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Start Preamble Start Printed Page cheap cipro online canada 40921 U.S. Small Business Administration. Interim final rule cheap cipro online canada. This interim final rule implements changes related to the forgiveness of loans made under the Paycheck Protection Program (PPP), which was originally established under the antibiotics Aid, Relief, and Economic Security Act (CARES Act) to provide economic relief to small businesses nationwide adversely impacted by the antibiotics Disease 2019 (buy antibiotics), as amended.

SBA has issued a number of interim final rules implementing the PPP Program. This interim final rule further streamlines the forgiveness process for PPP loans of cheap cipro online canada $150,000 or less by allowing lenders to use a buy antibiotics Revenue Reduction Score at the time of forgiveness to document the required revenue reduction for Second Draw PPP Loans, and establishing a direct borrower forgiveness process for lenders that choose to opt-in as an alternative method of processing loan forgiveness applications. This interim final rule also extends the loan deferment period for those PPP loans where the borrower timely files an appeal of a final SBA loan review decision with the SBA Office of Hearings and Appeals. Effective cheap cipro online canada date.

The provisions of this interim final rule are effective July 28, 2021. Applicability date. The buy antibiotics Revenue Reduction Score portion of this interim final rule applies to all Second Draw PPP Loans for which the lender has not yet issued a loan forgiveness decision to SBA as of the effective date of cheap cipro online canada this rule. The direct borrower forgiveness process portion of this rule applies to all PPP loans for which a loan forgiveness application has not been submitted by the borrower to the lender as of the effective date of this rule.

The deferment portion of the rule applies to PPP appeals filed after the effective date of this rule and to those PPP appeals filed before the effective date of this rule for which a Notice and Order has not been issued. Comment date cheap cipro online canada. Comments must be received on or before August 30, 2021. You may submit comments, identified by docket number SBA-2021-0015 through the cheap cipro online canada Federal eRulemaking Portal.

Http://www.regulations.gov. Follow the instructions for submitting comments. SBA will post cheap cipro online canada all comments on www.regulations.gov. If you wish to submit confidential business information (CBI) as defined in the User Notice at www.regulations.gov, please send an email to ppp-ifr@sba.gov.

All other comments must be submitted through the Federal eRulemaking Portal cheap cipro online canada described above. Highlight the information that you consider to be CBI and explain why you believe SBA should hold this information as confidential. SBA will review the information and make the final determination whether it will publish the information. Start Further Info A Call cheap cipro online canada Center Representative at 833-572-0502 or the local SBA Field Office.

The list of offices can be found at https://www.sba.gov/​tools/​local-assistance/​districtoffices. If you use a telecommunications device for the deaf (TDD) or a text telephone (TTY), call the Federal Relay Service (FRS), toll free, at 1-800-877-8339. Individuals with disabilities can obtain this document in an accessible format that may be provided in Rich Text Format (RTF) or text format (txt), a thumb drive, an mp3 file, Braille, large print, cheap cipro online canada audiotape, or compact disc, or other accessible formats. End Further Info End Preamble Start Supplemental Information I.

Background Information cheap cipro online canada On March 27, 2020, the antibiotics Aid, Relief, and Economic Security Act (CARES Act) (Pub. L. 116-136) was enacted to provide emergency assistance and health care response for individuals, families, and businesses affected by the antibiotics Disease 2019 (buy antibiotics) cipro. Section 1102 of the CARES cheap cipro online canada Act temporarily permitted the Small Business Administration (SBA) to guarantee 100 percent of 7(a) loans under a new program titled the “Paycheck Protection Program,” pursuant to section 7(a)(36) of the Small Business Act (15 U.S.C.

636(a)(36)) (First Draw PPP Loans). Section 1106 of the CARES Act provided for cheap cipro online canada forgiveness of up to the full principal amount of qualifying loans guaranteed under the Paycheck Protection Program (PPP). On April 24, 2020, the Paycheck Protection Program and Health Care Enhancement Act (Pub. L.

116-139) was enacted, which provided cheap cipro online canada additional funding and authority for the PPP Program. On June 5, the Paycheck Protection Program Flexibility Act of 2020 (PPP Flexibility Act) (Pub. L. 116-142) was enacted, which changed provisions of the PPP relating to the maturity of PPP loans, cheap cipro online canada the deferral of PPP loan payments, and the forgiveness of PPP loans.

On July 4, 2020, Public Law 116-147 extended the authority to guarantee PPP loans to August 8, 2020. On December 27, cheap cipro online canada 2020, the Economic Aid to Hard-Hit Small Businesses, Nonprofits and Venues Act (Economic Aid Act) (Pub. L. 116-260) was enacted.

The Economic Aid Act cheap cipro online canada reauthorized lending under the PPP through March 31, 2021. The Economic Aid Act added a new temporary section 7(a)(37) to the Small Business Act, which authorizes SBA to guarantee additional PPP loans (Second Draw PPP Loans) to certain eligible borrowers that previously received a First Draw PPP Loan under generally the same terms and conditions available under section 7(a)(36) of the Small Business Act. Among other cheap cipro online canada things, to be eligible for a Second Draw PPP Loan, the borrower must have experienced a revenue reduction of not less than 25% in at least one quarter of 2020 compared to the same quarter in 2019. The Economic Aid Act also redesignated section 1106 of the CARES Act as section 7A of the Small Business Act, to appear after section 7 of the Small Business Act.

Additionally, the Economic Aid Act provided for a simplified forgiveness application process for PPP loans of $150,000 or less. On March 11, 2021, the American Rescue Plan Act cheap cipro online canada (ARPA) (Pub. L. 117-2) was enacted, and among other things, expanded eligibility for First Draw PPP Loans and Second Draw PPP Loans and revised exclusions from payroll costs for purposes of forgiveness.

On March cheap cipro online canada 30, 2021, the PPP Extension Act of 2021 (Pub. L. 117-6) was enacted, extending SBA's PPP program authority through June cheap cipro online canada 30, 2021. From April 3, 2020, through August 8, 2020, when the 2020 round of PPP expired, SBA guaranteed over 5.2 million PPP loans made by over 5,000 PPP lenders under delegated authority.

From January 11, 2021, when the PPP reopened, through June 30, 2021, when the PPP program authority expired, SBA guaranteed over 6.6 million additional PPP loans. Thus, the total number of PPP loans guaranteed by SBA exceeds cheap cipro online canada 11.8 million.[] The total dollar amount of Start Printed Page 40922the PPP loans guaranteed by SBA exceeds $806 billion. SBA posted the first interim final rule implementing the PPP on SBA's website on April 2, 2020, and published the rule in the Federal Register on April 15, 2020 (85 FR 20811). SBA subsequently issued numerous additional cheap cipro online canada interim final rules.

On June 1, 2020, SBA published an interim final rule on loan forgiveness requirements (85 FR 33004) and an interim final rule on loan review procedures (85 FR 33010). Prior to the publication of the loan forgiveness and loan review interim final rules, on May 15, 2020, SBA issued SBA Form 3508, which was a loan forgiveness application to be used by all PPP borrowers. On June 26, 2020, SBA published an interim final rule revising the loan forgiveness and loan review procedures to conform to the key forgiveness changes made by the PPP Flexibility Act (85 FR cheap cipro online canada 38304). In conjunction with the rule, SBA issued a second loan forgiveness application form, SBA Form 3508EZ, which is a streamlined form that incorporates the forgiveness safe harbors established under the PPP Flexibility Act.

SBA's 2020 PPP program authority expired on August 8, 2020. On August 10, 2020, SBA began accepting PPP lender decisions on PPP borrower loan forgiveness applications through SBA's Paycheck Protection Platform (Platform) cheap cipro online canada (forgiveness.sba.gov). PPP borrowers were required to submit their loan forgiveness applications to their PPP lenders, and as required by section 1106 of the CARES Act (now section 7A of the Small Business Act), lenders were required to issue a decision to SBA on the borrower's loan forgiveness application within 60 days of receipt of the application. On August 27, 2020, SBA issued an interim final rule on Appeals of cheap cipro online canada SBA Loan Review Decisions under the Paycheck Protection Program (85 FR 52883).

On October 2, 2020, SBA began remitting forgiveness payments to PPP lenders that submitted forgiveness decisions to SBA through the Platform. SBA continues to remit forgiveness payments to PPP lenders, and as of July 12, 2021, SBA has remitted over 4.3 million forgiveness payments to lenders.[] On October 19, 2020, in response to borrower and lender concerns about the complexity of the loan forgiveness process for the smallest of borrowers, SBA and the Department of the Treasury (Treasury) jointly issued an interim final rule revising the loan forgiveness and loan review procedures to simplify the forgiveness process for PPP loans of $50,000 or less. Among other things, the rule exempted borrowers with loans of $50,000 cheap cipro online canada or less from the full-time equivalent employee (FTE) and salary/wage reduction penalties included in section 1106 of the CARES Act, under the joint SBA/Treasury statutory authority to make de minimis exemptions to those penalties. In conjunction with the rule, SBA issued a third loan forgiveness application, SBA Form 3508S, which was a further streamlined loan forgiveness application available for use by borrowers with loans of $50,000 or less.

On January 14, 2021, SBA published interim final rules implementing the Economic Aid Act amendments to the PPP. The first interim final rule implemented Economic Aid cheap cipro online canada Act changes to, among other things, PPP eligibility, and consolidated numerous prior interim final rules on PPP (86 FR 3692) (Consolidated Eligibility IFR). The second interim final rule implemented the Second Draw PPP Loan program authorized by the Economic Aid Act under section 7(a)(37) of the Small Business Act (86 FR 3712) (Second Draw IFR). On February 5, 2021, SBA published a third interim final rule implementing Economic Aid Act changes related to the forgiveness and review of PPP loans (86 FR 8283) (Consolidated cheap cipro online canada Forgiveness and Loan Review IFR).

Among other things, the Consolidated Forgiveness and Loan Review IFR implemented the simplified forgiveness application process for loans of $150,000 or less required by the Economic Aid Act. In conjunction with this rule, on January 19, 2021, SBA issued a revised SBA Form 3508S, which increased the loan amount for which the form could be used from $50,000 to $150,000.[] The new SBA Form 3508S was also shortened to one page, as required by the Economic Aid Act, and no longer requires the submission of supporting forgiveness documentation, as mandated by the Economic Aid Act. Following the publication of the interim final cheap cipro online canada rules implementing the Economic Aid Act, SBA published another interim final rule on March 8, 2021, revising certain loan amount calculation and eligibility provisions for PPP (86 FR 13149). On March 22, 2021, SBA published an interim final rule implementing the PPP provisions of ARPA (86 FR 15083).

As described below, this interim final rule further streamlines the forgiveness process for PPP loans of $150,000 or less by (a) allowing lenders to use a buy antibiotics Revenue Reduction Score at the time of loan forgiveness to document the required revenue reduction for Second Draw PPP loans of $150,000 or less, and (b) establishing a direct borrower forgiveness process for lenders that choose to opt-in as an alternative method of processing loan forgiveness applications for PPP Loans of $150,000 or cheap cipro online canada less. This interim final rule also extends the loan deferment period for those PPP loans where the borrower timely files an appeal of a final SBA loan review decision with the SBA Office of Hearings and Appeals. II. Comments and Immediate Effective Date This interim final rule is being issued without advance notice and public comment because section 1114 cheap cipro online canada of the CARES Act and section 303 of the Economic Aid Act authorize SBA to issue regulations to implement the Paycheck Protection Program without regard to notice requirements.

Even otherwise, SBA finds good cause for setting aside the advance notice-and-public-comment procedure because that procedure would be impracticable and contrary to the public interest. The intent of the CARES Act and the Economic Aid Act is to afford SBA the flexibility to provide relief to America's small businesses and nonprofit organizations expeditiously. Given the urgent need to provide borrowers with timely relief, the purpose of the rule is to minimize the burdens of the current loan forgiveness cheap cipro online canada process that, without modification, could result in borrowers unnecessarily having to make principal and interest payments on loans that should be forgiven. If SBA were to follow the advance notice-and-public-comment process, that would delay issuance of the rule by at least three months.

SBA understands—based on its expertise and consistent portfolio analysis—that cheap cipro online canada a significant number of borrowers will have to apply for loan forgiveness in the next three months. Therefore, if the proposed rule is still undergoing notice and comment during that time, these borrowers will be applying under the current process, which (as noted above) would mean these borrowers could unnecessarily have to make principal and interest payments on loans that should be forgiven and would not be positively Start Printed Page 40923impacted by a later rule change. Providing for notice and comment would render the rule effectively moot and useless for millions of intended beneficiaries. For these same reasons, SBA has determined that it is impractical and not in cheap cipro online canada the public interest to provide a 30-day delayed effective date.

An immediate effective date will allow SBA to expedite loan forgiveness to small businesses and nonprofit organizations and remit forgiveness payments to lenders. This good cause justification also supports waiver of the 60-day delayed effective date for major rules under Subtitle E of the Small Business Regulatory Enforcement Fairness Act of 1996 (also known as the cheap cipro online canada Congressional Review Act) at 5 U.S.C. 808(2). Although this interim final rule is effective immediately, comments are solicited from interested members of the public on all aspects of the interim final rule.

These comments must cheap cipro online canada be submitted on or before August 30, 2021. SBA will consider these comments and the need for making any revisions as a result of these comments. III. Paycheck Protection cheap cipro online canada Program—buy antibiotics Revenue Reduction Score, Direct Borrower Forgiveness Process, and Appeals Deferment Overview A.

Further Streamlining Forgiveness for PPP Loans of $150,000 or Less A key feature of the PPP is that a borrower may obtain forgiveness of up to the full amount of its PPP loan provided that the borrower complied with PPP requirements. Since SBA issued the first loan forgiveness application form (SBA Form 3508) in May 2020 and published the first loan forgiveness and loan review rules in June 2020, SBA has received comments from borrowers and lenders that the loan forgiveness process is overwhelming and difficult to cheap cipro online canada manage and requesting simplification of the process. In response to borrower and lender requests for simplification of the loan forgiveness process, Congress enacted the PPP Flexibility Act in June 2020, which created safe harbors from the FTE and salary/wage reduction penalties of section 1106 of the CARES Act, and in response, SBA issued a new streamlined loan forgiveness application (SBA Form 3508EZ) implementing those changes. In October 2020, SBA and Treasury exempted borrowers with loans of $50,000 or less from the FTE and salary/wage reduction penalties and issued a second new streamlined loan forgiveness application (SBA Form 3508S) implementing those changes.

Borrowers and lenders continued to express concerns about the complexity of the loan forgiveness process, and in December 2020, Congress enacted the Economic Aid Act, which provides for a simplified loan forgiveness application cheap cipro online canada process for borrowers with loans of $150,000 or less. SBA implemented this requirement by revising the second streamlined loan forgiveness application (SBA Form 3508S) to allow all borrowers with loans of $150,000 or less to use the form. Loans of cheap cipro online canada $150,000 or less represent 93 percent of the outstanding PPP loans. Despite the implementation of the streamlined loan forgiveness application for borrowers with loans of $150,000 or less, many smaller PPP lenders continue to express concerns to SBA that they do not have the technology or human resources to develop efficient electronic loan forgiveness platforms to process the new streamlined loan forgiveness application.[] SBA has also become aware that because lenders are overwhelmed by the volume of PPP loans and are mindful of the statutory 60-day requirement for lenders to issue a forgiveness decision to SBA from receipt of the borrower's loan forgiveness application, lenders are limiting when loan forgiveness applications are accepted from borrowers, creating uncertainty among borrowers that they are going to have to start making payments on their PPP loans while they are waiting for their lenders to accept and process their loan forgiveness applications.

Additionally, SBA has heard concerns from PPP lenders of all sizes that the requirement for borrowers to submit and lenders to review at the time of forgiveness the revenue reduction documentation for Second Draw PPP Loans of $150,000 or less is delaying the forgiveness process for these borrowers. To further simplify and streamline the forgiveness process for loans $150,000 or less, SBA is making cheap cipro online canada two changes under this interim final rule. First, for Second Draw PPP Loans of $150,000 or less, where the borrower is required to provide revenue reduction documentation at the time of loan forgiveness, SBA is allowing lenders to use a buy antibiotics Revenue Reduction Score developed by SBA's contractor as an optional method to document the borrower's revenue reduction. Second, SBA is making available a direct borrower forgiveness process for lenders that choose to opt-in as an alternative method for processing borrower loan forgiveness applications for all PPP loans of $150,000 or less.

1. buy antibiotics Revenue Reduction Score Among other things, to be eligible for a Second Draw PPP Loan, a PPP borrower is required to have experienced a revenue reduction of not less than 25% during one quarter of 2020 compared to the same quarter in 2019. Under section 7(a)(37)(I) of the Small Business Act, when a borrower applies for a Second Draw PPP Loan of $150,000 or less, the borrower can submit a certification that the borrower meets the revenue reduction standard, provided that on or before the date on which the borrower submits an application for loan forgiveness, the borrower produces adequate documentation that the borrower has met the revenue reduction standard. All Second Draw PPP Loan borrowers were required to certify on their loan applications (SBA Forms 2483-SD and 2483-SD-C) that they realized a reduction in gross receipts in excess of 25% relative to the relevant comparison time period.

The Second Draw PPP Loan IFR and the Loan Forgiveness and Loan Review IFR implementing the Economic Aid Act provide that if a borrower with a Second Draw PPP Loan of $150,000 or less did not produce documentation of revenue reduction at the time of application, the borrower must, on or before the date the borrower applies for loan forgiveness, submit to the lender documentation adequate to establish that the borrower experienced a revenue reduction of 25% or greater in 2020 relative to 2019, and such documentation may include relevant tax forms, including annual tax forms, or if relevant tax forms are not available, quarterly financial statements or bank statements. The rules also provide that where a borrower with a Second Draw PPP Loan of $150,000 or less does not provide documentation of revenue reduction with its loan application, the lender must perform a good faith review of the documents provided by the borrower at or before forgiveness, including the borrower's calculations and supporting documents.[] Start Printed Page 40924 To streamline forgiveness of Second Draw PPP Loans of $150,000 or less where the borrower did not submit documentation of revenue reduction at the time of the loan application, SBA has determined that an alternative form of revenue reduction confirmation is warranted to document the borrower's revenue reduction. An independent third-party SBA contractor has developed a buy antibiotics Revenue Reduction Score (score) based on a variety of inputs including industry, geography, and business size. The score uses current data on economic recovery and return of businesses to operational status.[] Each Second Draw PPP Loan of $150,000 or less will be assigned a score, which will be maintained in the Platform and will be visible to lenders to use on an optional basis as an alternative to document revenue reduction.

Additionally, the score will be visible to those borrowers that submit their loan forgiveness applications through the Platform using the direct borrower forgiveness process. When the score meets or exceeds the value required for validation of the borrower's revenue reduction, use of the score will satisfy the requirement for the borrower to document revenue reduction. When the score does not meet the value required for validation of the borrower's revenue reduction, and if the borrower has not already provided documentation to the lender that validates the borrower's revenue reduction, the borrower must provide documentation either directly to the lender (for those lenders that do not opt-in to the direct borrower forgiveness process) or provide documentation to the lender by uploading it to the Platform. Shortly after issuance of this rule, SBA will be providing additional guidance regarding the procedures for lenders and borrowers to use the buy antibiotics Revenue Reduction Score, including when a score meets or exceeds the value required for validation of the required reductions in gross receipts and thus is considered adequate documentation of the borrower's revenue reduction.

2. Direct Borrower Forgiveness Process In response to PPP lender and borrower concerns, SBA is implementing a direct borrower forgiveness process. The direct borrower forgiveness process is an optional technology solution that SBA is providing to PPP lenders that will leverage SBA's existing and proven Platform and align with and seamlessly integrate the streamlined forgiveness application for loans of $150,000 or less mandated by the Economic Aid Act. When a PPP lender opts-in to the direct borrower forgiveness process, the Platform will provide a single secure location for all of its borrowers with loans of $150,000 or less to apply for loan forgiveness through the Platform using the electronic equivalent of SBA Form 3508S.

Upon receipt of notice that a borrower has applied for forgiveness through the Platform, lenders will review the loan forgiveness application in the Platform and issue a forgiveness decision to SBA inside the Platform. SBA believes that lenders that opt-in to using the direct borrower forgiveness process will benefit with reduced costs, increased efficiency, and more timely remittance of forgiveness payments from SBA, while borrowers will benefit from the ability to submit loan forgiveness applications directly through the Platform and reduce the wait time and uncertainty associated with submission through their lender. Shortly after issuance of this rule, SBA will be issuing more detailed procedural guidance regarding (1) the process for lenders to opt-in to the direct borrower forgiveness process, (2) the process for borrowers with loans of $150,000 or less to access the Platform and submit their loan forgiveness applications directly through the Platform, and (3) the process for lenders to access the forgiveness applications in the Platform to perform reviews of their borrowers' applications, issue forgiveness decisions to SBA, and request forgiveness payments from SBA. During the transition period after the launch of the direct borrower forgiveness process, lenders that opt-in will be expected to complete the processing of any loan forgiveness applications that have already been submitted by borrowers to the lender and should inform such borrowers not to submit a duplicate loan forgiveness application through the Platform.

After the launch of the direct borrower forgiveness process, borrowers will continue to submit loan forgiveness applications to their lenders, rather than through the Platform, under the following circumstances. The PPP lender does not opt-in to use the direct borrower forgiveness process. The borrower's PPP loan amount is greater than $150,000. The borrower does not agree with the data as provided by the SBA system of record, or cannot validate their identity in the Platform (for example, if there is an unreported change of ownership).

Or For any other reason where the Platform rejects the borrower's submission. In such circumstances, borrowers must follow instructions from their lender regarding how the lender expects the borrower to submit a forgiveness application for its PPP loan. B. Deferment Extension for OHA Appeals Currently, the rule for appeals of final SBA loan review decisions on PPP loans provides that because a PPP borrower must begin making payments of principal and interest on the remaining balance of its PPP loan when SBA remits the loan forgiveness amount to the PPP lender (or notifies the lender that no loan forgiveness is allowed), an appeal by a PPP borrower of any final SBA loan review decision does not extend the deferment period of the PPP loan.

SBA is amending the appeals rule to, among other things, provide that a borrower's timely appeal of a final SBA loan review decision will extend the deferment period for the PPP loan until SBA's Office of Hearings and Appeals (OHA) issues a final decision on the appeal. The revised OHA rule will provide that the borrower should notify the lender of the appeal so that the lender can extend the deferment period. Under the revised OHA rule, an appeal petition must be filed with OHA within 30 calendar days after the appellant's receipt of the final SBA loan review decision. SBA has determined that, in order to avoid the potential administrative burden of having to reverse implementation of the final SBA loan review decision, including the refund of borrower payments by the lender and the processing of forgiveness payments by SBA, a timely appeal by a PPP borrower of a final SBA loan review decision should extend the deferment period of the PPP loan.

SBA believes Start Printed Page 40925that allowing for continued deferment is in the best interest of the borrower. For these reasons, SBA is conforming the applicable PPP rules to provide that a timely appeal by a PPP borrower of a final SBA loan review decision extends the deferment period of the PPP loan until OHA's decision becomes final under 13 CFR 134.1211. IV. Revisions to Prior PPP Rules Therefore, the following changes are made to PPP rules.

1st Revision. The first sentence of Part IV.2.a. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8287) is revised to read as follows. 2.

Loan Forgiveness Process a. What is the general process to obtain loan forgiveness?. To receive loan forgiveness on either a First Draw PPP Loan or a Second Draw PPP Loan, a borrower must complete and submit the Loan Forgiveness Application [] to its lender (or to the lender servicing its loan), or for loans of $150,000 or less if directed by its lender, through the Paycheck Protection Platform (forgiveness.sba.gov). * * * * * * * * 2nd Revision.

Part IV.2.b. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8288) is revised by adding a sentence to the end of the paragraph to read as follows. B. When must a borrower apply for loan forgiveness or start making payments on a loan?.

€‰[] * * * Notwithstanding the foregoing, a borrower's timely appeal of a final SBA loan review decision extends the deferment period on the PPP loan until SBA's Office of Hearings and Appeals issues a final decision on the appeal under 13 CFR 134.1211. 3rd Revision. Part IV.6.a. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8293) is revised by adding a sentence to the end of the first paragraph to read as follows.

6. Documentation Requirements a. What must borrowers submit for forgiveness of their PPP loans?. * * * If a Second Draw PPP Loan borrower's buy antibiotics Revenue Reduction Score in the Paycheck Protection Platform meets or exceeds the value required to validate the borrower's revenue reduction, no additional documentation is required to be submitted by the borrower.

* * * * * 4th Revision. The first sentence of Part IV.6.b. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8293) is revised to read as follows. B.

What documentation are borrowers who are individuals with self-employment income who file a Form 1040, Schedule C or F required to submit to their lender with their request for loan forgiveness?. For borrowers that received loans of $150,000 or less that use the SBA Form 3508S, the borrower must submit the certification and information required by section 7A(l)(1)(A) of the Small Business Act and, for a Second Draw PPP Loan, revenue reduction documentation (which could be the buy antibiotics Revenue Reduction Score, if applicable) if such documentation was not provided at the time of application.[] * * * * * * * * 5th Revision. Part IV.6.c. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8293) is revised by adding a sentence to the end of the third paragraph to read as follows.

C. What additional documentation must a borrower submit when the President of the United States, Vice President of the United States, the head of an Executive department, or a Member of Congress, or the spouse of any of the preceding, directly or indirectly holds a controlling interest in the borrower?. * * * * * * * * If a borrower with a First Draw PPP Loan of $150,000 or less submits its loan forgiveness application through the Paycheck Protection Platform (Platform), the borrower must submit any required SBA Form 3508D through the Platform not later than 30 days after submitting its application through the Platform. * * * * * 6th Revision.

Footnote 82 in Part V.1.f. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8295) is revised to read as follows. See 85 FR 52833 (Aug. 27, 2020), as amended.

7th Revision. The SBA Form 3508S subsection of Part V.2.a. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8296) is revised to read as follows. 2.

The Loan Forgiveness Process for Lenders a. What should a lender review?. * * * * * When a borrower submits SBA Form 3508S or lender's equivalent form, the lender shall. I.

Confirm receipt of the borrower certifications contained in the SBA Form 3508S or lender's equivalent form. Ii. In the case of a Second Draw PPP Loan of $150,000 or less for which the borrower did not provide documentation of revenue reduction with its application and the lender did not conduct a review of the documentation at the time of application. If the borrower submits its loan forgiveness application to the lender, the lender may review the borrower's buy antibiotics Revenue Reduction Score (score) in the Platform to confirm that it meets or exceeds the value required to validate the required reduction in gross receipts.

If the borrower's score does not meet or exceed the required value, the lender must confirm the dollar amount and percentage of the borrower's revenue reduction by performing a good faith review, in a reasonable time, of the borrower's calculations and supporting documents concerning the borrower's revenue reduction.[] If the borrower submits its loan forgiveness application through the Paycheck Protection Platform (Platform), the lender must review the borrower's score in the Platform to confirm that it meets or exceeds the value required to validate the required reduction in gross receipts. If the borrower's score does not meet or exceed the required value, the lender must review the revenue reduction documentation uploaded by the borrower into the Platform and confirm the dollar amount and percentage of the borrower's revenue reduction by performing a good faith review, in a reasonable time, of the borrower's calculations and supporting documents concerning the borrower's revenue reduction. For those borrowers that are required to submit documentation regarding revenue reduction (other than a buy antibiotics Revenue Reduction Score), if the lender identifies errors in the borrower's calculation or material lack of substantiation in the borrower's supporting documents regarding revenue reduction, the lender should work with the borrower to remedy the issue. Providing an accurate calculation Start Printed Page 40926of the loan forgiveness amount is the responsibility of the borrower, and the borrower attests to the accuracy of its reported information and calculations on the Loan Forgiveness Application.

The borrower shall not receive forgiveness without submitting all required documentation to the lender. As the First Interim Final Rule [] and section IV.7 above indicate, lenders may rely on borrower representations. As stated in paragraph III.3.c of the First Interim Final Rule, the lender does not need to independently verify the borrower's reported information if the borrower submits documentation supporting its request for loan forgiveness (if required) and attests that it accurately verified the payments for eligible costs. 8th Revision.

The first sentence of the first paragraph of Part V.2.b. Of the Consolidated Forgiveness and Loan Review IFR (86 FR 8283, 8296) is revised to read as follows. B. What is the timeline for the lender's decision on a loan forgiveness application?.

The lender must issue a decision to SBA on a loan forgiveness application not later than 60 days after receipt of a complete loan forgiveness application from the borrower or, if applicable, notification by the Paycheck Protection Platform (Platform) that the borrower has submitted a loan forgiveness application into the Platform. * * * * * * * * 9th Revision. Part III.B.9. Of the Consolidated Eligibility IFR (86 FR 3692, 3703) is revised to add a fourth paragraph at the end that reads as follows.

9. When will I have to begin paying principal and interest on my PPP loan?. * * * * * Notwithstanding the foregoing, a borrower's timely appeal of a final SBA loan review decision extends the deferment period on the PPP loan until SBA's Office of Hearings and Appeals issues a final decision on the appeal under 13 CFR 134.1211. 10th Revision.

Part IV.(g)(2)(v) of the Second Draw IFR (86 FR 3712, 3721) is revised to read as follows. (g) How do I submit an application for a Second Draw PPP Loan and what documentation must I provide to demonstrate eligibility?. * * * * * (2) * * * (v) For loans with a principal amount of $150,000 or less, the applicant must submit documentation sufficient to establish that the applicant experienced a reduction in revenue as provided in subsection (c)(1)(i) of this section at the time of application, on or before the date the borrower submits an application for loan forgiveness, or, if the borrower does not apply for loan forgiveness, at SBA's request. Such documentation may include relevant tax forms, including annual tax forms, or, if relevant tax forms are not available, a copy of the applicant's quarterly income statements or bank statements.

A buy antibiotics Revenue Reduction Score that meets or exceeds the value required to validate the required reduction in gross receipts will be considered adequate documentation of the borrower's revenue reduction. 11th Revision. Part IV.(h)(2)(D) of the Second Draw IFR (86 FR 3712, 3721) is revised to read as follows. (h) What do lenders need to know and do?.

(2) * * * (D) For a Second Draw PPP Loan greater than $150,000 or a loan of $150,000 or less where the borrower provides documentation of revenue reduction, confirm the dollar amount and percentage of the borrower's revenue reduction by performing a good faith review, in a reasonable time, of the borrower's calculations and supporting documents concerning the borrower's revenue reduction. For a loan of $150,000 or less where the borrower does not provide documentation of revenue reduction with its application, the lender shall perform this review when the borrower provides such documentation. If the lender identifies errors in the borrower's calculation or material lack of substantiation in the borrower's supporting documents, the lender should work with the borrower to remedy the issue. For loans of $150,000 or less where the lender elects to use the buy antibiotics Revenue Reduction Score (score) in the Paycheck Protection Platform (Platform) or where the lender has opted-in to the direct borrower forgiveness process and the borrower submits a loan forgiveness application to the lender through the Platform, the lender must review the borrower's score to confirm that it meets or exceeds the value required to validate the required reduction in gross receipts, otherwise the lender must review the borrower's supporting documentation in accordance with the foregoing requirements.

* * * * * 12th Revision. Part IV.(j) of the Second Draw IFR (86 FR 3712, 3722) is revised to read as follows. (j) Are Second Draw PPP Loans eligible for loan forgiveness?. Second Draw PPP Loans are eligible for loan forgiveness on the same terms and conditions as First Draw PPP Loans, except that Second Draw PPP Loan borrowers with a principal amount of $150,000 or less are required to provide documentation of revenue reduction if such documentation was not provided at the time of the loan application as specified in subsections (g)(2)(iv) and (v) of this section.

If a lender elects to use the buy antibiotics Revenue Reduction Score (score) in the Paycheck Protection Platform (Platform) or where the lender has opted-in to the direct borrower forgiveness process and the borrower submits a loan forgiveness application to the lender through the Platform, a score that meets or exceeds the value required to validate the required reduction in gross receipts will be considered adequate documentation of the borrower's revenue reduction. V. Additional Information SBA may provide further guidance, if needed, through SBA notices that will be posted on SBA's website at www.sba.gov. Questions on the Paycheck Protection Program may be directed to the Lender Relations Specialist in the local SBA Field Office.

The local SBA Field Office may be found at https://www.sba.gov/​tools/​local-assistance/​districtoffices. Compliance With Executive Orders 12866, 12988, 13132 and 13563, the Congressional Review Act, the Administrative Procedure Act, the Paperwork Reduction Act (44 U.S.C. Ch. 35), and the Regulatory Flexibility Act (5 U.S.C.

601-612). Executive Orders 12866 and 13563 OMB's Office of Information and Regulatory Affairs (OIRA) has determined that this interim final rule is economically significant for the purposes of Executive Orders 12866 and 13563. SBA, however, is proceeding under the emergency provision at Executive Order 12866 section 6(a)(3)(D) based on the need to move expeditiously to mitigate the current economic conditions arising from the buy antibiotics emergency. This rule is necessary to provide economic relief to small businesses and nonprofit organizations nationwide adversely impacted under the buy antibiotics Emergency Declaration.

We anticipate that this rule will result in substantial benefits to small businesses, nonprofit organizations, their employees, and the communities they serve. However, we lack data to estimate the effects of this rule.Start Printed Page 40927 Congressional Review Act and Administrative Procedure Act OIRA has determined that this is a major rule for purposes of Subtitle E of the Small Business Regulatory Enforcement and Fairness Act of 1996 (also known as the Congressional Review Act or CRA) (5 U.S.C. 804(2) et seq.). Under the CRA, a major rule takes effect 60 days after the rule is published in the Federal Register.

5 U.S.C. 801(a)(3). Notwithstanding this requirement, the CRA allows agencies to dispense with the requirements of section 801 when the agency for good cause finds that such procedure would be impracticable, unnecessary, or contrary to the public interest and the rule shall take effect at such time as the agency promulgating the rule determines. 5 U.S.C.

808(2). Pursuant to section 808(2), SBA for good cause finds that a 60-day delay to provide public notice is impracticable and contrary to the public interest. Likewise, for the same reasons, SBA for good cause finds that there are grounds to waive the 30-day effective date delay under the Administrative Procedure Act. 5 U.S.C.

553(d)(3). As discussed elsewhere in this interim final rule, given the urgent need to provide borrowers with timely relief and the short period of time before certain borrowers will be required to begin making principal and interest payments if they have not yet applied for forgiveness with their lenders, SBA has determined that it is impractical and not in the public interest to provide a delayed effective date. An immediate effective date will allow SBA to expedite loan forgiveness to small businesses and nonprofit organizations and remit forgiveness payments to lenders. Executive Order 12988 SBA has drafted this rule, to the extent practicable, in accordance with the standards set forth in section 3(a) and 3(b)(2) of Executive Order 12988, to minimize litigation, eliminate ambiguity, and reduce burden.

The rule has no preemptive or retroactive effect. Executive Order 13132 SBA has determined that this rule will not have substantial direct effects on the States, on the relationship between the National Government and the States, or on the distribution of power and responsibilities among the various layers of government. Therefore, SBA has determined that this rule has no federalism implications warranting preparation of a federalism assessment. Paperwork Reduction Act, 44 U.S.C.

Chapter 35 SBA has determined that this rule will require revisions to existing recordkeeping or reporting requirements of the Paycheck Protection Program (PPP) information collection, OMB Control Number 3245-0407. The revisions will affect SBA Forms 3508S and 3508D. SBA Form 3508S will be revised to incorporate the direct borrower forgiveness process and the buy antibiotics Revenue Reduction Score. SBA Form 3508D will be revised to incorporate the direct borrower forgiveness process.

SBA has requested Office of Management and Budget (OMB) emergency approval of the revisions to the information collections to give small businesses and nonprofits affected by this interim final rule the maximum amount of time to apply for loan forgiveness under the new procedures. Regulatory Flexibility Act (RFA) The Regulatory Flexibility Act (RFA) generally requires that when an agency issues a proposed rule, or a final rule pursuant to section 553(b) of the Administrative Procedure Act or another law, the agency must prepare a regulatory flexibility analysis that meets the requirements of the RFA and publish such analysis in the Federal Register. 5 U.S.C. 603, 604.

Rules that are exempt from notice and comment are also exempt from the RFA requirements, including conducting a regulatory flexibility analysis, when among other things the agency for good cause finds that notice and public procedure are impracticable, unnecessary, or contrary to the public interest. SBA Office of Advocacy guide. How to Comply with the Regulatory Flexibility Act, Ch.1. P.9.

Since this rule is exempt from notice and comment, SBA is not required to conduct a regulatory flexibility analysis. Start Authority 15 U.S.C. 636(a)(36). 15 U.S.C.

636(a)(37). And 15 U.S.C. 636m. antibiotics Aid, Relief, and Economic Security Act, Pub.

L. 116-136, section 1114, and Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, Pub. L. 116-260, section 303.

End Authority Start Signature Isabella Casillas Guzman, Administrator. End Signature End Supplemental Information [FR Doc. 2021-16358 Filed 7-28-21. 4:15 pm]BILLING CODE 8026-03-PExplore full-page version of the map The number of new buy antibiotics s has increased significantly for the fourth consecutive week, according to a Daily Yonder analysis.

The death rate remained relatively unchanged last week compared to two weeks ago. New s in rural counties climbed 60% last week to a total of 46,141. The rate of new s has more than tripled since the last week of June. The number of buy antibiotics-related deaths recorded in rural counties last week declined by 11 to 343.

The rate of new s was virtually identical in rural and metropolitan counties last week, 100 new cases per 100,000 in rural counties vs. 104 new cases per 100,000 in metropolitan counties. This week’s analysis covers Sunday, July 15, through Saturday, July 24. The data is from USA Facts.

An Increase in Red-Zone Counties The map above highlights “red-zone” counties – localities where new s total at least 100 new cases for every 100,000 in population over one week. The White House antibiotics Response Group recommends that counties in the red zone take additional steps to contain the cipro. Like this story?. Sign up for our newsletter.

The growth in new s is climbing fastest in the Deep South and in states adjacent to Missouri and Arkansas, the epicenter of the resurgence caused by the delta variant of the antibiotics.Mississippi had a four-fold increase in red-zone counties last week, climbing from 15 to 67. Forty-one of the new red-zone counties were in rural areas. Nearly 80% of Mississippi’s 65 rural counties are in the red zone. Just one month ago, Mississippi had no red-zone counties.Alabama’s red-zone counties jumped from 20 two weeks ago to 54 last week.

Nearly 80% of the state’s 38 rural counties are on the red-zone list.The number of red-zone counties in Texas more than doubled, from 59 two weeks ago to 137 last week.All but one of Arkansas’ 75 counties is in the red zone.Other states seeing significant increases in red-zone counties were Kentucky (from 21 red-zone counties two weeks ago to 56 red-zone counties last week), Kansas (from 30 to 45 red-zone counties), Tennessee (from one to 33 red-zone counties), Oklahoma (from 11 to 32 red-zone counties), and Illinois (from 26 to 39 red-zone counties). Iowa, with Higher Vaccination Rate, Resists Surge To the north of Missouri, Iowa saw a decline in red-zone counties, from 13 two weeks ago to five last week. In the latest Daily Yonder vaccination analysis, Iowa ranked 15th in its rural vaccination rate (43.8% of the population completely vaccinated). Missouri ranked 42nd (27.7%).Arkansas, where the rate of new rural s doubled last week, ranked 41st for rural vaccinations (29.5%)Other states in the region with below-average rural vaccination rates and large numbers of red-zone counties were Louisiana (27.1% of rural population fully vaccinated), Tennessee (30.6%), Florida (31%), Oklahoma (31.8%), Mississippi (32.2%), Texas (32.2%), Kansas (35.2%).

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Today, thanks http://stephaniehosford.com/my-interview-on-kpcc-with-patt-morrison/ to the American Rescue Plan, the US Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA) awarded $125 million to support 14 nonprofit private or public organizations can i split cipro 500 in half to reach underserved communities in all 50 states plus the District of Columbia, Puerto Rico, Guam and the Freely Associated States to develop and support a community-based workforce that will engage in locally tailored efforts to build treatment confidence and bolster buy antibiotics vaccinations in underserved communities.These awards reflect the first of two funding opportunities announced by President Biden last month for community-based efforts to hire and mobilize community outreach workers, community health workers, social support specialists, and others to increase treatment access for the hardest-hit and highest-risk communities through high-touch, on-the-ground outreach to educate and assist individuals in getting the information they need about vaccinations. €œFor many of us, it’s best to hear from a friend or community leader when deciding whether to make a big decision, like taking the buy antibiotics treatment. To reach can i split cipro 500 in half President Biden’s goal of 70 percent of the U.S. Adult population having one treatment shot by July 4th, we are doing everything we can to reach marginalized communities with lower vaccination rates,” said HHS Secretary Xavier Becerra. “These awards will enable trusted, community-based organizations to use strategies tailored to the populations and areas they know best to address persistent racial, ethnic, and socioeconomic health inequities.” The workers supported with this funding will answer individual questions, help make treatment appointments, and assist can i split cipro 500 in half with transportation and other needs.

Award recipients will collaborate with regional and local partners to ensure a broad geographic reach with the goal of getting as many people vaccinated as possible. €œTrusted messengers play an essential role in sharing information about buy antibiotics treatments, can i split cipro 500 in half answering questions, and ultimately convincing people to get vaccinated,” said Acting HRSA Administrator Diana Espinosa. €œThis funding will support national, regional, and local organizations that will work directly with hard-hit, underserved, and high-risk communities to help bolster buy antibiotics vaccination rates.” For a list of awards recipients, see www.hrsa.gov/antibiotics/community-based-workforce. HRSA has also released a second notice of funding opportunity targeting smaller community-based organizations, with awards expected to be released in July 2021. Contact CBOtreatmentOutreach@hrsa.gov with any can i split cipro 500 in half questions.

Learn more about how HRSA is addressing buy antibiotics and health equity.Start Preamble U.S. Government Accountability can i split cipro 500 in half Office (GAO). Request for letters of nomination and resumes. The Medicare Access and CHIP Reauthorization Act of 2015 established the Physician-Focused Payment Model can i split cipro 500 in half Technical Advisory Committee to provide comments and recommendations to the Secretary of Health and Human Services on physician payment models and gave the Comptroller General responsibility for appointing its members. GAO is now accepting nominations of individuals for this committee.

Letters of nomination and how to get cipro over the counter resumes should be submitted no later than July 16, 2021, to ensure adequate opportunity for review and consideration of nominees prior to appointment. Appointments will be made can i split cipro 500 in half in October 2021. Submit letters of nomination and resumes to PTACcommittee@gao.gov. Start Further Info Greg Giusto can i split cipro 500 in half at (202) 512-8268 or giustog@gao.gov if you do not receive an acknowledgement within a week of submission or you need additional information. For general information, contact GAO's Office of Public Affairs at (202) 512-4800.

Start Authority Sec can i split cipro 500 in half. 101(e), Pub. L. 114-10, 129 can i split cipro 500 in half Stat. 87, 115 (2015).

End Authority Start Signature Gene can i split cipro 500 in half L. Dodaro, Comptroller General of the United States. End Signature End Further Info End Preamble [FR can i split cipro 500 in half Doc. 2021-12145 Filed 6-11-21. 8:45 am]BILLING CODE 1610-02-P.

Today, thanks to the American Rescue Plan, the US Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA) awarded $125 million to support 14 nonprofit private or public organizations to reach underserved communities in all 50 states plus the District of Columbia, Puerto Rico, cipro price Guam and the Freely Associated States to develop and support a community-based workforce that will engage in locally tailored efforts to build treatment confidence and bolster buy antibiotics vaccinations in underserved communities.These awards reflect the first of two funding opportunities announced by President Biden last month for community-based efforts to hire and mobilize community outreach workers, community health workers, social support specialists, and others to increase treatment access for the hardest-hit and highest-risk communities through high-touch, on-the-ground outreach to educate and assist individuals in getting cheap cipro online canada the information they need about vaccinations. €œFor many of us, it’s best to hear from a friend or community leader when deciding whether to make a big decision, like taking the buy antibiotics treatment. To reach cheap cipro online canada President Biden’s goal of 70 percent of the U.S. Adult population having one treatment shot by July 4th, we are doing everything we can to reach marginalized communities with lower vaccination rates,” said HHS Secretary Xavier Becerra.

“These awards will enable trusted, community-based organizations to use strategies tailored to the populations and areas they know best to address persistent racial, ethnic, and socioeconomic health inequities.” The workers supported with this funding will answer individual questions, help make treatment cheap cipro online canada appointments, and assist with transportation and other needs. Award recipients will collaborate with regional and local partners to ensure a broad geographic reach with the goal of getting as many people vaccinated as possible. €œTrusted messengers play an essential role in sharing information about buy antibiotics treatments, answering questions, and cheap cipro online canada ultimately convincing people to get vaccinated,” said Acting HRSA Administrator Diana Espinosa. €œThis funding will support national, regional, and local organizations that will work directly with hard-hit, underserved, and high-risk communities to help bolster buy antibiotics vaccination rates.” For a list of awards recipients, see www.hrsa.gov/antibiotics/community-based-workforce.

HRSA has also released a second notice of funding opportunity targeting smaller community-based organizations, with awards expected to be released in July 2021. Contact CBOtreatmentOutreach@hrsa.gov cheap cipro online canada with any questions. Learn more about how HRSA is addressing buy antibiotics and health equity.Start Preamble U.S. Government Accountability cheap cipro online canada Office (GAO).

Request for letters of nomination and resumes. The Medicare Access and CHIP Reauthorization Act of 2015 established the Physician-Focused Payment Model Technical Advisory Committee to provide comments and recommendations to the Secretary of Health and Human Services on physician payment models and gave the cheap cipro online canada Comptroller General responsibility for appointing its members. GAO is now accepting nominations of individuals for this committee. Letters of nomination and resumes should be submitted no later than July 16, 2021, best site to ensure adequate opportunity for review and consideration of nominees prior to appointment.

Appointments will be made in October cheap cipro online canada 2021. Submit letters of nomination and resumes to PTACcommittee@gao.gov. Start Further Info Greg Giusto at (202) 512-8268 or giustog@gao.gov if you do not receive an acknowledgement within a week of submission or you need additional cheap cipro online canada information. For general information, contact GAO's Office of Public Affairs at (202) 512-4800.

Start Authority cheap cipro online canada Sec. 101(e), Pub. L. 114-10, 129 cheap cipro online canada Stat.

87, 115 (2015). End Authority cheap cipro online canada Start Signature Gene L. Dodaro, Comptroller General of the United States. End Signature cheap cipro online canada End Further Info End Preamble [FR Doc.

2021-12145 Filed 6-11-21. 8:45 am]BILLING CODE 1610-02-P.

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Tell your doctor or health care professional if your symptoms do not improve.

Do not treat diarrhea with over the counter products. Contact your doctor if you have diarrhea that lasts more than 2 days or if it is severe and watery.

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Cipro alcohol

Rheumatic mitral stenosis (MS) remains the most common type of valvular heart disease worldwide yet there are few studies on optimal timing of intervention in asymptomatic patients cipro alcohol. Postulated benefits of intervention before symptom onset include prevention of left atrial dilation, atrial fibrillation (AF) and pulmonary hypertension leading to fewer thromboembolic events, less heart failure, preserved exercise capacity and in improved quality of life. In this issue of Heart, Kang and colleagues1 report a randomised clinical trial of in 374 patients with severe MS (valve cipro alcohol area 1.0–1.5 cm2) comparing early percutaneous mitral commissurotomy (PMC) to conventional care. The primary composite endpoint of PMC-related complications, cardiovascular mortality, cerebral infarction and systemic thromboembolic events occurred in seven patients in the early PMC group (8.3%) compared with nine patients in the conventional care group (10.8%) (HR 0.77. 95% CI 0.29 to cipro alcohol 2.07.

P=0.61) at a median follow-up of 6 years (figure 1).Summary of the MITIGATE (mitral intervention vs conventional management in asymptomatic mitral stenosis) trial. MS, mitral cipro alcohol stenosis. PMC, percutaneous mitral commissurotomy." data-icon-position data-hide-link-title="0">Figure 1 Summary of the MITIGATE (mitral intervention vs conventional management in asymptomatic mitral stenosis) trial. MS, mitral cipro alcohol stenosis. PMC, percutaneous mitral commissurotomy.Karthikeyan2 points out that there is only a sparse evidence base for management of mitral stenosis.

Although this study by Kang and colleagues1 is commendable, replication in larger studies in countries with endemic rheumatic heart disease is needed. In the meanwhile, ‘even minimally symptomatic patients with severe MS often deteriorate, due to AF cipro alcohol and fast ventricular rates, triggered by drug noncompliance or inter-current illness. In such situations, patients may not have timely access to acute care (and emergency PMC), which may be life-saving. Therefore, a case can be made for performing early PMC in asymptomatic patients cipro alcohol with significant MS (mitral valve area ≤1.5 cm2, or ≤1.3 cm2 if body surface area is <1.5 m2), provided the procedure can be performed safely (procedure-related death or mitral regurgitation requiring surgery <3%). Close medical follow-up should be reserved for patients in sinus rhythm, without evidence of left atrial hypertension, or a propensity for haemodynamic deterioration or systemic embolism.’Also in this issue of Heart, Garcia Granja and colleagues3 present an observational study of 605 patients with left-sided infective endocarditis.

The 405 patients who underwent surgery during the active phase of the disease were compared with cipro alcohol the 200 who received only medical therapy. On multivariable analysis, early surgery was a independent predictor of survival (OR 0.260, 95% CI 0.162 to 0.416), particularly in those at highest risk (predicted mortality 80%–100%. OR 0.08, 95% CI 0.021 to 0.299) and those with uncontrolled (figure 2).Association between cardiac surgery and in-hospital mortality according to the surgical indication." data-icon-position data-hide-link-title="0">Figure 2 Association between cardiac surgery and in-hospital cipro alcohol mortality according to the surgical indication.In the accompanying editorial, Donal and colleagues4 discuss the limitations of this study and provide the context that in ‘the largest retrospective study provided by the International Collaboration on Endocarditis consortium. The comparison of early cardiac surgery vs conservative management was neutral.’’ Even so, they conclude that the study by Garcia Granja et al3 brings ‘another piece of evidence that left-sided endocarditis is a disease that requires rapid, well-organised and expert teams for an early diagnosis, early decision-making process and very early access to the operating room and to the intensive cares required to save, undoubtedly, lives!. €™The optimal cipro alcohol approach to detection of familial hypercholesterolaemia (FH) remains controversial.

FH, a preventable cause of cardiovascular disease, is present in about 0.4% of the population suggesting that early detection and treatment would impact public health. Qureshi et al5 applied the FH Case Ascertainment Tool (FAMCAT1) to the electronic medical records cipro alcohol of over 82 thousand patients. Of the 4% identified as having a high risk of FH, 283 patients agreed to genetics testing which found pathogenic variants in 16 and variants of uncertain significance in 10 patients, matching the expected population prevalence of this condition. All these patients were referred for specialist care. An additional 153 patients were found to have polygenic hypercholesterolaemia and cipro alcohol were managed by primary care.In an editorial, Brett and Watts6 help make sense of the various proposed approaches for diagnosis of FH, discuss the balance between primary and specialist care, and provide a useful algorithm for clinical practice (figure 3).

In order to diagnose and treat all cases of FH, they suggest ‘A new approach, possibly involving some form of universal screening in youth combined with reverse cascade testing or even population-based genomic testing, will be needed.’Ascertainment tool. CVD, cardiovascular cipro alcohol disease. FH, familial hypercholesterolaemia. GP, general cipro alcohol practitioner. HeFH, heterozygous FH.

HoFH, homozygous FH cipro alcohol. LDL-C, low-density lipoprotein-cholesterol. PCSK9, proprotein cipro alcohol convertase subtilisin/kexin type 9. VUS, variant of uncertain significance, *Refer to Sturm et al 10 and Brett T et al 11 DLCNC, Dutch Lipid Clinic Network Critieria. FAMCAT1, familial hypercholesterolaemia case ascertainment tool." data-icon-position data-hide-link-title="0">Figure 3 Ascertainment tool.

CVD, cardiovascular cipro alcohol disease. FH, familial hypercholesterolaemia. GP, general practitioner cipro alcohol. HeFH, heterozygous FH. HoFH, homozygous FH cipro alcohol.

LDL-C, low-density lipoprotein-cholesterol. PCSK9, proprotein convertase subtilisin/kexin cipro alcohol type 9. VUS, variant of uncertain significance, *Refer to Sturm et al10 and Brett T et al11 DLCNC, Dutch Lipid Clinic Network Critieria. FAMCAT1, familial hypercholesterolaemia case ascertainment tool.A provocative Point and Counterpoint set of articles addresses transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with native valvular aortic regurgitation (AR). Kahn and Baron7 conclude that ‘while a dedicated transcatheter device for the treatment cipro alcohol of AR is ideal, there is a clear need now for percutaneous aortic valve treatment in the subset of patients with AR who cannot undergo SAVR.

With appropriate patient selection, careful device sizing and optimal intraprocedural imaging and techniques, TAVI using currently available devices off-label has demonstrated reasonable outcomes and offers a viable therapeutic option for this previously untreated patient population.’ In contrast, Huded et al8 conclude ‘TAVI for AR is becoming increasingly feasible with newer generation devices, but outcomes still lag behind the high benchmark established for TAVI in patients with AS. There are cipro alcohol no randomised controlled trials and no mid-term data to support the routine application of TAVI for isolated AR’ (figure 4). Taken together, these two articles provide a thoughtful and comprehensive review of the current literature.Challenges of performing transcatheter aortic valve implantation in isolated aortic regurgitation. Key anatomic cipro alcohol and physiological aspects of isolated aortic regurgitation which contribute to technical challenges during transcatheter aortic valve implantation are shown." data-icon-position data-hide-link-title="0">Figure 4 Challenges of performing transcatheter aortic valve implantation in isolated aortic regurgitation. Key anatomic and physiological aspects of isolated aortic regurgitation which contribute to technical challenges during transcatheter aortic valve implantation are shown.The Education in Heart article in this issue9 provides a clear approach to distinguishing ventricular tachycardia from supraventricular tachycardia in patients with a wide complex tachycardia.

This article also provides a summary of the numerous proposed algorithms for differentiation of ventricular from supraventricular tachycardia in clinical practice.Ethics statementsPatient consent for publicationNot applicable.IntroductionFamilial hypercholesterolaemia (FH) is a preventable cause of premature coronary artery disease and death, with significant potential impact on public health1 and meeting all criteria for screening for a condition cipro alcohol. Early detection of FH rests on the premise that the burden of atherosclerotic cardiovascular disease due to genetically elevated low-density lipoprotein cholesterol begins at birth and accumulates over time, and that treatment in childhood prevents coronary events and reduces mortality.2The public health importance of FH is also underpinned by knowledge that its prevalence is as high as 1:250.1 However, only 10% of people worldwide are currently recognised as having FH.2 A recent international global call to action3 has championed the need for improved screening and diagnosis.To identify >90% of the population with FH requires multiple approaches, but integrating cascade testing of family members of index cases with some form of universal screening at younger ages may have the highest potential. Opportunistic, selective, systematic and universal screening strategies, employing cipro alcohol phenotypic and genetic testing, are other approaches that are reported as cost-effective.2 More recently, whole population genetic screening has been proposed.Genetic testing has several advantages. It improves precision of diagnosis and risk prediction, facilitates family counselling and cascade testing, and can improve adherence to therapy.4 General practice plays a key role in the detection of FH for several reasons, including ease of access to services, a preference for patients to receive treatment locally and awareness of intergenerational conditions in families. A key goal of the WHO is to focus on primary healthcare to facilitate easy and equitable access to quality health services.5Recent studyThe study by Qureshi et al6 offers a new approach to increase primary care involvement in diagnosing FH by offering FH genetic testing through general practitioners (GPs) for ….

Rheumatic mitral stenosis (MS) remains the cheap cipro online canada most common type of valvular heart disease worldwide yet there are few studies on optimal timing of intervention in asymptomatic patients. Postulated benefits of intervention before symptom onset include prevention of left atrial dilation, atrial fibrillation (AF) and pulmonary hypertension leading to fewer thromboembolic events, less heart failure, preserved exercise capacity and in improved quality of life. In this issue of Heart, Kang and colleagues1 report a randomised clinical trial cheap cipro online canada of in 374 patients with severe MS (valve area 1.0–1.5 cm2) comparing early percutaneous mitral commissurotomy (PMC) to conventional care.

The primary composite endpoint of PMC-related complications, cardiovascular mortality, cerebral infarction and systemic thromboembolic events occurred in seven patients in the early PMC group (8.3%) compared with nine patients in the conventional care group (10.8%) (HR 0.77. 95% CI 0.29 to 2.07 cheap cipro online canada. P=0.61) at a median follow-up of 6 years (figure 1).Summary of the MITIGATE (mitral intervention vs conventional management in asymptomatic mitral stenosis) trial.

MS, mitral stenosis cheap cipro online canada. PMC, percutaneous mitral commissurotomy." data-icon-position data-hide-link-title="0">Figure 1 Summary of the MITIGATE (mitral intervention vs conventional management in asymptomatic mitral stenosis) trial. MS, mitral cheap cipro online canada stenosis.

PMC, percutaneous mitral commissurotomy.Karthikeyan2 points out that there is only a sparse evidence base for management of mitral stenosis. Although this study by Kang and colleagues1 is commendable, replication in larger studies in countries with endemic rheumatic heart disease is needed. In the meanwhile, cheap cipro online canada ‘even minimally symptomatic patients with severe MS often deteriorate, due to AF and fast ventricular rates, triggered by drug noncompliance or inter-current illness.

In such situations, patients may not have timely access to acute care (and emergency PMC), which may be life-saving. Therefore, a case can be made for performing early PMC in asymptomatic patients with significant MS (mitral valve area ≤1.5 cm2, or ≤1.3 cm2 if body surface area cheap cipro online canada is <1.5 m2), provided the procedure can be performed safely (procedure-related death or mitral regurgitation requiring surgery <3%). Close medical follow-up should be reserved for patients in sinus rhythm, without evidence of left atrial hypertension, or a propensity for haemodynamic deterioration or systemic embolism.’Also in this issue of Heart, Garcia Granja and colleagues3 present an observational study of 605 patients with left-sided infective endocarditis.

The 405 patients who underwent surgery during the active phase of the disease were cheap cipro online canada compared with the 200 who received only medical therapy. On multivariable analysis, early surgery was a independent predictor of survival (OR 0.260, 95% CI 0.162 to 0.416), particularly in those at highest risk (predicted mortality 80%–100%. OR 0.08, 95% CI 0.021 to 0.299) and those with uncontrolled (figure 2).Association between cardiac surgery and in-hospital mortality according to the surgical indication." data-icon-position data-hide-link-title="0">Figure 2 Association between cardiac surgery and in-hospital mortality according to the surgical indication.In cheap cipro online canada the accompanying editorial, Donal and colleagues4 discuss the limitations of this study and provide the context that in ‘the largest retrospective study provided by the International Collaboration on Endocarditis consortium.

The comparison of early cardiac surgery vs conservative management was neutral.’’ Even so, they conclude that the study by Garcia Granja et al3 brings ‘another piece of evidence that left-sided endocarditis is a disease that requires rapid, well-organised and expert teams for an early diagnosis, early decision-making process and very early access to the operating room and to the intensive cares required to save, undoubtedly, lives!. €™The optimal approach cheap cipro online canada to detection of familial hypercholesterolaemia (FH) remains controversial. FH, a preventable cause of cardiovascular disease, is present in about 0.4% of the population suggesting that early detection and treatment would impact public health.

Qureshi et al5 applied the FH Case Ascertainment Tool (FAMCAT1) to cheap cipro online canada the electronic medical records of over 82 thousand patients. Of the 4% identified as having a high risk of FH, 283 patients agreed to genetics testing which found pathogenic variants in 16 and variants of uncertain significance in 10 patients, matching the expected population prevalence of this condition. All these patients were referred for specialist care.

An additional 153 patients were found to cheap cipro online canada have polygenic hypercholesterolaemia and were managed by primary care.In an editorial, Brett and Watts6 help make sense of the various proposed approaches for diagnosis of FH, discuss the balance between primary and specialist care, and provide a useful algorithm for clinical practice (figure 3). In order to diagnose and treat all cases of FH, they suggest ‘A new approach, possibly involving some form of universal screening in youth combined with reverse cascade testing or even population-based genomic testing, will be needed.’Ascertainment tool. CVD, cardiovascular cheap cipro online canada disease.

FH, familial hypercholesterolaemia. GP, general cheap cipro online canada practitioner. HeFH, heterozygous FH.

HoFH, homozygous cheap cipro online canada FH. LDL-C, low-density lipoprotein-cholesterol. PCSK9, proprotein convertase subtilisin/kexin type 9 cheap cipro online canada.

VUS, variant of uncertain significance, *Refer to Sturm et al 10 and Brett T et al 11 DLCNC, Dutch Lipid Clinic Network Critieria. FAMCAT1, familial hypercholesterolaemia case ascertainment tool." data-icon-position data-hide-link-title="0">Figure 3 Ascertainment tool. CVD, cardiovascular cheap cipro online canada disease.

FH, familial hypercholesterolaemia. GP, general cheap cipro online canada practitioner. HeFH, heterozygous FH.

HoFH, homozygous FH cheap cipro online canada. LDL-C, low-density lipoprotein-cholesterol. PCSK9, proprotein convertase subtilisin/kexin type 9 cheap cipro online canada.

VUS, variant of uncertain significance, *Refer to Sturm et al10 and Brett T et al11 DLCNC, Dutch Lipid Clinic Network Critieria. FAMCAT1, familial hypercholesterolaemia case ascertainment tool.A provocative Point and Counterpoint set of articles addresses transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with native valvular aortic regurgitation (AR). Kahn and Baron7 conclude that ‘while a dedicated transcatheter device for the treatment of AR is ideal, there is a clear need now for percutaneous aortic valve treatment in the subset of patients with AR cheap cipro online canada who cannot undergo SAVR.

With appropriate patient selection, careful device sizing and optimal intraprocedural imaging and techniques, TAVI using currently available devices off-label has demonstrated reasonable outcomes and offers a viable therapeutic option for this previously untreated patient population.’ In contrast, Huded et al8 conclude ‘TAVI for AR is becoming increasingly feasible with newer generation devices, but outcomes still lag behind the high benchmark established for TAVI in patients with AS. There are no randomised controlled trials and no mid-term data to support the routine application cheap cipro online canada of TAVI for isolated AR’ (figure 4). Taken together, these two articles provide a thoughtful and comprehensive review of the current literature.Challenges of performing transcatheter aortic valve implantation in isolated aortic regurgitation.

Key anatomic and physiological aspects of isolated aortic regurgitation which contribute to technical challenges during transcatheter aortic valve implantation are shown." data-icon-position data-hide-link-title="0">Figure 4 Challenges of performing transcatheter aortic valve implantation cheap cipro online canada in isolated aortic regurgitation. Key anatomic and physiological aspects of isolated aortic regurgitation which contribute to technical challenges during transcatheter aortic valve implantation are shown.The Education in Heart article in this issue9 provides a clear approach to distinguishing ventricular tachycardia from supraventricular tachycardia in patients with a wide complex tachycardia. This article also provides a summary of the numerous proposed algorithms for differentiation of ventricular from supraventricular tachycardia in cheap cipro online canada clinical practice.Ethics statementsPatient consent for publicationNot applicable.IntroductionFamilial hypercholesterolaemia (FH) is a preventable cause of premature coronary artery disease and death, with significant potential impact on public health1 and meeting all criteria for screening for a condition.

Early detection of FH rests on the premise that the burden of atherosclerotic cardiovascular disease due to genetically elevated low-density lipoprotein cholesterol begins at birth and accumulates over time, and that treatment in childhood prevents coronary events and reduces mortality.2The public health importance of FH is also underpinned by knowledge that its prevalence is as high as 1:250.1 However, only 10% of people worldwide are currently recognised as having FH.2 A recent international global call to action3 has championed the need for improved screening and diagnosis.To identify >90% of the population with FH requires multiple approaches, but integrating cascade testing of family members of index cases with some form of universal screening at younger ages may have the highest potential. Opportunistic, selective, systematic and universal screening strategies, employing phenotypic and genetic testing, are other approaches that are reported as cheap cipro online canada cost-effective.2 More recently, whole population genetic screening has been proposed.Genetic testing has several advantages. It improves precision of diagnosis and risk prediction, facilitates family counselling and cascade testing, and can improve adherence to therapy.4 General practice plays a key role in the detection of FH for several reasons, including ease of access to services, a preference for patients to receive treatment locally and awareness of intergenerational conditions in families.

A key goal of the WHO is to focus on primary healthcare to facilitate easy and equitable access to quality health services.5Recent studyThe study by Qureshi et al6 offers a new approach to increase primary care involvement in diagnosing FH by offering FH genetic testing through general practitioners (GPs) for ….

Bactrim vs cipro prostatitis

SSA lists the income and resource limits for Extra Help on their website, where you can also bactrim vs cipro prostatitis file an application online wikipedia reference and get more information about the program. You can also find out information about Extra Help in many different languages. See Medicare Rights Center chart on Extra Help Income and Asset Limits - updated annually You can apply for Extra Help and MSP at the same time through SSA. SSA will forward your Extra Help application data to the New York State Department bactrim vs cipro prostatitis of Health, who will use that data to assess your eligibility for MSP. Individuals who apply for LIS through SSA and those who are deemed into LIS should receive written confirmation of their Extra Help status through SSA.

Of course, individuals who apply for LIS through SSA and are found ineligible are also entitled to a written notice and have appeal rights. Benefits of Extra Help bactrim vs cipro prostatitis 1) Assistance with Part D cost-sharing The Extra Help program provides a subsidy which covers most (but not all) of beneficiary’s cost sharing obligations. Extra Help beneficiaries do not have to worry about hitting the “donut hole” – the LIS subsidy continues to cover them through the donut hole and into catastrophic coverage. Full Extra Help. LIS beneficiaries with incomes up to 135% FPL are generally eligible for "full" Extra bactrim vs cipro prostatitis Help -- meaning they pay no Part D deductible, no charge for monthly premiums up to the benchmark amount, and fixed, relatively low co-pays (between $1.30 and $8.95 for 2020 depending on the person's income level and the tier category of the drug.

Medicaid beneficiaries in nursing homes, waiver programs, or managed long term care have $0 co-pays). Full Extra Help beneficiaries who hit the catastrophic coverage limit have $0 co-pays. See current co-pay levels here bactrim vs cipro prostatitis. Partial Extra Help. Beneficiaries between 135%-150% FPL receive "partial" Extra Help, which limits the Part D deductible to $89 (2020 figure - click here for updated chart).

Sets sliding scale fees for monthly bactrim vs cipro prostatitis premiums. And limits co-pays to 15%, until the beneficiary reaches the catastrophic coverage limit, at which point co-pays are limited to a $8.95 maximum (2020 or see current amount here) or 5% of the drug cost, whichever is greater. 2) Facilitated enrollment into a Part D plan Extra Help recipients who aren’t already enrolled in a Part D plan and don’t want to choose one on their own will be automatically enrolled into a benchmark plan by CMS. This facilitated enrollment ensures bactrim vs cipro prostatitis that Extra Help recipients have Part D coverage. However, the downside to facilitated enrollment is that the plan may not be the best “fit” for the beneficiary, if it doesn’t cover all his/her drugs, assesses a higher tier level for covered drugs than other comparable plans, and/or requires the beneficiary to go through administrative hoops like prior authorization, quantity limits and/or step therapy.

Fortunately, Extra Help recipients can always enroll in a new plan … see #3 below. 3) Continuous special enrollment period Extra Help recipients have a continuous special enrollment period, meaning that they can switch plans at any time bactrim vs cipro prostatitis. They are not “locked into” the annual open enrollment period (October 15-December 7). NOTE. This bactrim vs cipro prostatitis changed in 2019.

Starting in 2019, those with Extra Help will no longer have a continuous enrollment period. Instead, Extra Help recipients will be eligible to enroll no more than once per quarter for each of the first three quarters of the year. 4) No late enrollment penalty Non LIS beneficiaries generally face a premium penalty (higher monthly bactrim vs cipro prostatitis premium) if they delayed their enrollment into Part D, meaning that they didn’t enroll when they were initially eligible and didn’t have “creditable coverage.” Extra Help recipients do not have to worry about this problem – the late enrollment penalty provision does not apply to LIS beneficiaries. 1) For “deemed” beneficiaries (Medicaid/Medicare Savings Program recipients). Extra Help status lasts at least until the end of the current calendar year, even if the individual loses their Medicaid or Medicare Savings Program coverage during that year.

Individuals who receive Medicaid or a Medicare Savings Program any bactrim vs cipro prostatitis month between July and December keep their LIS status for the remainder of that calendar year and the following year. Getting Medicaid coverage for even just a short period of time (ie, meeting a spenddown for just one month) can help ensure that the individual obtains Extra Help coverage for at least 6 months, and possibly as long as 18 months. TIP. People with a high spend-down who want to receive Medicaid for just one month in bactrim vs cipro prostatitis order to get Extra Help for 6-18 months can use past medical bills to meet their spend-down for that one month. There are different rules for using past paid medical bills verses past unpaid medical bills.

For information see Spend down training materials. Individuals who are losing their deemed status at the end of a calendar bactrim vs cipro prostatitis year because they are no longer receiving Medicaid or the Medicare Savings Program should be notified in advance by SSA, and given an opportunity to file an Extra Help application through SSA. 2) For “non-deemed” beneficiaries (those who filed their LIS applications through SSA) Non-deemed beneficiaries retain their LIS status until/unless SSA does a redetermination and finds the individual ineligible for Extra Help. There are no reporting requirements per se in the Extra Help program, but beneficiaries must respond to SSA’s redetermination request. What to do if the Part D plan doesn't know that someone has Extra Help Sometimes there are lengthy delays between the date that someone is approved for Medicaid or a Medicare bactrim vs cipro prostatitis Savings Program and when that information is formally conveyed to the Part D plan by CMS.

As a practical matter, this often results in beneficiaries being charged co-pays, premiums and/or deductibles that they can't afford and shouldn't have to pay. To protect LIS beneficiaries, CMS has a "Best Available Evidence" policy which requires plans to accept alternative forms of proof of someone's LIS status and adjust the person's cost-sharing obligation accordingly. LIS beneficiaries who are being charged improperly should bactrim vs cipro prostatitis be sure to contact their plan and provide proof of their LIS status. If the plan still won't recognize their LIS status, the person or their advocate should file a complaint with the CMS regional office. The federal regulations governing the Low Income Subsidy program can be found at 42 CFR Subpart P (sections 423.771 through 423.800).

Also, CMS provides detailed guidance on the bactrim vs cipro prostatitis LIS provisions in chapter 13 of its Medicare Prescription Drug Benefit Manual. This article was authored by the Empire Justice Center.Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in QMB receive additional bactrim vs cipro prostatitis subsidies for Medicare costs. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law.

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

2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3.

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

Applications for People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!.

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

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

See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down.

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

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

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

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

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

The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP.

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

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

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

1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance.

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

For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only.

QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both.

It is their choice. DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB. 4.

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

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

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

18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July.

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

Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010.

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

Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification.

Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit.

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

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

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

Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive.

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

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

See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too.

One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan.

GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

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

People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare.

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

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

Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply.

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

See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program.

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

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

!. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?. ​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application.

18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year.

The Extra Help income limits are 150% FPL and there cheap cipro online canada is an asset test. SSA lists the income and resource limits for Extra Help on their website, where you can also file an application online and get more information about the program. You can also find out information about Extra Help in many different languages. See Medicare Rights Center chart on Extra Help Income and Asset Limits - updated annually You can apply for Extra Help cheap cipro online canada and MSP at the same time through SSA. SSA will forward your Extra Help application data to the New York State Department of Health, who will use that data to assess your eligibility for MSP.

Individuals who apply for LIS through SSA and those who are deemed into LIS should receive written confirmation of their Extra Help status through SSA. Of course, cheap cipro online canada individuals who apply for LIS through SSA and are found ineligible are also entitled to a written notice and have appeal rights. Benefits of Extra Help 1) Assistance with Part D cost-sharing The Extra Help program provides a subsidy which covers most (but not all) of beneficiary’s cost sharing obligations. Extra Help beneficiaries do not have to worry about hitting the “donut hole” – the LIS subsidy continues to cover them through the donut hole and into catastrophic coverage. Full Extra cheap cipro online canada Help.

LIS beneficiaries with incomes up to 135% FPL are generally eligible for "full" Extra Help -- meaning they pay no Part D deductible, no charge for monthly premiums up to the benchmark amount, and fixed, relatively low co-pays (between $1.30 and $8.95 for 2020 depending on the person's income level and the tier category of the drug. Medicaid beneficiaries in nursing homes, waiver programs, or managed long term care have $0 co-pays). Full Extra Help beneficiaries who hit the cheap cipro online canada catastrophic coverage limit have $0 co-pays. See current co-pay levels here. Partial Extra Help.

Beneficiaries between 135%-150% FPL receive "partial" Extra Help, which limits the Part D deductible to $89 (2020 cheap cipro online canada figure - click here for updated chart). Sets sliding scale fees for monthly premiums. And limits co-pays to 15%, until the beneficiary reaches the catastrophic coverage limit, at which point co-pays are limited to a $8.95 maximum (2020 or see current amount here) or 5% of the drug cost, whichever is greater. 2) Facilitated enrollment into a Part D plan Extra Help recipients who aren’t already enrolled in a Part D plan and don’t want to choose one on their own will be automatically enrolled into a cheap cipro online canada benchmark plan by CMS. This facilitated enrollment ensures that Extra Help recipients have Part D coverage.

However, the downside to facilitated enrollment is that the plan may not be the best “fit” for the beneficiary, if it doesn’t cover all his/her drugs, assesses a higher tier level for covered drugs than other comparable plans, and/or requires the beneficiary to go through administrative hoops like prior authorization, quantity limits and/or step therapy. Fortunately, Extra cheap cipro online canada Help recipients can always enroll in a new plan … see #3 below. 3) Continuous special enrollment period Extra Help recipients have a continuous special enrollment period, meaning that they can switch plans at any time. They are not “locked into” the annual open enrollment period (October 15-December 7). NOTE cheap cipro online canada.

This changed in 2019. Starting in 2019, those with Extra Help will no longer have a continuous enrollment period. Instead, Extra Help recipients will be eligible to cheap cipro online canada enroll no more than once per quarter for each of the first three quarters of the year. 4) No late enrollment penalty Non LIS beneficiaries generally face a premium penalty (higher monthly premium) if they delayed their enrollment into Part D, meaning that they didn’t enroll when they were initially eligible and didn’t have “creditable coverage.” Extra Help recipients do not have to worry about this problem – the late enrollment penalty provision does not apply to LIS beneficiaries. 1) For “deemed” beneficiaries (Medicaid/Medicare Savings Program recipients).

Extra Help status lasts at least until the end of the current cheap cipro online canada calendar year, even if the individual loses their Medicaid or Medicare Savings Program coverage during that year. Individuals who receive Medicaid or a Medicare Savings Program any month between July and December keep their LIS status for the remainder of that calendar year and the following year. Getting Medicaid coverage for even just a short period of time (ie, meeting a spenddown for just one month) can help ensure that the individual obtains Extra Help coverage for at least 6 months, and possibly as long as 18 months. TIP cheap cipro online canada. People with a high spend-down who want to receive Medicaid for just one month in order to get Extra Help for 6-18 months can use past medical bills to meet their spend-down for that one month.

There are different rules for using past paid medical bills verses past unpaid medical bills. For information see Spend down training cheap cipro online canada materials. Individuals who are losing their deemed status at the end of a calendar year because they are no longer receiving Medicaid or the Medicare Savings Program should be notified in advance by SSA, and given an opportunity to file an Extra Help application through SSA. 2) For “non-deemed” beneficiaries (those who filed their LIS applications through SSA) Non-deemed beneficiaries retain their LIS status until/unless SSA does a redetermination and finds the individual ineligible for Extra Help. There are no reporting requirements per se in the Extra Help program, but beneficiaries must respond to SSA’s redetermination cheap cipro online canada request.

What to do if the Part D plan doesn't know that someone has Extra Help Sometimes there are lengthy delays between the date that someone is approved for Medicaid or a Medicare Savings Program and when that information is formally conveyed to the Part D plan by CMS. As a practical matter, this often results in beneficiaries being charged co-pays, premiums and/or deductibles that they can't afford and shouldn't have to pay. To protect LIS beneficiaries, CMS has a "Best Available Evidence" policy which requires plans to cheap cipro online canada accept alternative forms of proof of someone's LIS status and adjust the person's cost-sharing obligation accordingly. LIS beneficiaries who are being charged improperly should be sure to contact their plan and provide proof of their LIS status. If the plan still won't recognize their LIS status, the person or their advocate should file a complaint with the CMS regional office.

The federal regulations governing the Low Income Subsidy program can be cheap cipro online canada found at 42 CFR Subpart P (sections 423.771 through 423.800). Also, CMS provides detailed guidance on the LIS provisions in chapter 13 of its Medicare Prescription Drug Benefit Manual. This article was authored by the Empire Justice Center.Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is cheap cipro online canada discussed below. Those in QMB receive additional subsidies for Medicare costs.

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

§ 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &.

Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?. 4. FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5.

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

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

See “Part A Buy-In” YES YES Pays Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year.

(No retro for January application). See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid.

Cannot have both, not even Medicaid with a spend-down. 2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below.

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

N.Y. Soc. Serv. L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7.

Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS.

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

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

Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work.

Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP.

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

The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations.

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

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

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

They cannot be in both. It is their choice. DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB.

4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments.

Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy.

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

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

Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A.

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

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

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

The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods.

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

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

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

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

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

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

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

One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program.

In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification.

NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test.

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

08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability).

Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan.

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

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

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

SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7.

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

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

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

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Singapore's Ministry of Health through the Health Promotion Board is building an online portal that will serve as a trove of resources for mental health.The website will feature mental and wellbeing is cipro good for uti content "curated by experts". The information will is cipro good for uti be a resource for "individuals who want to find information for themselves or their loved ones". It will be introduced on HealthHub, the ministry's web and mobile app-based platform that hosts a range of health content, rewards and e-services. According to a press statement, the HPB is planning to launch the pilot web portal in the latter part of this year.WHY IT MATTERSThe development of an online portal for national mental health resources is one of the key recommendations by the buy antibiotics Mental Wellness Taskforce (CoMWT) to address the psychosocial impact of the cipro on the Singaporean population.The task force said the existence of numerous online resources on mental health and wellbeing can be "confusing and overwhelming" for those who are seeking information is cipro good for uti. Based on engagement sessions of the Youth Mental Well-being Network with over 1,500 individuals, there are some concerns with the "currency, legitimacy and credibility" of the information found on various online sites.THE LARGER CONTEXTAside from the need for a one-stop online repository of resources around mental wellness, the CoMWT, which was set up last year in October, identified two other key issues that must be addressed through a whole-of-government approach.

The need for an overarching strategy is cipro good for uti to guide the alignment and track the progress of efforts around mental health across government agencies. And secondly, a better alignment of mental health training resources and more trained mental health professionals. Given these issues, the health ministry moved forward with expanding the task force into an interagency is cipro good for uti platform that will primarily oversee the implementation of the recommended actions on the stated issues. It will supervise the development of a national mental health and wellbeing strategy, which will be developed through a public consultation for next year. After the national strategy is formed, is cipro good for uti it will then track the progress of its implementation and impact.

The interagency will also coordinate efforts and monitor outcomes, "focusing on cross-cutting issues that require multi and interagency collaborations". The new is cipro good for uti body will be led by Dr Janil ​​Puthucheary, senior state minister of the MOH. Moreover, the task force has recommended setting up a national mental health competency framework with a common set of training standards and degrees of competencies expected of professionals and para-professionals who support persons with mental health conditions.Based on in-depth research conducted by the Institute of Mental is cipro good for uti Health (IMH) about 13% of over 1,000 Singaporean adults polled between May 2020 and June 2021 said they experienced symptoms of depression or anxiety.Over half of youth respondents surveyed by the National Youth Council claimed that the cipro has challenged their mental wellbeing. Top stressors cited were anxiety over the future, stress over finances and worries about academic or work performance.Another study conducted by the Singapore Management University's Centre for Research on Successful Ageing found a "stark" increase in feelings of isolation among the elderly since the imposition of a lockdown in April last year.The IMH has observed a 50% rise in calls made via its Mental Health Helpline last year compared to the previous year. Although it gradually waned by the end of is cipro good for uti 2020, there was an uptick again between January and May this year.

Callers cited concerns such as anxiety from work-from-home adjustments or home-based learning and social isolation.The National CARE Hotline, another service that was launched to provide psychological first aid and emotional support, has received over 45,000 calls as of May this year. The top three issues heard through the hotline were the is cipro good for uti need for emotional support, mental health-related issues and family-related or social matters.To support Singaporean citizens' mental health, various government agencies and non-profit organisations launched or expanded some 40 initiatives during the cipro. One of these is mindline.sg by the MOH Office for Healthcare Transformation. It is a web-based repository is cipro good for uti of resources and tools to improve mental wellbeing. Users can access a clinically validated self-assessment tool through the portal to understand their state of emotional wellbeing.

Based on the assessment, the platform is cipro good for uti can recommend appropriate intervention and support channels. ON THE RECORD"To succeed, we need to internalise the lessons learnt, not is cipro good for uti only in managing infectious diseases but also in addressing the mental health needs of the population moving forward. This is one of the key reasons why we have evolved the buy antibiotics Mental Wellness Taskforce... To look at addressing the population’s mental health in the longer term, with a focus on cross-cutting issues across agency is cipro good for uti lines," Masagos Zulkifli, Singapore's second Minister for Health, said in a speech delivered at the Singapore Mental Health Conference on Tuesday.Kaiser Permanente has donated a total of $143,000 to four safety net organizations that aim to expand virtual care to low-income and unhoused communities across Hawaii. The organization did so through the Virtual Care Innovation Network, a Kaiser Permanente-founded collaboration that aims to solve challenges associated with telehealth's implementation and sustainability.

"Virtual care has the potential to dramatically enhance access to is cipro good for uti high-quality care for underserved populations across our state," said Dr. John Yang, president and medical director for the Hawaii Permanente Medical Group, in a statement. WHY IT MATTERS Telehealth can play a particularly impactful role in Hawaii, where many is cipro good for uti of the residents would have to board a plane to access specialty care. According to the organization, Kaiser will award $57,000 each to the Community Clinic of Maui, in Wailuku, and the Honolulu-based Hawai'i Health and Harm Reduction Center. Kokua Kalihi Valley Comprehensive Family Services, also in Honolulu, will receive $12,000, and the West Hawaii Community Health Center, based in Kailua-Kona, is cipro good for uti will receive $17,000.

"We deeply appreciate the work of these safety net organizations to bridge this need in our communities and help achieve health equity for the people of Hawaii," said Yang.The money is part of $2.37 million total given to 59 safety net organizations across Kaiser Permanente's footprint, aimed toward expanding virtual care access in vulnerable communities. "The Virtual Care Innovation Network funding has helped our health centers in Hawaii expand access to virtual care through homeless outreach programs and also street medicine programs," said Robert Hirokawa, chief executive officer of the Hawaii Primary Care Association, is cipro good for uti in a statement. THE LARGER TREND Sen is cipro good for uti. Brian Schatz, D-Hawaii, told HIMSS TV earlier this summer that telemedicine is vital for any region with medically fragile individuals who may have trouble reaching in-person care."It's extraordinarily important for a couple reasons," he said. "You may live on Hawaii island, is cipro good for uti and the expert is on Oahu … or in New York City.

And this gives you access to the best physicians on the planet." Policymakers have also flagged the importance of centering the needs of at-risk populations in expanding access to telehealth, noting that both rural and urban people could be left behind in the virtual care revolution. ON is cipro good for uti THE RECORD "The grant has helped health centers bring care to their patient’s doorstep, thus reducing barriers to access and addressing digital equity for vulnerable patients," said Hirokawa about Kaiser Permanente's donation. Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.Healthcare organizations can use agile connected apps to supplement their electronic health records, as well as using HIE data to supplement internal clinical data, all while improving clinical workflows and improving data exchange and interoperability.This was the topic of a HIMSS21 Digital discussion between Harm Scherpbier, CMIO for HealthShare Exchange, and Subha Airan-Javia, founder and CEO of TrekIT Health, who pointed out the ways in which integrated health data exchanges can improve quality of care."The reality is that so many errors are related to communication failures," Airan-Javia said, noting they cost health systems more than $110 billion per year.

"We need a shared workspace where we can work together across specialties and disciplines to do things like flag critical status, share team-based tasks and see what everyone is working on at the same time."Team and task management applications, which provide shared task lists, will provide patient status updates in real time, for example."Another aspect of driving improved clinical care is providing access to real time, relevant data at the point of care," she added. "By bringing today data from multiple different sources, HIEs can drive a level of informed decision making that we can't do otherwise."Scherpbier noted having access to HIEs will better enable coordinated care, improve quality and outcomes, and lower costs—which all contributes to providing a better patient experience."Apps connected to HIEs can help bridge organizational data gaps, while FHIR-connected apps can bridge workflow gaps and data gaps," he said. "There are simply limitations to single vendor implementations, which healthcare organizations today prefer when it comes to EHRs."Care coordination and patient handoffs are where some of the most significant workflow gaps can occur.From Scherpbier's perspective, the aim is to bridge those gaps with HIEs, all while improving teamwork and communication and maintaining a single record and single point of truth.Airan-Javia agreed, noting agile technologies that are structured around how care is delivered, and which offer flexibility, will allow for changes in care over time, making it imperative that care providers have care applications that can adjust to that."It's really about access to information that's updated in real time, in a way that's easily accessible," she said. "Our ability to do smart, on-FHIR applications can really help drive what we can do with technology even further in healthcare.".

Singapore's Ministry of How to get propecia Health through the Health Promotion Board is building an online portal that will serve cheap cipro online canada as a trove of resources for mental health.The website will feature mental and wellbeing content "curated by experts". The information cheap cipro online canada will be a resource for "individuals who want to find information for themselves or their loved ones". It will be introduced on HealthHub, the ministry's web and mobile app-based platform that hosts a range of health content, rewards and e-services. According to a press statement, the HPB is planning to launch the pilot web portal in the latter part of this year.WHY IT MATTERSThe development of an online portal for national mental health resources is one of the key recommendations by the buy antibiotics Mental Wellness Taskforce (CoMWT) to address the psychosocial impact of cheap cipro online canada the cipro on the Singaporean population.The task force said the existence of numerous online resources on mental health and wellbeing can be "confusing and overwhelming" for those who are seeking information. Based on engagement sessions of the Youth Mental Well-being Network with over 1,500 individuals, there are some concerns with the "currency, legitimacy and credibility" of the information found on various online sites.THE LARGER CONTEXTAside from the need for a one-stop online repository of resources around mental wellness, the CoMWT, which was set up last year in October, identified two other key issues that must be addressed through a whole-of-government approach.

The need for an overarching strategy to guide the alignment and cheap cipro online canada track the progress of efforts around mental health across government agencies. And secondly, a better alignment of mental health training resources and more trained mental health professionals. Given these cheap cipro online canada issues, the health ministry moved forward with expanding the task force into an interagency platform that will primarily oversee the implementation of the recommended actions on the stated issues. It will supervise the development of a national mental health and wellbeing strategy, which will be developed through a public consultation for next year. After the national strategy is formed, it will then track the progress of cheap cipro online canada its implementation and impact.

The interagency will also coordinate efforts and monitor outcomes, "focusing on cross-cutting issues that require multi and interagency collaborations". The new body will be led by Dr Janil ​​Puthucheary, senior cheap cipro online canada state minister of the MOH. Moreover, the task force has recommended setting up a national mental health competency framework with a common set of training standards and degrees of competencies expected of professionals and para-professionals who support persons with mental health conditions.Based on in-depth research conducted by the Institute of Mental Health cheap cipro online canada (IMH) about 13% of over 1,000 Singaporean adults polled between May 2020 and June 2021 said they experienced symptoms of depression or anxiety.Over half of youth respondents surveyed by the National Youth Council claimed that the cipro has challenged their mental wellbeing. Top stressors cited were anxiety over the future, stress over finances and worries about academic or work performance.Another study conducted by the Singapore Management University's Centre for Research on Successful Ageing found a "stark" increase in feelings of isolation among the elderly since the imposition of a lockdown in April last year.The IMH has observed a 50% rise in calls made via its Mental Health Helpline last year compared to the previous year. Although it gradually waned by the end of 2020, there was an uptick again between cheap cipro online canada January and May this year.

Callers cited concerns such as anxiety from work-from-home adjustments or home-based learning and social isolation.The National CARE Hotline, another service that was launched to provide psychological first aid and emotional support, has received over 45,000 calls as of May this year. The top three issues heard through the hotline were the need for emotional support, mental health-related issues and family-related or social matters.To support Singaporean citizens' cheap cipro online canada mental health, various government agencies and non-profit organisations launched or expanded some 40 initiatives during the cipro. One of these is mindline.sg by the MOH Office for Healthcare Transformation. It is a web-based repository of resources and cheap cipro online canada tools to improve mental wellbeing. Users can access a clinically validated self-assessment tool through the portal to understand their state of emotional wellbeing.

Based on the assessment, the platform can recommend appropriate intervention and cheap cipro online canada support channels. ON THE RECORD"To succeed, we need to internalise the lessons learnt, not only in managing infectious diseases but also in cheap cipro online canada addressing the mental health needs of the population moving forward. This is one of the key reasons why we have evolved the buy antibiotics Mental Wellness Taskforce... To look at addressing the population’s mental health in the longer term, with a focus on cross-cutting issues across agency lines," Masagos Zulkifli, Singapore's second Minister for Health, said in a speech delivered at the Singapore Mental Health Conference on Tuesday.Kaiser Permanente has donated a total of $143,000 cheap cipro online canada to four safety net organizations that aim to expand virtual care to low-income and unhoused communities across Hawaii. The organization did so through the Virtual Care Innovation Network, a Kaiser Permanente-founded collaboration that aims to solve challenges associated with telehealth's implementation and sustainability.

"Virtual care has the potential to dramatically enhance access to high-quality cheap cipro online canada care for underserved populations across our state," said Dr. John Yang, president and medical director for the Hawaii Permanente Medical Group, in a statement. WHY IT MATTERS cheap cipro online canada Telehealth can play a particularly impactful role in Hawaii, where many of the residents would have to board a plane to access specialty care. According to the organization, Kaiser will award $57,000 each to the Community Clinic of Maui, in Wailuku, and the Honolulu-based Hawai'i Health and Harm Reduction Center. Kokua Kalihi Valley Comprehensive Family Services, also in Honolulu, will cheap cipro online canada receive $12,000, and the West Hawaii Community Health Center, based in Kailua-Kona, will receive $17,000.

"We deeply appreciate the work of these safety net organizations to bridge this need in our communities and help achieve health equity for the people of Hawaii," said Yang.The money is part of $2.37 million total given to 59 safety net organizations across Kaiser Permanente's footprint, aimed toward expanding virtual care access in vulnerable communities. "The Virtual Care Innovation Network funding cheap cipro online canada has helped our health centers in Hawaii expand access to virtual care through homeless outreach programs and also street medicine programs," said Robert Hirokawa, chief executive officer of the Hawaii Primary Care Association, in a statement. THE cheap cipro online canada LARGER TREND Sen. Brian Schatz, D-Hawaii, told HIMSS TV earlier this summer that telemedicine is vital for any region with medically fragile individuals who may have trouble reaching in-person care."It's extraordinarily important for a couple reasons," he said. "You may live on Hawaii island, and the expert is on Oahu … or in New cheap cipro online canada York City.

And this gives you access to the best physicians on the planet." Policymakers have also flagged the importance of centering the needs of at-risk populations in expanding access to telehealth, noting that both rural and urban people could be left behind in the virtual care revolution. ON THE RECORD "The cheap cipro online canada grant has helped health centers bring care to their patient’s doorstep, thus reducing barriers to access and addressing digital equity for vulnerable patients," said Hirokawa about Kaiser Permanente's donation. Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.Healthcare organizations can use agile connected apps to supplement their electronic health records, as well as using HIE data to supplement internal clinical data, all while improving clinical workflows and improving data exchange and interoperability.This was the topic of a HIMSS21 Digital discussion between Harm Scherpbier, CMIO for HealthShare Exchange, and Subha Airan-Javia, founder and CEO of TrekIT Health, who pointed out the ways in which integrated health data exchanges can improve quality of care."The reality is that so many errors are related to communication failures," Airan-Javia said, noting they cost health systems more than $110 billion per year.

"We need a shared workspace where we can work together across specialties and disciplines to do things like flag critical status, share team-based tasks and see what everyone is working on at the same time."Team and task management applications, which provide shared task lists, will provide patient status updates in real time, for example."Another aspect of driving improved clinical care is providing access to real time, relevant data at the point of care," she added. "By bringing today data from multiple different sources, HIEs can drive a level of informed decision making that we can't do otherwise."Scherpbier noted having access to HIEs will better enable coordinated care, improve quality and outcomes, and lower costs—which all contributes to providing a better patient experience."Apps connected to HIEs can help bridge organizational data gaps, while FHIR-connected apps can bridge workflow gaps and data gaps," he said. "There are simply limitations to single vendor implementations, which healthcare organizations today prefer when it comes to EHRs."Care coordination and patient handoffs are where some of the most significant workflow gaps can occur.From Scherpbier's perspective, the aim is to bridge those gaps with HIEs, all while improving teamwork and communication and maintaining a single record and single point of truth.Airan-Javia agreed, noting agile technologies that are structured around how care is delivered, and which offer flexibility, will allow for changes in care over time, making it imperative that care providers have care applications that can adjust to that."It's really about access to information that's updated in real time, in a way that's easily accessible," she said. "Our ability to do smart, on-FHIR applications can really help drive what we can do with technology even further in healthcare.".

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The Framework for mental health and psychosocial support in radiological and nuclear emergencies, released today, brings together, for the first time, existing knowledge from the fields of mental health and who can buy cipro online protection does cipro make you urinate more from radiation in an integrated guide for preparedness for and response to nuclear and radiological emergencies. Past nuclear and radiological accidents have shown that the mental health and psychosocial consequences of such events can outweigh the direct physical health impacts of does cipro make you urinate more radiation exposure. Both the Chernobyl and Fukushima nuclear accidents were reported to have considerable diverse does cipro make you urinate more and long-lasting social, psychological and mental health consequences affecting both individuals and societies as a whole.

The Framework is intended for officials and specialists involved in radiation emergency planning and risk management as well as mental health and psychosocial support (MHPSS) experts working in health emergencies.Up to 5 million deaths a year could be averted if the global population was more active. At a time when many people are home bound due to buy antibiotics, new WHO Guidelines on physical activity and sedentary behaviour, launched today, emphasize that everyone, of all ages and abilities, can be physically active and that every type of movement counts.The new guidelines recommend at least 150 to 300 minutes of moderate to vigorous aerobic activity per week for all adults, including people living with chronic conditions or disability, and an average of 60 minutes per day for children and adolescents.WHO statistics show that one in four does cipro make you urinate more adults, and four out of five adolescents, do not get enough physical activity. Globally this is estimated to cost US$54 billion in direct does cipro make you urinate more health care and another US$14 billion to lost productivity.The guidelines encourage women to maintain where can you buy cipro over the counter regular physical activity throughout pregnancy and post-delivery.

They also highlight the valuable health benefits of physical activity for people living with disabilities.Older adults (aged 65 years or older) are advised to add activities which emphasize balance and coordination, as well as muscle strengthening, to help prevent falls and improve health.Regular physical activity is key to preventing and helping to manage heart disease, type-2 diabetes, and cancer, as well as reducing symptoms of depression and anxiety, reducing cognitive decline, improving memory and boosting brain health.“Being physically active is critical for health and well-being – it can help to add years to life and life to years,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. €œEvery move counts, especially now does cipro make you urinate more as we manage the constraints of the buy antibiotics cipro. We must all move every day – safely and creatively.” All does cipro make you urinate more physical activity is beneficial and can be done as part of work, sport and leisure or transport (walking, wheeling and cycling), but also through dance, play and everyday household tasks, like gardening and cleaning.“Physical activity of any type, and any duration can improve health and wellbeing, but more is always better,” said Dr Ruediger Krech, Director of Health Promotion, World Health Organization, “and if you must spend a lot of time sitting still, whether at work or school, you should do more physical activity to counter the harmful effects of sedentary behaviour.”“These new guidelines highlight how important being active is for our hearts, bodies and minds, and how the favourable outcomes benefit everyone, of all ages and abilities”, said Dr Fiona Bull, Head of the Physical Activity Unit which led the development of the new WHO guidelines.WHO encourages countries to adopt the global guidelines to develop national health policies in support of the WHO Global action plan on physical activity 2018-2030.

The plan was agreed by global health leaders at the 71st World Health Assembly in 2018 to reduce physical inactivity by 15% by 2030..

The Framework for mental health and psychosocial support in radiological and nuclear emergencies, released today, brings together, for the first time, existing knowledge from the fields of mental health and protection from radiation in an integrated guide for preparedness for and response cheap cipro online canada to nuclear and radiological emergencies http://robertflannagan.com/?page_id=2. Past nuclear and radiological accidents have shown that the mental health and psychosocial consequences of such events can outweigh the direct physical health impacts of cheap cipro online canada radiation exposure. Both the Chernobyl and Fukushima nuclear accidents were reported to have considerable diverse and long-lasting social, psychological and cheap cipro online canada mental health consequences affecting both individuals and societies as a whole. The Framework is intended for officials and specialists involved in radiation emergency planning and risk management as well as mental health and psychosocial support (MHPSS) experts working in health emergencies.Up to 5 million deaths a year could be averted if the global population was more active. At a time when many people are home bound due to buy antibiotics, new WHO Guidelines on physical activity and sedentary behaviour, launched today, emphasize that everyone, of all ages and abilities, can be physically active and that every type of movement counts.The new guidelines cheap cipro online canada recommend at least 150 to 300 minutes of moderate to vigorous aerobic activity per week for all adults, including people living with chronic conditions or disability, and an average of 60 minutes per day for children and adolescents.WHO statistics show that one in four adults, and four out of five adolescents, do not get enough physical activity.

Globally this is estimated to cost US$54 billion in direct health care and another cheap cipro online canada US$14 billion to lost productivity.The guidelines encourage women to maintain regular physical activity throughout pregnancy and post-delivery. They also highlight the valuable health benefits of physical activity for people living with disabilities.Older adults (aged 65 years or older) are advised to add activities which emphasize balance and coordination, as well as muscle strengthening, to help prevent falls and improve health.Regular physical activity is key to preventing and helping to manage heart disease, type-2 diabetes, and cancer, as well as reducing symptoms of depression and anxiety, reducing cognitive decline, improving memory and boosting brain health.“Being physically active is critical for health and well-being – it can help to add years to life and life to years,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. €œEvery move counts, cheap cipro online canada especially now as we manage the constraints of the buy antibiotics cipro. We must all move every day – safely and creatively.” All physical activity is beneficial and can be done as part of work, sport and leisure or transport (walking, wheeling and cycling), but also through dance, play and everyday household tasks, like gardening and cleaning.“Physical activity of any type, and any duration can improve health and wellbeing, but more is always better,” said Dr cheap cipro online canada Ruediger Krech, Director of Health Promotion, World Health Organization, “and if you must spend a lot of time sitting still, whether at work or school, you should do more physical activity to counter the harmful effects of sedentary behaviour.”“These new guidelines highlight how important being active is for our hearts, bodies and minds, and how the favourable outcomes benefit everyone, of all ages and abilities”, said Dr Fiona Bull, Head of the Physical Activity Unit which led the development of the new WHO guidelines.WHO encourages countries to adopt the global guidelines to develop national health policies in support of the WHO Global action plan on physical activity 2018-2030. The plan was agreed by global health leaders at the 71st World Health Assembly in 2018 to reduce physical inactivity by 15% by 2030..

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