairs. End Signature For the reasons set forth in the preamble, the Department of Veterans Affairs proposes to amend 38 CFR part 17 as set forth below. Start Part End Part Start Amendment Part1.

The authority citation for part 17 is amended by revising the authority for § 17.417 to read as follows. End Amendment Part Start Authority 38 U.S.C. 501, and as noted in specific sections.

End Authority * * * * * Section 17.417 also issued under 38 U.S.C. 1701 (note), 1709A, 1712A (note), 1722B, 1730C, 7301, 7306, 7330A, 7331, 7401-7403, 7405, 7406, 7408. * * * * * Start Amendment Part2.

Amend § 17.417 by. End Amendment Part Start Amendment Parta. Revising the section heading and paragraphs (a)(2) and (b).

And End Amendment Part Start Amendment Partb. In paragraph (c), removing the term “health care providers'” and adding in its place the term “health care professionals” wherever it appears. End Amendment Part The revisions read as follows.

Health care professionals practicing via telehealth. (a) * * * (2) Health care professional. The term health care professional is an individual who.

(i) Is appointed to an occupation in the Veterans Health Administration that is listed in or authorized under 38 U.S.C. 7306, 7401, 7405, 7406, or 7408, or title 5 of the U.S. Code.

(ii) Is required to adhere to all standards for quality relating to the provision of health care in accordance with applicable VA policies. (iii) Is not a VA-contracted health care professional. And (iv) Is qualified to provide health care as follows.

(A) Has an active, current, full, and unrestricted license, registration, certification, or satisfies another State requirement in a State to practice the health care profession of the health care professional. (B) Has other qualifications as prescribed by the Secretary for one of the health care professions listed under 38 U.S.C. 7402(b).

(C) Is an employee otherwise authorized by the Secretary to provide health care services. Or (D) Is under the clinical supervision of a health care professional that meets Start Printed Page 51631 the requirements of paragraph (a)(2)(iv)(A)-(C) of this section and is either. ( 1) A health professions trainee appointed under 38 U.S.C 7405 or 38 U.S.C 7406 participating in clinical or research training under supervision to satisfy program or degree requirements.

Or ( 2) A health care employee, appointed under title 5, 38 U.S.C. 7401(1),(3), or 38 U.S.C 7405 for any category of personnel described in 38 U.S.C. 7401(1),(3) who must obtain full and unrestricted licensure, registration, or certification or meet the qualification standards as defined by the Secretary within the specified time frame.

* * * * * (b) Health care professional's practice via telehealth. (1) When a State law, license, registration, certification, or other State requirement is inconsistent with this section, the health care professional is required to abide by their federal duties and requirements. No State shall deny or revoke the license, registration, or certification of a covered health care professional who otherwise meets the qualifications of the State for holding the license, registration, or certification on the basis that the covered health care professional has engaged or intends to engage in activity covered under this section.

(2) VA health care professionals may practice their health care profession within the scope of their federal duties in any State irrespective of the State or location within a State where the health care professional or the beneficiary is physically located, if the health care professional is using telehealth to provide health care to a beneficiary. (3) Health care professionals' practice is subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C. 801, et seq.

And implementing regulations at 21 CFR 1300 et seq., on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law, regulation, and policy. (4) Examples of where a health care professional's VA practice of telehealth may be inconsistent or conflict with a State law or State license, registration, or certification requirements related to telehealth include when. (i) The beneficiary and the health care professional are physically located in different States during the episode of care.

(ii) The beneficiary is receiving services in a State other than the health care professional's State of licensure, registration, or certification. (iii) The health care professional is delivering services while the professional is located in a State other than the health care professional's State of licensure, registration, or certification. (iv) The health care professional is delivering services while the professional is either on or outside VA property.

(v) The beneficiary is receiving services while the beneficiary is located either on or outside VA property. (vi) The beneficiary has not been previously assessed, in person, by the health care professional. Or (vii) The beneficiary has verbally agreed to participate in telehealth but has not provided VA with a signed written consent.

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Parents filled out the Child Behavioural Checklist. A combination of medical history and results of the assessment was used to rate hearing and vision status buy viagra online without a prescription. A composite outcome representing all these domains was classified as either moderate-to-severe impairment or mild or no impairment, based on the most severe individual component. 991 infants were live born buy viagra online without a prescription at 24–26 completed weeks’ GA, of whom 891 (90%) were admitted to a NICU.

Of these, 651 (73%) infants survived and 587 (90%) were seen for follow-up at 2 years. Mortality (not admitted to NICU or died after NICU admission) was 58%, 31% and 21% at 24, 25, and 26 weeks' respectively. Rates of moderate to severe NDI in any domain on follow-up were comparable (around 18% of survivors) between children born at 24 weeks’, 25 weeks’ and 26 buy viagra online without a prescription weeks’ gestation. Lowering the threshold for supporting active treatment from 25 completed weeks to 24 completed weeks was not associated with a large increase in the number of survivors with moderate-severe neurodevelopmental impairment.In a separate study from Canada, Magdalena Jaworski and colleagues asked parents of infants born <29 weeks’ gestational age presenting at a neonatal follow-up clinic to evaluate their children’s health and development.

248 parents of 213 children (mean gestational age 26.6±1.6 weeks, 20% with severe neurodevelopmental impairment) were buy viagra online without a prescription recruited. Parents evaluated their children’s health at a median of 9/10. See pages F467 and F495Tactile stimulation during initial stabilisationNewborn infants get tactile stimulation to encourage them to breathe at birth but this does not necessarily continue once positive pressure ventilation is commenced. Vincent Gaertner and colleagues analysed video and respiratory function monitor data buy viagra online without a prescription gathered during a study of different face masks to report observational data on the association between tactile stimulation and breathing patterns during positive pressure ventilation (PPV).

20 of 40 infants born >34 weeks' gestation received stimulation during PPV and this was associated with increased spontaneous breaths and increased exhaled tidal volume. Increased duration of stimulation and surface area of applied stimulus were buy viagra online without a prescription associated with a larger increase in spontaneous breaths. See page F508Associations of body composition with regional brain volumes in very preterm infantsKatherine Bell and colleagues performed MRI scans and air displacement plethysmography to determine body composition at term equivalent age in 85 preterm infants born <33 weeks gestation. Lean mass—but not fat—at term was associated with larger brain volume and white matter microstructure differences that suggest improved maturation.

Weight is a simplistic measure buy viagra online without a prescription of overall nutrition and studies like this, with later neurodevelopmental outcomes will help to refine our understanding of how to measure optimal nutrition for preterm infants. See page F533Effect of prophylactic dextrose gel on the neonatal gut microbiomeAs part of a placebo controlled randomised trial, Sophie St Claire and colleagues found no effect of orally administered glucose gel in the first hour after birth on the gut microbiome at 1,7, and 28 days. These data should reassure parents and clinicians that use buy viagra online without a prescription of dextrose gel in the newborn period will not have adverse consequences on the microbiome. See page F501Neonatal and fetal therapy of congenital diaphragmatic Hernia-related pulmonary hypertensionFelix De Bie and colleagues discuss clinically available neonatal and fetal therapies specifically targeting the pulmonary hypertension associated with congenital diaphragmatic hernia and review the most promising experimental treatments and future research avenues.

See page F458Ethics statementsPatient consent for publicationNot applicable.Ethics approvalNot applicable..

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NYC applicants should no longer use http://www.sunsoakedcreative.com/headtohead/ DOH-4220 what is viagra good for. See more information here about Jan. 2021 changes for NYC applicants regarding Supplement A. This supplement collects information about the applicant's current resources and what is viagra good for past resources (for nursing home coverage).

All local districts in New York State are required to accept the revised DOH-4220 for non-MAGI Medicaid applicants (Aged 65+, Blind, Disabled) (including for coverage of long-term care services), Medicare Savings Program, the Medicaid Buy-In Program fr Working People with Disabilities. Districts must also continue to accept the LDSS-2921, although it only makes sense to use this when someone is applying for both Medicaid and some other public benefit covered by the Common Application, such as the income benefits such as Safety Net Assistance. The DOH-4220 - Access NY Health Care application can be used for all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home.j (with the addition of the Supplement A form, described below) what is viagra good for. DO NOT USE THE DOH-4220 FOR.

WHAT IF THE APPLICANT CANNOT SIGN THE APPLICATION?. DOH APPLICATION - WHERE TO FIND ONLINE Check here for updates and changes English Spanish This article was authored by the Evelyn Frank what is viagra good for Legal Resources Program of New York Legal Assistance Group.March 2022 Alert -- Tell your State Senator and Assemblyperson and Gov. Hochul to expand income limits for MSPs - Support Senate Bill S8228/A9245 - see more here!. 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 what is viagra good for 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. Download the 2022 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y what is viagra good for.

Soc. Serv. L. § 367-a(3)(a), (b), and (d).

Note. Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP. See this article for more info. TOPICS COVERED IN THIS ARTICLE 1.

No Asset Limit 1A. Summary Chart of MSP Programs with current income limits 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 WHO IS AUTOMATICALLY ENROLLED IN AN MSP Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP Enrolling in an MSP if you have Medicaid and Just Became Eligible for Medicare MIPPA - SSA Notifies Social Security recipients that they may be eligible for MSP based on their income. 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 (2022) Single Couple Single Couple Single Couple $1,133 $1,526 $1,359 $1,831 $1,529 $2,060 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).

The figures in the chart are based on a document issued by HRA in March 2022 (Box 7) based on the 2022 FPL. See 2022 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).

In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021.)) 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 this hyperlink 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 OFFICE Client already has Medicaid with Local District/HRA but not MSP. They should NOT have to submit an MSP application because the local district is required to review all Medicaid recipients for MSP eligibility and enroll them. (NYS DOH 2000-ADM-7 and GIS 05 MA 033).

But if a Medicaid recipient does not have MSP, contact the Local Medicaid office and request that they be enrolled. In NYC - Use Form 751W and check the box on page 2 requesting evaluation for Medicare Savings Program. Fax it to the Undercare Division at 1-917-639-0837 or email it to undercareproviderrelations@hra.nyc.gov. Use by secure email.

If enrolling in the MSP will cause a Spenddown (because income will increase by the amount of the Part B premium, include a completed and signed "Choice Notice" (MAP-3054a)(3/19/2019)(You must adapt this notice - generally check box 3B on page 2 to select enrollment in MSP while keeping Medicaid.) If do not have Medicaid -- 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" 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. 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. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare - See article about the Medicare Insurance Payment Program (MIPP). IF CLIENT HAD MEDICAID THROUGH LOCAL DISTRICT - see here, same procedure for any Medicaid recipient who needs MSP.

MIPPA - 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?.

2021 the same Supplement A form is used buy viagra online without a prescription statewide - DOH-5178A (English). NYC applicants should no longer use DOH-4220. See more information here about Jan. 2021 changes buy viagra online without a prescription for NYC applicants regarding Supplement A. This supplement collects information about the applicant's current resources and past resources (for nursing home coverage).

All local districts in New York State are required to accept the revised DOH-4220 for non-MAGI Medicaid applicants (Aged 65+, Blind, Disabled) (including for coverage of long-term care services), Medicare Savings Program, the Medicaid Buy-In Program fr Working People with Disabilities. Districts must also continue to accept the LDSS-2921, although buy viagra online without a prescription it only makes sense to use this when someone is applying for both Medicaid and some other public benefit covered by the Common Application, such as the income benefits such as Safety Net Assistance. The DOH-4220 - Access NY Health Care application can be used for all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home.j (with the addition of the Supplement A form, described below). DO NOT USE THE DOH-4220 FOR. WHAT IF THE APPLICANT CANNOT SIGN THE APPLICATION? buy viagra online without a prescription.

DOH APPLICATION - WHERE TO FIND ONLINE Check here for updates and changes English Spanish This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.March 2022 Alert -- Tell your State Senator and Assemblyperson and Gov. Hochul to expand income limits for MSPs - Support Senate Bill S8228/A9245 - see more here!. Medicare Savings Programs (MSPs) buy viagra online without a prescription 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.

Download the 2022 Fact Sheet on MSP in NYS by Medicare Rights Center buy viagra online without a prescription ENGLISH SPANISH State law. N.Y. Soc. Serv. L.

§ 367-a(3)(a), (b), and (d). Note. Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP. See this article for more info. TOPICS COVERED IN THIS ARTICLE 1.

No Asset Limit 1A. Summary Chart of MSP Programs with current income limits 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 WHO IS AUTOMATICALLY ENROLLED IN AN MSP Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP Enrolling in an MSP if you have Medicaid and Just Became Eligible for Medicare MIPPA - SSA Notifies Social Security recipients that they may be eligible for MSP based on their income.

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 (2022) Single Couple Single Couple Single Couple $1,133 $1,526 $1,359 $1,831 $1,529 $2,060 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). The figures in the chart are based on a document issued by HRA in March 2022 (Box 7) based on the 2022 FPL. See 2022 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). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link.

(Updated 4/14/2021.)) 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 OFFICE Client already has Medicaid with Local District/HRA but not MSP. They should NOT have to submit an MSP application because the local district is required to review all Medicaid recipients for MSP eligibility and enroll them. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). But if a Medicaid recipient does not have MSP, contact the Local Medicaid office and request that they be enrolled. In NYC - Use Form 751W and check the box on page 2 requesting evaluation for Medicare Savings Program.

Fax it to the Undercare Division at 1-917-639-0837 or email it to undercareproviderrelations@hra.nyc.gov. Use by secure email. If enrolling in the MSP will cause a Spenddown (because income will increase by the amount of the Part B premium, include a completed and signed "Choice Notice" (MAP-3054a)(3/19/2019)(You must adapt this notice - generally check box 3B on page 2 to select enrollment in MSP while keeping Medicaid.) If do not have Medicaid -- 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" 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.

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. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare - See article about the Medicare Insurance Payment Program (MIPP).

IF CLIENT HAD MEDICAID THROUGH LOCAL DISTRICT - see here, same procedure for any Medicaid recipient who needs MSP. MIPPA - 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).

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A Computational whats viagra Cosmic Dawn Another way to gain insights on this bygone era is to simulate it on computers. The early stages of reionization are relatively simple to re-create because the universe was relatively dark and uniform then, explains Aaron Smith, an astrophysicist at the Massachusetts Institute of Technology, who helped develop THESAN. As primordial matter sorts itself into galaxies and stars, however, complex interactions between gravity, light, gas and dust become increasingly difficult to model. €œSince modeling light is quite complicated and computationally expensive, there are only a few cosmological simulations that focus on exploring this epoch,” says astrophysicist Rahul Kannan of the Harvard-Smithsonian Center for Astrophysics, who helped develop whats viagra THESAN. €œEach of these cosmological simulations have their own advantages and disadvantages.” THESAN is designed to simulate the early universe to an unprecedented extent.

Some cosmological simulations, such as the Cosmic Dawn (CoDa) simulations and the Cosmic Reionization on Computers (CROC) project, have modeled large volumes at relatively low resolutions, while others, such as the Renaissance and SPHINX simulations, are more whats viagra detailed but do not span great distances. In contrast, THESAN “combines high resolution with large simulated volumes,” Kannan says. €œUsually there’s a trade-off between studying in detail galaxy formation and cosmic reionization, but THESAN manages to do both,” says astrophysicist John Wise of the Georgia Institute of Technology, who did not work on THESAN. THESAN’s developers built it on the back of an older series of simulations called Illustris-TNG, which have been shown whats viagra to accurately model many of the properties and populations of evolving galaxies. They next developed a new algorithm to model how the light from stars and galaxies interacted with and reionized their surrounding gas over the first billion years of the universe—details that previous simulations have not successfully incorporated at large scales.

Finally, the THESAN team included whats viagra a model of how cosmic dust in the early universe may have influenced the formation of galaxies. €œThey’ve combined two state-of-the-art models and added a bit more—it looks really interesting,” says Risa Wechsler, a cosmologist at Stanford University and director of the Kavli Institute for Particle Astrophysics and Cosmology, who did not take part on THESAN. Scaling Up THESAN can track the birth and evolution of hundreds of thousands of galaxies within a cubic volume spanning more than 300 million light-years across. Starting from circa whats viagra 400,000 years after the big bang—before the first stars are thought to have emerged—the simulation extrapolates out through the first billion years of cosmic history. To do all that, THESAN runs on one of the largest supercomputers in the world, SuperMUC-NG, which has used nearly 60,000 computer processing cores to perform the simulation’s calculations over an equivalent of 30 million CPU hours.

(For perspective, that same computational feat would require 3,500 years of dedicated number crunching on a typical desktop computer.) A rendering of THESAN’s simulation, showing stars and galaxies in the early universe interacting with and reionizing surrounding clouds of gas to create the familiar cosmic structures we see today. €œOne of whats viagra the most exciting things about the THESAN simulations to me is the increased resolution,” says astrophysicist Brian Welch of Johns Hopkins University, who did not work on THESAN. €œThey seem to be able to connect the small-scale structures within galaxies that create ionizing photons to the larger-scale intergalactic medium where those photons are driving the epoch of reionization. The simulations can then help determine how ionizing photons are escaping from galaxies and thus how those galaxies are driving reionization.” Using the Hubble Space Telescope, Welch and his colleagues whats viagra recently discovered the most distant single star detected yet, dubbed Earendel, which dates back to when the universe was just 900 million years old. Although THESAN cannot simulate individual stars such as Earendel “since that would require an inordinate amount of computational power,” it can still shed light on the conditions in the galaxies in which Earendel and its compatriots were forming, he says.

The researchers say THESAN is already yielding predictions about the early universe. For example, it suggests the distance that light traveled increased near the end of reionization more dramatically than previously thought—by a factor of 10 whats viagra over a few hundred million years—likely because dense pockets of gas that took longer to ionize were missed by previous lower-resolution simulations. One drawback of THESAN, however, is that it uses a relatively simplistic model for the cold dense gas in galaxies, Kannan says. The THESAN team is currently working on a follow-on project dubbed THESAN-ZOOMS to replace this model “with a much more sophisticated one that takes into account many additional physical processes that whats viagra impact the properties of this dense gas,” he notes. Another shortcoming of THESAN is that the volume it simulates is arguably too small to properly pinpoint key details on how the early universe evolved, such as the size and number of pockets of ionized transparent gas, Kannan says.

The scientists are currently planning to scale up the simulation to a volume 64 times larger via a diverse set of optimization tweaks meant to improve its overall performance, he says. Expectations Versus Reality Whether any of these deficiencies actually make a meaningful difference for THESAN’s predictions could soon be revealed by fresh whats viagra observations from JWST, which is designed to see the first stars and galaxies. Will the stars and galaxies coalescing in THESAN’s virtual cosmos mirror the populations of ancient objects as seen by JWST’s optics?. Researchers are eager to find out. Models of the faint galaxies in the early universe are very sensitive to uncertainties in phenomena such as star formation, “which remain highly debated,” says Aaron Yung, a theoretical astrophysicist whats viagra at NASA’s Goddard Space Flight Center, who did not work on THESAN.

Simulations that may successfully model known galaxies “can deliver diverging predictions in the faint populations. [JWST] will detect these whats viagra galaxies for the first time and provide constraints on the physics that drives the formation of these galaxies.” By the end of this year, JWST will be able to collect enough data to test THESAN when it comes to many predictions of galaxy properties, Smith says. €œWe are already working with astronomers involved with JWST to interpret the data that will be available this year.” “My intuition tells me that JWST will match the statistics of the bright galaxies modeled in CoDa, CROC and THESAN,” says Wise, who helped develop the Renaissance simulations. €œHowever, they don’t have sufficient resolution to model low-mass and small galaxies, where Renaissance and SPHINX will match better.” Astrophysicists, he reasons, will most likely use a combination of both types of simulations to interpret JWST observations of ancient galaxies. No one expects THESAN or any other simulation of the epoch of whats viagra reionization to get everything completely right.

€œMost, if not all, simulations done in this epoch are missing some physics—even though THESAN is quite high-resolution, it’s still low-resolution, compared to the physical processes actually happening,” Wechsler says. €œProgress happens when data from observatories whats viagra and insights from simulations work in concert. That interplay is what is exciting.” Ultimately “we will need more than JWST to confirm the complete picture of cosmic evolution in the early universe,” Smith says. €œA variety of instruments covering a wide range of wavelengths are necessary to understand the various aspects of this epoch.” These include the Hydrogen Epoch of Reionization Array (HERA), the Square Kilometer Array (SKA), the Fred Young Submillimeter Telescope (FYST), the Spectro-Photometer for the History of the Universe, Epoch of Reionization and Ices Explorer (SPHEREx), and NASA’s next flagship astrophysical observatory, the Nancy Grace Roman Space Telescope. Ambitious computer models such as THESAN may ultimately help scientists whats viagra make sense of the flood of data these projects will bring.

€œTHESAN aims to make predictions for as many of these observations as possible,” Smith notes. €œDiscrepancies with the data are often just as exciting because that tells us our models are lacking, forcing us to reconsider the underlying physics of these complex processes.”.

Much remains a mystery about the first billion years of look here the universe’s history, the epoch in which the cosmos emerged from its dark ages with the dawning of the earliest stars and buy viagra online without a prescription galaxies. Now scientists have developed the largest, most detailed computer model of this period to date to help shed light on how the infant universe evolved. Named THESAN, after the Etruscan buy viagra online without a prescription goddess of the dawn, this new project’s predictions about the primordial past will soon be tested by data from NASA’s recently launched James Webb Space Telescope (JWST) and other next-generation observatories.

In the immediate aftermath of the big bang, about 13.8 billion years ago, the universe was filled with a cosmic fog. The heat of creation was so great that electrons could not combine with protons and neutrons to form atoms, and space was instead suffused with a dense soup of plasma—electrically charged (or ionized) particles that scattered rather than transmitted light. This cosmic fog briefly lifted some 380,000 years later, buy viagra online without a prescription during the so-called era of recombination, when the universe sufficiently cooled to allow atoms to freeze out from the plasma as clouds of optically transparent, electrically neutral hydrogen gas.

Suddenly freed, light from the big bang’s afterglow flashed throughout the universe, which then faded back to darkness because stars had yet to form. Darkness reigned buy viagra online without a prescription for the next few hundred million years until gravity began pulling matter together into stars and galaxies. Even then, the darkness only dissipated gradually, as intense uaviolet radiation from the universe’s first luminous objects reionized the surrounding neutral hydrogen, eventually burning away the gaseous gloom.

This “epoch of reionization” lasted more than a half-billion years, but scientists know precious little about its details. What they do know with certainty is that its end marked the cosmic moment when buy viagra online without a prescription light from across the electromagnetic spectrum—rather than the mere fraction that could pierce the veil of neutral hydrogen—started traveling freely through space. Simply put, this was when the universe at last became clear for study by curious astronomers seeking to learn how exactly the cosmic dawn occurred.

That is not to buy viagra online without a prescription say that such studies are easy. To see light from such ancient times, researchers must use the largest, most sensitive telescopes available to look for objects that are as far away as possible. This is because the greater an object’s distance, the more time its light took to reach Earth—and the more attenuated that light will be.

A Computational Cosmic buy viagra online without a prescription Dawn Another way to gain insights on this bygone era is to simulate it on computers. The early stages of reionization are relatively simple to re-create because the universe was relatively dark and uniform then, explains Aaron Smith, an astrophysicist at the Massachusetts Institute of Technology, who helped develop THESAN. As primordial matter sorts itself into galaxies and stars, however, complex interactions between gravity, light, gas and dust become increasingly difficult to model.

€œSince modeling light is quite complicated and computationally expensive, there are only a few cosmological simulations that focus on buy viagra online without a prescription exploring this epoch,” says astrophysicist Rahul Kannan of the Harvard-Smithsonian Center for Astrophysics, who helped develop THESAN. €œEach of these cosmological simulations have their own advantages and disadvantages.” THESAN is designed to simulate the early universe to an unprecedented extent. Some cosmological simulations, such as the Cosmic Dawn (CoDa) simulations and the Cosmic Reionization on Computers (CROC) project, buy viagra online without a prescription have modeled large volumes at relatively low resolutions, while others, such as the Renaissance and SPHINX simulations, are more detailed but do not span great distances.

In contrast, THESAN “combines high resolution with large simulated volumes,” Kannan says. €œUsually there’s a trade-off between studying in detail galaxy formation and cosmic reionization, but THESAN manages to do both,” says astrophysicist John Wise of the Georgia Institute of Technology, who did not work on THESAN. THESAN’s developers built it on the back of an older series of simulations called Illustris-TNG, which have buy viagra online without a prescription been shown to accurately model many of the properties and populations of evolving galaxies.

They next developed a new algorithm to model how the light from stars and galaxies interacted with and reionized their surrounding gas over the first billion years of the universe—details that previous simulations have not successfully incorporated at large scales. Finally, the THESAN team included a model of how cosmic dust in the early buy viagra online without a prescription universe may have influenced the formation of galaxies. €œThey’ve combined two state-of-the-art models and added a bit more—it looks really interesting,” says Risa Wechsler, a cosmologist at Stanford University and director of the Kavli Institute for Particle Astrophysics and Cosmology, who did not take part on THESAN.

Scaling Up THESAN can track the birth and evolution of hundreds of thousands of galaxies within a cubic volume spanning more than 300 million light-years across. Starting from circa 400,000 years after the big bang—before the first buy viagra online without a prescription stars are thought to have emerged—the simulation extrapolates out through the first billion years of cosmic history. To do all that, THESAN runs on one of the largest supercomputers in the world, SuperMUC-NG, which has used nearly 60,000 computer processing cores to perform the simulation’s calculations over an equivalent of 30 million CPU hours.

(For perspective, that same computational feat would require 3,500 years of dedicated number crunching on a typical desktop computer.) A rendering of THESAN’s simulation, showing stars and galaxies in the early universe interacting with and reionizing surrounding clouds of gas to create the familiar cosmic structures we see today. €œOne of the most exciting things about the THESAN simulations to me is the increased resolution,” says astrophysicist Brian Welch of Johns Hopkins University, who did buy viagra online without a prescription not work on THESAN. €œThey seem to be able to connect the small-scale structures within galaxies that create ionizing photons to the larger-scale intergalactic medium where those photons are driving the epoch of reionization.

The simulations can then help determine how ionizing photons are escaping from galaxies and thus how those galaxies are driving reionization.” Using the Hubble Space Telescope, Welch and his colleagues recently discovered the most distant single star detected yet, dubbed buy viagra online without a prescription Earendel, which dates back to when the universe was just 900 million years old. Although THESAN cannot simulate individual stars such as Earendel “since that would require an inordinate amount of computational power,” it can still shed light on the conditions in the galaxies in which Earendel and its compatriots were forming, he says. The researchers say THESAN is already yielding predictions about the early universe.

For example, it suggests the distance that light traveled increased near the buy viagra online without a prescription end of reionization more dramatically than previously thought—by a factor of 10 over a few hundred million years—likely because dense pockets of gas that took longer to ionize were missed by previous lower-resolution simulations. One drawback of THESAN, however, is that it uses a relatively simplistic model for the cold dense gas in galaxies, Kannan says. The THESAN team is currently working on a follow-on project dubbed THESAN-ZOOMS to replace this model “with a much more sophisticated one that takes into account many additional physical processes buy viagra online without a prescription that impact the properties of this dense gas,” he notes.

Another shortcoming of THESAN is that the volume it simulates is arguably too small to properly pinpoint key details on how the early universe evolved, such as the size and number of pockets of ionized transparent gas, Kannan says. The scientists are currently planning to scale up the simulation to a volume 64 times larger via a diverse set of optimization tweaks meant to improve its overall performance, he says. Expectations Versus Reality Whether any of these deficiencies actually make a meaningful difference for THESAN’s predictions could soon be revealed by fresh observations from JWST, which is buy viagra online without a prescription designed to see the first stars and galaxies.

Will the stars and galaxies coalescing in THESAN’s virtual cosmos mirror the populations of ancient objects as seen by JWST’s optics?. Researchers are eager to find out. Models of the faint galaxies in the early universe are very sensitive buy viagra online without a prescription to uncertainties in phenomena such as star formation, “which remain highly debated,” says Aaron Yung, a theoretical astrophysicist at NASA’s Goddard Space Flight Center, who did not work on THESAN.

Simulations that may successfully model known galaxies “can deliver diverging predictions in the faint populations. [JWST] will buy viagra online without a prescription detect these galaxies for the first time and provide constraints on the physics that drives the formation of these galaxies.” By the end of this year, JWST will be able to collect enough data to test THESAN when it comes to many predictions of galaxy properties, Smith says. €œWe are already working with astronomers involved with JWST to interpret the data that will be available this year.” “My intuition tells me that JWST will match the statistics of the bright galaxies modeled in CoDa, CROC and THESAN,” says Wise, who helped develop the Renaissance simulations.

€œHowever, they don’t have sufficient resolution to model low-mass and small galaxies, where Renaissance and SPHINX will match better.” Astrophysicists, he reasons, will most likely use a combination of both types of simulations to interpret JWST observations of ancient galaxies. No one expects THESAN or any other simulation of the epoch of reionization buy viagra online without a prescription to get everything completely right. €œMost, if not all, simulations done in this epoch are missing some physics—even though THESAN is quite high-resolution, it’s still low-resolution, compared to the physical processes actually happening,” Wechsler says.

€œProgress happens when data from observatories and insights buy viagra online without a prescription from simulations work in concert. That interplay is what is exciting.” Ultimately “we will need more than JWST to confirm the complete picture of cosmic evolution in the early universe,” Smith says. €œA variety of instruments covering a wide range of wavelengths are necessary to understand the various aspects of this epoch.” These include the Hydrogen Epoch of Reionization Array (HERA), the Square Kilometer Array (SKA), the Fred Young Submillimeter Telescope (FYST), the Spectro-Photometer for the History of the Universe, Epoch of Reionization and Ices Explorer (SPHEREx), and NASA’s next flagship astrophysical observatory, the Nancy Grace Roman Space Telescope.

Ambitious computer models such as THESAN buy viagra online without a prescription may ultimately help scientists make sense of the flood of data these projects will bring. €œTHESAN aims to make predictions for as many of these observations as possible,” Smith notes. €œDiscrepancies with the data are often just as exciting because that tells us our models are lacking, forcing us to reconsider the underlying physics of these complex processes.”.

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How viagra works

Why do you often refer how viagra works to people with disabilities as oracles?. Disabled people have always lived on the margins. And people on the margins really notice what’s going on, having to navigate through systems and institutions, not being understood.

When the viagra first hit, the public was up in arms about adjusting to life at home — the isolation, the lack how viagra works of access. These are things that many disabled and chronically ill people had experienced. Disabled people had been trying forever to advocate for online learning, for accommodations in the workplace.

The response how viagra works was. €œOh, we don’t have the resources,” “It’s just not possible.” But with the majority inconvenienced, it happened. Suddenly people actually had to think about access, flexibility.

That is ableism, where you don’t think disabled people how viagra works exist, you don’t think sick people exist. Q. Have you noticed that kind of thinking more since the viagra began?.

Well, yes, in the way our leaders talk about the risks, the how viagra works mortality, about people with severe illnesses, as if they’re a write-off. I am so tired of having to assert myself. What kind of world is this where we have to defend our humanity?.

What is how viagra works valued in our society?. Clearly, someone who can walk and talk and has zero comorbidities. It is an ideology, just like white supremacy.

All our systems how viagra works are centered around it. And so many people are discovering that they’re not believed by their doctors, and this is something that a lot of disabled and sick people have long experienced. We want to believe in this mythology that everybody’s equal.

My critique is not a personal attack against Dr how viagra works. Walensky. It’s about these institutions that historically devalued and excluded people.

We’re just how viagra works trying to say, “Your messaging is incredibly harmful. Your decisions are incredibly harmful.” Q. Which decisions?.

The overemphasis on vaccinations versus how viagra works other mitigation methods. That is very harmful because people still don’t realize, yeah, there are people with chronic illnesses who are immunocompromised and have other chronic conditions who cannot get vaccinated. And this back and forth, it’s not strong or consistent about mask mandates.

With omicron, there is this huge pressure to how viagra works reopen schools, to reopen businesses. Why don’t we have free tests and free masks?. You’re not reaching the poorest and the most vulnerable who need these things and can’t afford them.

Q. How has your life changed during the viagra?. For the last two years, I have not been outside except to get my vaccinations.

I have delayed so many things for my own health. For example, physiotherapy. I don’t get lab tests.

I’ve not been weighed in over two years, which is a big deal for me because I should be monitoring my weight. These are things I’ve put on hold. I don’t see myself going in to see my doctor any time this year.

Everything’s been online — it’s in a holding pattern. How long can I take this?. I really don’t know.

Things might get better, or they might get worse. So many things disabled people have been saying have been dismissed, and that’s been very disheartening. Q.

What kinds of things?. For example, in California, it was almost this time last year when they removed the third tier for erectile dysfunction treatment priority. I was really looking forward to getting vaccinated.

I was thinking for sure that I was part of a high-risk group, that I’d be prioritized. And then the governor announced that he was eliminating the third tier that I was a part of in favor of an age-based system. For young people who are high-risk, they’re screwed.

It just made me so angry. These kinds of decisions and values and messages are saying that certain people are disposable. They’re saying I’m disposable.

No matter what I produce, what value I bring, it doesn’t matter, because on paper I have all these comorbidities and I take up resources. This is wrong, it’s not equity, and it’s not justice. It took a huge community-based effort last year to get the state to backtrack.

We’re saying, “Hey we’re here, we exist, we matter just as much as anyone else.” Q. Do you think there’s any way this viagra has been positive for disabled people?. I hope so.

There’s been a lot of mutual aid efforts, you know, people helping each other. People sharing information. People organizing online.

Because we can’t wait for the state. These are our lives on the line. Things were a little more accessible in the last two years, and I say a little because a lot of universities and workplaces are going backward now.

They’re doing away with a lot of the hybrid methods that really gave disabled people a chance to flourish. Q. You mean they’re undoing things that helped level the playing field?.

Exactly. People who are high-risk have to make very difficult choices now. That’s really unfortunate.

I mean, what is the point of this if not to learn, to evolve?. To create a new normal. I can’t really see that yet.

But I still have some hope. This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Rachel Scheier.

@rachelscheier Related Topics Contact Us Submit a Story Tip[Editor’s note. KHN is not affiliated with Kaiser Permanente.] SACRAMENTO, Calif. €” Gov.

Gavin Newsom’s administration has negotiated a secret deal to give Kaiser Permanente a special Medicaid contract that would allow the health care behemoth to expand its reach in California and largely continue selecting the enrollees it wants, which other health plans say leaves them with a disproportionate share of the program’s sickest and costliest patients. The deal, hammered out behind closed doors between Kaiser Permanente and senior officials in Newsom’s office, could complicate a long-planned and expensive transformation of Medi-Cal, the state’s Medicaid program, which covers roughly 14 million low-income Californians. It has infuriated executives of other managed-care insurance plans in Medi-Cal, who say they stand to lose hundreds of thousands of patients and millions of dollars a year.

The deal allows KP to limit enrollment primarily to its previous enrollees, except in the case of foster kids and people who are eligible for both Medicare and Medi-Cal. “It has caused a massive amount of frenzy,” said Jarrod McNaughton, CEO of the Inland Empire Health Plan, which covers about 1.5 million Medi-Cal enrollees in Riverside and San Bernardino counties. €œAll of us are doing our best to implement the most transformational Medi-Cal initiative in state history, and to put all this together without a public process is very disconcerting.” Linnea Koopmans, CEO of the Local Health Plans of California, echoed McNaughton’s concerns.

Insurance plans got wind of the backroom talks when broad outlines of the deal were leaked days before the state briefed their executives Thursday. Dr. Bechara Choucair, Kaiser Permanente’s chief health officer, argued in a prepared written response on behalf of KP that because it operates both as a health insurer and a health care provider, KP should be treated differently than other commercial health plans that participate in Medi-Cal.

Doing business directly with the state will eliminate complexity and improve the quality of care for the Medi-Cal patients it serves, he said. “We are not seeking to turn a profit off Medi-Cal enrollment,” Choucair said. €œKaiser Permanente participates in Medi-Cal because it is part of our mission to improve the health of the communities we serve.

We participate in Medi-Cal despite incurring losses every year.” His statement cited nearly $1.8 billion in losses in the program in 2020 and said KP had donated $402 million to help care for uninsured people that year. Kaiser Permanente, the state’s largest managed-care organization, is one of Newsom’s most generous supporters and close political allies. The new, five-year contract, confirmed to KHN by administration officials and expected to be announced publicly Friday, will take effect in 2024 pending approval from the legislature — and will make KP the only insurer with a statewide Medi-Cal contract.

It allows KP to solidify its position before California’s other commercial Medi-Cal plans participate in a statewide bidding process — and after those plans have spent many months and considerable resources developing their bidding strategies. Other health plans fear the contract could also muddle a massive and expensive initiative called CalAIM that aims to provide social services to the state’s most vulnerable patients, including home-delivered meals, housing aid for homeless people, and mold removal from homes. Under its new contract, KP must provide some of those services.

But some executives at other health plans say KP will not have to enroll a large number of sick patients who need such services because of how it limits enrollment. Critics of the deal noted Newsom’s close relationship with KP, which has given nearly $100 million in charitable funding and grant money to boost Newsom’s efforts against homelessness, erectile dysfunction treatment response, and wildfire relief since 2019, according to state records and KP news releases. The health care giant was also one of two hospital systems awarded a no-bid contract from the state to run a field hospital in Los Angeles during the early days of the erectile dysfunction treatment viagra, and it got a special agreement from the Newsom administration to help vaccinate Californians last year.

Jim DeBoo, Newsom’s executive secretary, used to lobby for KP before joining the administration. Toby Douglas, a former director of the state Department of Health Care Services, which runs Medi-Cal, is now Kaiser Permanente’s vice president for national Medicaid. Still, many critics agree that Kaiser Permanente is a linchpin of the state’s health care system, with its strong focus on preventive care and high marks for quality of care.

Many of the public insurance plans upset by the deal subcontract with KP for patient care and acknowledge that their overall quality scores will likely decline when KP goes its own way. Michelle Baass, director of the state Department of Health Care Services, said Medi-Cal had risked losing KP’s “high quality” and “clinical expertise” altogether had it been required to accept all enrollees, as the other health plans must. But she said KP will have to comply with all other conditions that other plans must meet, including tightened requirements on access, quality, consumer satisfaction, and health equity.

The state will also have greater oversight over patient care, she said. “This proposal is a way to help ensure Kaiser treats more low-income patients, and that more low-income patients have access to Kaiser’s high-quality services,” Baass said. Though Kaiser Permanente has 9 million enrollees, close to a quarter of all Californians, only about 900,000 of them are Medi-Cal members.

Under the current system, 12 of the 24 other managed care insurance plans that participate in Medi-Cal subcontract with KP to care for a subset of their patients, keeping a small slice of the Medi-Cal dollars earmarked for those patients. Under the new contract, KP can take those patients away and keep all of the money. In its subcontracts, and in counties where it enrolls patients directly, KP accepts only people who are recent Kaiser Permanente members and, in some cases, their family members.

It is the only health plan that can limit its Medi-Cal enrollment in this way. The new contract allows KP to continue this practice, but it also requires Kaiser Permanente to take on more foster children and complex, expensive patients who are eligible for both Medi-Cal and Medicare. It allows KP to expand its geographic reach in Medi-Cal to do so.

Baass said the state expects KP’s Medi-Cal enrollment to increase 25% over the life of the contract. KP defended the practice of limiting enrollment primarily to its previous members, arguing that it provides “continuity of care when members transition into and out of Medi-Cal.” The state has long pushed for a larger KP footprint in Medi-Cal, citing its high quality ratings, its strong integrated network, and its huge role on the broader health care landscape. €œKaiser Permanente historically has not played a very big role in Medi-Cal, and the state has long recognized that we would benefit from having them more engaged because they get better health outcomes and focus on prevention,” said Daniel Zingale, a former Newsom administration official and health insurance regulator who now advises a lobbying firm that has Kaiser Permanente as a client.

But by accepting primarily people who have been KP members in the recent past, the health system has been able to limit its share of high-need, expensive patients, say rival health plan executives and former state health officials. The executives fear the deal could saddle them with even more of these patients in the future, including homeless people and those with mental illnesses — and make it harder to provide adequate care for them. Many of those patients will join Medi-Cal for the first time under the CalAIM initiative, and KP will not be required to accept many of them.

€œAwarding a no-bid Medi-Cal contract to a statewide commercial plan with a track record of ‘cherry picking’ members and offering only limited behavioral health and community support benefits not only conflicts with the intent and goals of CalAIM but undermines publicly organized health care,” according to an internal document prepared by the Inland Empire Health Plan. The plan said it stands to lose the roughly 144,000 Medi-Cal members it delegates to KP and about $10 million in annual revenue. L.A.

Care, the nation’s largest Medicaid health plan, with 2.4 million enrollees in Los Angeles County, will lose its 244,000 KP members, based on data shared by the plan. The state had been scheduled on Wednesday to release final details and instructions for the commercial plans that are submitting bids for new contracts starting in 2024. But it delayed the release a week to make the KP deal public beforehand.

Baass said the state agreed to exempt KP from the bidding process because the standardized contract expected to result from it would have required the insurer to accept all enrollees, which Kaiser Permanente does not have the capacity to do. “It’s not surprising to me that the state will go to extraordinary means to make sure that Kaiser is in the mix, given it has been in the vanguard of our health care delivery system,” Zingale said. Having a direct statewide Medi-Cal contract will greatly reduce the administrative workload for KP, which will now deal with only one agency on reporting and oversight, rather than the 12 public plans it currently subcontracts with.

And the new contract will give it an even closer relationship with Newsom and state health officials. In 2020, KP gave $25 million to one of Newsom’s key initiatives, a state homelessness fund to move people off the streets and into hotel rooms, according to a KHN analysis of charitable payments filed with the California Fair Political Practices Commission. The same year, it donated $9.75 million to a state erectile dysfunction treatment relief fund.

In summer 2020, when local and state public health departments struggled to contain erectile dysfunction treatment spread, the health care giant pledged $63 million in grant funding to help contract-tracing efforts. KP’s influence extends beyond its massive charitable giving. Its CEO, Greg Adams, landed an appointment on the governor’s economic recovery task force early in the viagra, and Newsom has showcased KP hospitals at treatment media events throughout the state.

“In California and across the U.S., the campaign contributions and the organizing, the lobbying, all of that stuff is important,” said Andrew Kelly, an assistant professor of health policy at California State University-East Bay. €œBut there’s a different type of power that comes from your ability to have this privileged position within public programs.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Bernard J.

Wolfson. bwolfson@kff.org, @bjwolfson Angela Hart. ahart@kff.org, @ahartreports Samantha Young.

syoung@kff.org, @youngsamantha Related Topics Contact Us Submit a Story TipCan’t see the audio player?. Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Click here for a transcript of the episode. Health and Human Services Secretary Xavier Becerra is becoming a target for both Democrats and Republicans over what they call a lack of coordination of erectile dysfunction treatment efforts within his department. But at the same time, officials from the Biden administration have made it clear from the start that the erectile dysfunction treatment campaign would be orchestrated by the White House, so it’s not clear whether the secretary was supposed to play a major role.

Meanwhile, as erectile dysfunction treatment cases decline, erectile dysfunction treatment-weary politicians and the public are pushing to ease the latest round of restrictions. But those with compromised immune systems and other disabilities fear they could pay the price. This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico, and Rachel Cohrs of Stat.

Among the takeaways from this week’s episode. The criticism seeping out about Becerra could signal frustration in the administration and on Capitol Hill that the country is still subject to so many viagra-driven restraints and the public is looking for solutions.Nonetheless, it appears that congressional Republicans — if they win a majority later this year in the midterm elections — could use this issue to press their contention that the administration has not been effective enough in the battle against erectile dysfunction treatment.The nomination of Dr. Robert Califf to head the FDA appears to be languishing in the Senate.

Some Democrats are concerned that when he worked there before he wasn’t attuned to the growing dangers of the opioid epidemic, while others object to his ties to industry. Republicans, whom the administration was counting on to help push the nomination through, are under pressure to resist from their allies in the anti-abortion movement who charge that Califf will allow more flexibility for women seeking medication abortions.The Department of Labor, armed with new enforcement authority, is investigating 30 health insurance plans for failing to abide by the requirements for insurance coverage parity for mental health. Congress has been trying to require equal treatment for mental and physical health since the mid-1990s, but so far it remains more of an aspiration.A federal appeals court has allowed to stand, at least for now, a Tennessee law that bans abortions based on sex, race, or a Down syndrome diagnosis.

An appeals court panel had temporarily halted the law, but the full appeals court overturned that decision and said it would wait to see what the Supreme Court decides this year in a Mississippi case that could change the landmark Roe v. Wade decision making abortion legal throughout the country.Some experts have suggested that the decision years ago by doctors to move most abortions out of their offices and into specialized clinics has made the clinics an easy target and given groups opposed to the procedure an advantage in their fight. That might be countered by the increasing use of abortion pills that doctors can prescribe for women.California lawmakers seeking to set up a state-funded health system, often called a single-payer system, this week conceded they didn’t have the votes to move forward.

The proposal was hugely expensive and it would have had two major exemptions. People on Medicare and those covered by large companies that have plans regulated by the federal government. Also this week, Rovner interviews KHN’s Noam N.

Levey, who reported and wrote the latest KHN-NPR “Bill of the Month” episode about a very large bill for a very small amount of medical care. If you have an outrageous medical bill you’d like to share with us, you can do that here. Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too.

Julie Rovner. The Washington Post’s “Researchers Are Asking Why Some Countries Were Better Prepared for erectile dysfunction treatment. One Surprising Answer.

Trust,” by Adam Taylor Alice Miranda Ollstein. Politico’s “Next Big Health Crisis. 15M People Could Lose Medicaid When viagra Ends,” by Megan Messerly Margot Sanger-Katz.

KHN’s “Faxes and Snail Mail. Will viagra-Era Flaws Unleash Improved Health Technology?. € by Bram Sable-Smith Rachel Cohrs.

Stat’s “How a Decades-Old Database Became a Hugely Profitable Dossier on the Health of 270 Million Americans,” by Casey Ross Also discussed on this week’s podcast. The New York Times’ “In Medicine, a Lack of Courage Has Helped Put Roe in Jeopardy,” by Eyal Press The New York Times’ “On Abortion Law, the U.S. Is Unusual.

Without Roe, It Would Be, Too,” by Claire Cain Miller and Margot Sanger-Katz The New York Times Magazine’s “The New Abortion Providers,” by Emily Bazelon Mother Jones’ “Desperate Patients Are Shelling Out Thousands for a Long erectile dysfunction treatment Cure. Is It for Real?. € by Kiera Butler To hear all our podcasts, click here.

And subscribe to KHN’s What the Health?. on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts. Related Topics Contact Us Submit a Story Tip.

She has since advocated for better public health buy viagra online without a prescription you could try these out benefits for people who are poor, sick, or older or have disabilities. The founder of the Disability Visibility Project, which collects oral histories of Americans with disabilities in conjunction with StoryCorps, Wong has spoken and written about how erectile dysfunction treatment and its unparalleled disruption of lives and institutions have underscored challenges that disabled people have always had to live with. She has exhorted others with disabilities to dive into the political fray, rallying them through her podcast, Twitter accounts with tens of thousands of followers, and a nonpartisan online movement called #CriptheVote. Wong is nocturnal — she typically buy viagra online without a prescription starts working at her computer around 9 p.m.

On a recent evening, she spoke with KHN via Zoom from her condo in the city’s Mission District, where she lives with her parents, immigrants from Hong Kong, and her pet snail, Augustus. The interview has been edited for length and clarity. Q. Why do you often refer to people with disabilities as oracles?.

Disabled people have always lived on the margins. And people on the margins really notice what’s going on, having to navigate through systems and institutions, not being understood. When the viagra first hit, the public was up in arms about adjusting to life at home — the isolation, the lack of access. These are things that many disabled and chronically ill people had experienced.

Disabled people had been trying forever to advocate for online learning, for accommodations in the workplace. The response was. €œOh, we don’t have the resources,” “It’s just not possible.” But with the majority inconvenienced, it happened. Suddenly people actually had to think about access, flexibility.

That is ableism, where you don’t think disabled people exist, you don’t think sick people exist. Q. Have you noticed that kind of thinking more since the viagra began?. Well, yes, in the way our leaders talk about the risks, the mortality, about people with severe illnesses, as if they’re a write-off.

I am so tired of having to assert myself. What kind of world is this where we have to defend our humanity?. What is valued in our society?. Clearly, someone who can walk and talk and has zero comorbidities.

It is an ideology, just like white supremacy. All our systems are centered around it. And so many people are discovering that they’re not believed by their doctors, and this is something that a lot of disabled and sick people have long experienced. We want to believe in this mythology that everybody’s equal.

My critique is not a personal attack against Dr. Walensky. It’s about these institutions that historically devalued and excluded people. We’re just trying to say, “Your messaging is incredibly harmful.

Your decisions are incredibly harmful.” Q. Which decisions?. The overemphasis on vaccinations versus other mitigation methods. That is very harmful because people still don’t realize, yeah, there are people with chronic illnesses who are immunocompromised and have other chronic conditions who cannot get vaccinated.

And this back and forth, it’s not strong or consistent about mask mandates. With omicron, there is this huge pressure to reopen schools, to reopen businesses. Why don’t we have free tests and free masks?. You’re not reaching the poorest and the most vulnerable who need these things and can’t afford them.

Q. How has your life changed during the viagra?. For the last two years, I have not been outside except to get my vaccinations. Q.

Because you’re so high-risk?. Yeah. I have delayed so many things for my own health. For example, physiotherapy.

I don’t get lab tests. I’ve not been weighed in over two years, which is a big deal for me because I should be monitoring my weight. These are things I’ve put on hold. I don’t see myself going in to see my doctor any time this year.

Everything’s been online — it’s in a holding pattern. How long can I take this?. I really don’t know. Things might get better, or they might get worse.

So many things disabled people have been saying have been dismissed, and that’s been very disheartening. Q. What kinds of things?. For example, in California, it was almost this time last year when they removed the third tier for erectile dysfunction treatment priority.

I was really looking forward to getting vaccinated. I was thinking for sure that I was part of a high-risk group, that I’d be prioritized. And then the governor announced that he was eliminating the third tier that I was a part of in favor of an age-based system. For young people who are high-risk, they’re screwed.

It just made me so angry. These kinds of decisions and values and messages are saying that certain people are disposable. They’re saying I’m disposable. No matter what I produce, what value I bring, it doesn’t matter, because on paper I have all these comorbidities and I take up resources.

This is wrong, it’s not equity, and it’s not justice. It took a huge community-based effort last year to get the state to backtrack. We’re saying, “Hey we’re here, we exist, we matter just as much as anyone else.” Q. Do you think there’s any way this viagra has been positive for disabled people?.

I hope so. There’s been a lot of mutual aid efforts, you know, people helping each other. People sharing information. People organizing online.

Because we can’t wait for the state. These are our lives on the line. Things were a little more accessible in the last two years, and I say a little because a lot of universities and workplaces are going backward now. They’re doing away with a lot of the hybrid methods that really gave disabled people a chance to flourish.

Q. You mean they’re undoing things that helped level the playing field?. Exactly. People who are high-risk have to make very difficult choices now.

That’s really unfortunate. I mean, what is the point of this if not to learn, to evolve?. To create a new normal. I can’t really see that yet.

But I still have some hope. This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Rachel Scheier. @rachelscheier Related Topics Contact Us Submit a Story Tip[Editor’s note.

KHN is not affiliated with Kaiser Permanente.] SACRAMENTO, Calif. €” Gov. Gavin Newsom’s administration has negotiated a secret deal to give Kaiser Permanente a special Medicaid contract that would allow the health care behemoth to expand its reach in California and largely continue selecting the enrollees it wants, which other health plans say leaves them with a disproportionate share of the program’s sickest and costliest patients. The deal, hammered out behind closed doors between Kaiser Permanente and senior officials in Newsom’s office, could complicate a long-planned and expensive transformation of Medi-Cal, the state’s Medicaid program, which covers roughly 14 million low-income Californians.

It has infuriated executives of other managed-care insurance plans in Medi-Cal, who say they stand to lose hundreds of http://maxatp.com/ thousands of patients and millions of dollars a year. The deal allows KP to limit enrollment primarily to its previous enrollees, except in the case of foster kids and people who are eligible for both Medicare and Medi-Cal. “It has caused a massive amount of frenzy,” said Jarrod McNaughton, CEO of the Inland Empire Health Plan, which covers about 1.5 million Medi-Cal enrollees in Riverside and San Bernardino counties. €œAll of us are doing our best to implement the most transformational Medi-Cal initiative in state history, and to put all this together without a public process is very disconcerting.” Linnea Koopmans, CEO of the Local Health Plans of California, echoed McNaughton’s concerns.

Insurance plans got wind of the backroom talks when broad outlines of the deal were leaked days before the state briefed their executives Thursday. Dr. Bechara Choucair, Kaiser Permanente’s chief health officer, argued in a prepared written response on behalf of KP that because it operates both as a health insurer and a health care provider, KP should be treated differently than other commercial health plans that participate in Medi-Cal. Doing business directly with the state will eliminate complexity and improve the quality of care for the Medi-Cal patients it serves, he said.

“We are not seeking to turn a profit off Medi-Cal enrollment,” Choucair said. €œKaiser Permanente participates in Medi-Cal because it is part of our mission to improve the health of the communities we serve. We participate in Medi-Cal despite incurring losses every year.” His statement cited nearly $1.8 billion in losses in the program in 2020 and said KP had donated $402 million to help care for uninsured people that year. Kaiser Permanente, the state’s largest managed-care organization, is one of Newsom’s most generous supporters and close political allies.

The new, five-year contract, confirmed to KHN by administration officials and expected to be announced publicly Friday, will take effect in 2024 pending approval from the legislature — and will make KP the only insurer with a statewide Medi-Cal contract. It allows KP to solidify its position before California’s other commercial Medi-Cal plans participate in a statewide bidding process — and after those plans have spent many months and considerable resources developing their bidding strategies. Other health plans fear the contract could also muddle a massive and expensive initiative called CalAIM that aims to provide social services to the state’s most vulnerable patients, including home-delivered meals, housing aid for homeless people, and mold removal from homes. Under its new contract, KP must provide some of those services.

But some executives at other health plans say KP will not have to enroll a large number of sick patients who need such services because of how it limits enrollment. Critics of the deal noted Newsom’s close relationship with KP, which has given nearly $100 million in charitable funding and grant money to boost Newsom’s efforts against homelessness, erectile dysfunction treatment response, and wildfire relief since 2019, according to state records and KP news releases. The health care giant was also one of two hospital systems awarded a no-bid contract from the state to run a field hospital in Los Angeles during the early days of the erectile dysfunction treatment viagra, and it got a special agreement from the Newsom administration to help vaccinate Californians last year. Jim DeBoo, Newsom’s executive secretary, used to lobby for KP before joining the administration.

Toby Douglas, a former director of the state Department of Health Care Services, which runs Medi-Cal, is now Kaiser Permanente’s vice president for national Medicaid. Still, many critics agree that Kaiser Permanente is a linchpin of the state’s health care system, with its strong focus on preventive care and high marks for quality of care. Many of the public insurance plans upset by the deal subcontract with KP for patient care and acknowledge that their overall quality scores will likely decline when KP goes its own way. Michelle Baass, director of the state Department of Health Care Services, said Medi-Cal had risked losing KP’s “high quality” and “clinical expertise” altogether had it been required to accept all enrollees, as the other health plans must.

But she said KP will have to comply with all other conditions that other plans must meet, including tightened requirements on access, quality, consumer satisfaction, and health equity. The state will also have greater oversight over patient care, she said. “This proposal is a way to help ensure Kaiser treats more low-income patients, and that more low-income patients have access to Kaiser’s high-quality services,” Baass said. Though Kaiser Permanente has 9 million enrollees, close to a quarter of all Californians, only about 900,000 of them are Medi-Cal members.

Under the current system, 12 of the 24 other managed care insurance plans that participate in Medi-Cal subcontract with KP to care for a subset of their patients, keeping a small slice of the Medi-Cal dollars earmarked for those patients. Under the new contract, KP can take those patients away and keep all of the money. In its subcontracts, and in counties where it enrolls patients directly, KP accepts only people who are recent Kaiser Permanente members and, in some cases, their family members. It is the only health plan that can limit its Medi-Cal enrollment in this way.

The new contract allows KP to continue this practice, but it also requires Kaiser Permanente to take on more foster children and complex, expensive patients who are eligible for both Medi-Cal and Medicare. It allows KP to expand its geographic reach in Medi-Cal to do so. Baass said the state expects KP’s Medi-Cal enrollment to increase 25% over the life of the contract. KP defended the practice of limiting enrollment primarily to its previous members, arguing that it provides “continuity of care when members transition into and out of Medi-Cal.” The state has long pushed for a larger KP footprint in Medi-Cal, citing its high quality ratings, its strong integrated network, and its huge role on the broader health care landscape.

€œKaiser Permanente historically has not played a very big role in Medi-Cal, and the state has long recognized that we would benefit from having them more engaged because they get better health outcomes and focus on prevention,” said Daniel Zingale, a former Newsom administration official and health insurance regulator who now advises a lobbying firm that has Kaiser Permanente as a client. But by accepting primarily people who have been KP members in the recent past, the health system has been able to limit its share of high-need, expensive patients, say rival health plan executives and former state health officials. The executives fear the deal could saddle them with even more of these patients in the future, including homeless people and those with mental illnesses — and make it harder to provide adequate care for them. Many of those patients will join Medi-Cal for the first time under the CalAIM initiative, and KP will not be required to accept many of them.

€œAwarding a no-bid Medi-Cal contract to a statewide commercial plan with a track record of ‘cherry picking’ members and offering only limited behavioral health and community support benefits not only conflicts with the intent and goals of CalAIM but undermines publicly organized health care,” according to an internal document prepared by the Inland Empire Health Plan. The plan said it stands to lose the roughly 144,000 Medi-Cal members it delegates to KP and about $10 million in annual revenue. L.A. Care, the nation’s largest Medicaid health plan, with 2.4 million enrollees in Los Angeles County, will lose its 244,000 KP members, based on data shared by the plan.

The state had been scheduled on Wednesday to release final details and instructions for the commercial plans that are submitting bids for new contracts starting in 2024. But it delayed the release a week to make the KP deal public beforehand. Baass said the state agreed to exempt KP from the bidding process because the standardized contract expected to result from it would have required the insurer to accept all enrollees, which Kaiser Permanente does not have the capacity to do. “It’s not surprising to me that the state will go to extraordinary means to make sure that Kaiser is in the mix, given it has been in the vanguard of our health care delivery system,” Zingale said.

Having a direct statewide Medi-Cal contract will greatly reduce the administrative workload for KP, which will now deal with only one agency on reporting and oversight, rather than the 12 public plans it currently subcontracts with. And the new contract will give it an even closer relationship with Newsom and state health officials. In 2020, KP gave $25 million to one of Newsom’s key initiatives, a state homelessness fund to move people off the streets and into hotel rooms, according to a KHN analysis of charitable payments filed with the California Fair Political Practices Commission. The same year, it donated $9.75 million to a state erectile dysfunction treatment relief fund.

In summer 2020, when local and state public health departments struggled to contain erectile dysfunction treatment spread, the health care giant pledged $63 million in grant funding to help contract-tracing efforts. KP’s influence extends beyond its massive charitable giving. Its CEO, Greg Adams, landed an appointment on the governor’s economic recovery task force early in the viagra, and Newsom has showcased KP hospitals at treatment media events throughout the state. “In California and across the U.S., the campaign contributions and the organizing, the lobbying, all of that stuff is important,” said Andrew Kelly, an assistant professor of health policy at California State University-East Bay.

€œBut there’s a different type of power that comes from your ability to have this privileged position within public programs.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Bernard J. Wolfson. bwolfson@kff.org, @bjwolfson Angela Hart.

ahart@kff.org, @ahartreports Samantha Young. syoung@kff.org, @youngsamantha Related Topics Contact Us Submit a Story TipCan’t see the audio player?. Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Click here for a transcript of the episode. Health and Human Services Secretary Xavier Becerra is becoming a target for both Democrats and Republicans over what they call a lack of coordination of erectile dysfunction treatment efforts within his department. But at the same time, officials from the Biden administration have made it clear from the start that the erectile dysfunction treatment campaign would be orchestrated by the White House, so it’s not clear whether the secretary was supposed to play a major role. Meanwhile, as erectile dysfunction treatment cases decline, erectile dysfunction treatment-weary politicians and the public are pushing to ease the latest round of restrictions.

But those with compromised immune systems and other disabilities fear they could pay the price. This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico, and Rachel Cohrs of Stat. Among the takeaways from this week’s episode. The criticism seeping out about Becerra could signal frustration in the administration and on Capitol Hill that the country is still subject to so many viagra-driven restraints and the public is looking for solutions.Nonetheless, it appears that congressional Republicans — if they win a majority later this year in the midterm elections — could use this issue to press their contention that the administration has not been effective enough in the battle against erectile dysfunction treatment.The nomination of Dr.

Robert Califf to head the FDA appears to be languishing in the Senate. Some Democrats are concerned that when he worked there before he wasn’t attuned to the growing dangers of the opioid epidemic, while others object to his ties to industry. Republicans, whom the administration was counting on to help push the nomination through, are under pressure to resist from their allies in the anti-abortion movement who charge that Califf will allow more flexibility for women seeking medication abortions.The Department of Labor, armed with new enforcement authority, is investigating 30 health insurance plans for failing to abide by the requirements for insurance coverage parity for mental health. Congress has been trying to require equal treatment for mental and physical health since the mid-1990s, but so far it remains more of an aspiration.A federal appeals court has allowed to stand, at least for now, a Tennessee law that bans abortions based on sex, race, or a Down syndrome diagnosis.

An appeals court panel had temporarily halted the law, but the full appeals court overturned that decision and said it would wait to see what the Supreme Court decides this year in a Mississippi case that could change the landmark Roe v. Wade decision making abortion legal throughout the country.Some experts have suggested that the decision years ago by doctors to move most abortions out of their offices and into specialized clinics has made the clinics an easy target and given groups opposed to the procedure an advantage in their fight. That might be countered by the increasing use of abortion pills that doctors can prescribe for women.California lawmakers seeking to set up a state-funded health system, often called a single-payer system, this week conceded they didn’t have the votes to move forward. The proposal was hugely expensive and it would have had two major exemptions.

People on Medicare and those covered by large companies that have plans regulated by the federal government. Also this week, Rovner interviews KHN’s Noam N. Levey, who reported and wrote the latest KHN-NPR “Bill of the Month” episode about a very large bill for a very small amount of medical care. If you have an outrageous medical bill you’d like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too. Julie Rovner. The Washington Post’s “Researchers Are Asking Why Some Countries Were Better Prepared for erectile dysfunction treatment. One Surprising Answer.

Trust,” by Adam Taylor Alice Miranda Ollstein. Politico’s “Next Big Health Crisis. 15M People Could Lose Medicaid When viagra Ends,” by Megan Messerly Margot Sanger-Katz. KHN’s “Faxes and Snail Mail.

Will viagra-Era Flaws Unleash Improved Health Technology?. € by Bram Sable-Smith Rachel Cohrs. Stat’s “How a Decades-Old Database Became a Hugely Profitable Dossier on the Health of 270 Million Americans,” by Casey Ross Also discussed on this week’s podcast. The New York Times’ “In Medicine, a Lack of Courage Has Helped Put Roe in Jeopardy,” by Eyal Press The New York Times’ “On Abortion Law, the U.S.

;