Cialis over the counter

Cialis costco pharmacy

IntroductionIn recent years, many studies have been published on new diagnostic possibilities and management approaches in cohorts of patients suspected to have a disorder/difference of sex development (DSD).1–13 Based on these studies, it has become clear cialis costco pharmacy that services and institutions still differ in the composition of the multidisciplinary teams that provide care for patients who have a DSD.11 14 Several projects have now worked to resolve this variability in care. The European Cooperation in Science and Technology (EU COST) action BM1303 ‘A systematic elucidation of differences of sex development’ has been a platform to achieve European agreement on harmonisation of clinical management and laboratory practices.15–17 Another such initiative involved an update of the 2006 DSD consensus document by an international group of professionals and patient representatives.18 These initiatives have highlighted how cultural and financial aspects and the availability of resources differ significantly between countries and societies, a situation that hampers supranational agreement on common diagnostic protocols. As only a few national guidelines have been published cialis costco pharmacy in international journals, comparison of these guidelines is difficult even though such a comparison is necessary to capture the differences and initiate actions to overcome them. Nonetheless, four DSD (expert) centres located in the Netherlands and Flanders (the Dutch-speaking Northern part of Belgium) have collaborated to produce a detailed guideline on diagnostics in DSD.19 This shows that a supranational guideline can be a reasonable approach for countries with similarly structured healthcare systems and similar resources. Within the guideline there is agreement cialis costco pharmacy that optimisation of expertise and care can be achieved through centralisation, for example, by limiting analysis of next-generation sequencing (NGS)-based diagnostic panels to only a few centres and by centralising pathological review of gonadal tissues.

International networks such as the European Reference Network for rare endocrine conditions (EndoERN), in which DSD is embedded, may facilitate the expansion of this kind of collaboration across Europe.This paper highlights key discussion points in the Dutch-Flemish guideline that have been insufficiently addressed in the literature thus far because they reflect evolving technologies or less visible stakeholders. For example, prenatal observation of an atypical aspect of the genitalia indicating a possible DSD is becoming increasingly cialis costco pharmacy common, and we discuss appropriate counselling and a diagnostic approach for these cases, including the option of using NGS-based genetic testing. So far, little attention has been paid to this process.20 21 Furthermore, informing patients and/or their parents about atypical sex development and why this may warrant referral to a specialised team may be challenging, especially for professionals with limited experience in DSD.22 23 Therefore, a section of the Dutch-Flemish guideline was written for these healthcare providers. Moreover, this enables DSD specialists to refer to the guideline when advising a referral cialis costco pharmacy. Transition from the prenatal to the postnatal team and from the paediatric to the adult team requires optimal communication between the specialists involved.

Application of NGS-based techniques may lead to a higher diagnostic yield, providing a molecular genetic diagnosis in previously unsolved cases.16 We address the timing of this testing and the problems associated with this technique such as the interpretation of variants of unknown clinical significance (VUS). Similarly, histopathological interpretation and classification of removed gonadal tissue is cialis costco pharmacy challenging and would benefit from international collaboration and centralisation of expertise.MethodsFor the guideline revision, an interdisciplinary multicentre group was formed with all members responsible for updating the literature for a specific part of the guideline. Literature search in PubMed was not systematic, but rather intended to be broad in order to cover all areas and follow expert opinions. This approach is more in line with the Clinical cialis costco pharmacy Practice Advisory Document method described by Burke et al24 for guidelines involving genetic practice because it is often troublesome to substantiate such guidelines with sufficient evidence due to the rapid changes in testing methods, for example, gene panels. All input provided by the group was synthesised by the chairperson (YvB), who also reviewed abstracts of papers on DSD published between 2010 and September 2017 for the guideline and up to October 2019 for this paper.

Abstracts had to be written in English and were identified using a broad range of Medical Subject Headings terms (eg, DSD, genetic, review, diagnosis, diagnostics, 46,XX DSD, 46,XY DSD, cialis costco pharmacy guideline, multidisciplinary care). Next, potentially relevant papers on diagnostic procedures in DSD were selected. Case reports were excluded, as were articles that were not open access or retrievable cialis costco pharmacy through institutional access. Based on this, a draft guideline was produced that was in line with the international principles of good diagnostic care in DSD. This draft was discussed by the writing cialis costco pharmacy committee and, after having obtained agreement on remaining points of discussion, revised into a final draft.

This version was sent to a broad group of professionals from academic centres and DSD teams whose members had volunteered to review the draft guideline. After receiving and incorporating their input, the final version was presented to the paediatric and genetic associations for approval. After approval by the members of the paediatric (NVK), clinical genetic (VKGN) and genetic laboratory (VKGL) associations, the guideline was published on their respective websites.19 Although Turner syndrome and Klinefelter syndrome are considered cialis costco pharmacy to be part of the DSD spectrum, they are not extensively discussed in this diagnostic guideline as guidelines dedicated to these syndromes already exist.25 26 However, some individuals with Turner syndrome or Klinefelter syndrome may present with ambiguous or atypical genitalia and may therefore initially follow the DSD diagnostic process.Guideline highlightsPrenatal settingPresentationThe most frequent prenatal presentation of a DSD condition is atypical genitalia found on prenatal ultrasound as an isolated finding or in combination with other structural anomalies. This usually occurs after the 20-week routine medical ultrasound for screening of congenital anomalies, but may also occur earlier, for example, when a commercial ultrasound is performed at the request of the parents.Another way DSD can be diagnosed before birth is when invasive prenatal genetic testing carried out for a different reason, for example, due to suspicion of other structural anomalies, reveals a discrepancy between the genotypic sex and the phenotypic sex seen by ultrasound. In certified laboratories, the possibility of a sample cialis costco pharmacy switch is extremely low but should be ruled out immediately.

More often, the discrepancy will be due to sex-chromosome mosaicism or a true form of DSD.A situation now occurring with increasing frequency is a discrepancy between the genotypic sex revealed by non-invasive prenatal testing (NIPT), which is now available to high-risk pregnant women in the Netherlands and to all pregnant women in Belgium, and later ultrasound findings. NIPT screens for CNVs in the fetus cialis costco pharmacy. However, depending on legal restrictions and/or ethical considerations, the X and Y chromosomes are not always included in NIPT analysis and reports. If the X and Y chromosomes are included, it is important to realise cialis costco pharmacy that the presence of a Y-chromosome does not necessarily imply male fetal development. At the time that NIPT is performed (usually 11–13 weeks), genital development cannot be reliably appreciated by ultrasound, so any discrepancy or atypical aspect of the genitalia will only be noticed later in pregnancy and should prompt further evaluation.Counselling and diagnosticsIf a DSD is suspected, first-line sonographers and obstetricians should refer the couple to their colleague prenatal specialists working with or in a DSD team.

After confirming an atypical genital on ultrasound, the specialist team should offer the couple a referral for genetic counselling to discuss the possibility of performing invasive prenatal testing (usually an amniocentesis) to identify an underlying cause that fits the ultrasound findings.22 23 To cialis costco pharmacy enable the parents to make a well-informed decision, prenatal counselling should, in our opinion, include. Information on the ultrasound findings and the limitations of this technique. The procedure(s) that can be followed, including the risks associated with an amniocentesis. And the type cialis costco pharmacy of information genetic testing can and cannot provide. Knowing which information has been provided and what words have been used by the prenatal specialist is very helpful for those involved in postnatal care.It is important that parents understand that the biological sex of a baby is determined by a complex interplay of chromosomes, genes and hormones, and thus that assessment of the presence or absence of a Y-chromosome alone is insufficient to assign the sex of their unborn child or, as in any unborn child, say anything about the child’s future gender identity.Expecting parents can be counselled by the clinical geneticist and the psychologist from the DSD team, although other DSD specialists can also be involved.

The clinical geneticist should be experienced in prenatal counselling and well informed about the diagnostic possibilities given the limited time span in which test results need to be available to allow parents cialis costco pharmacy to make a well-informed decision about whether or not to continue the pregnancy. Termination of pregnancy can be considered, for instance, in a syndromic form of DSD with multiple malformations, but when the DSD occurs as an apparently isolated condition, expecting parents may also consider termination of pregnancy, which, although considered controversial by some, is legal in Belgium and the Netherlands. The psychologist of the DSD team can support parents during and after pregnancy and help them cope with feelings of uncertainty and eventual considerations of a termination of pregnancy, as well as with practical issues, for cialis costco pharmacy example, how to inform others. The stress of not knowing exactly what the child’s genitalia will look like and uncertainty about the diagnosis, treatment and prognosis cannot be avoided completely. Parents are informed that if the postnatal phenotype is different from what was prenatally expected, the advice given about diagnostic testing can be adjusted accordingly, for cialis costco pharmacy example, if a hypospadias is milder than was expected based on prenatal ultrasound images.

In our experience, parents appreciate having already spoken to some members of the DSD team during pregnancy and having a contact person before birth.After expert prenatal counselling, a significant number of pregnant couples decline prenatal testing (personal experience IALG, MK, ABD, YvB, MC and HC-vdG). At birth, umbilical cord blood is a good source for (molecular) karyotyping and storage of DNA and can be obtained by the cialis costco pharmacy obstetrician, midwife or neonatologist. The terminology used in communication with parents should be carefully chosen,22 23 and midwives and staff of neonatal and delivery units should be clearly instructed to use gender-neutral and non-stigmatising vocabulary (eg, ‘your baby’) as long as sex assignment is pending.An algorithm for diagnostic evaluation of a suspected DSD in the prenatal situation is proposed in figure 1. When couples opt for invasive prenatal diagnosis, the genetic analysis usually involves an (SNP)-array. It was recently estimated that >30% of individuals who have a DSD have additional structural anomalies, with cardiac cialis costco pharmacy and neurological anomalies and fetal growth restriction being particularly common.27 28 If additional anomalies are seen, the geneticist can consider specific gene defects that may underlie a known genetic syndrome or carry out NGS.

NGS-based techniques have also now made their appearance in prenatal diagnosis of congenital anomalies.29 30 Panels using these techniques can be specific for genes involved in DSD, or be larger panels covering multiple congenital anomalies, and are usually employed with trio-analysis to compare variants identified in the child with the parents’ genetics.29–31 Finding a genetic cause before delivery can help reduce parental stress in the neonatal period and speed up decisions regarding gender assignment. In such cases there is no tight time limit, and we propose completing the analysis well before cialis costco pharmacy the expected delivery.Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 1 Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!.

Conventional karyotyping can be useful. NGS, next-generation sequencing.First contact by a professional less experienced in DSDWhereas most current guidelines start from the point when an individual has been referred to the DSD team,1 15 the Dutch-Flemish guideline dedicates a chapter to healthcare professionals less experienced in DSD as they are often the first to suspect or identify such a condition. Apart from the paper of Indyk,7 little guidance is available for these professionals about how to act in such a situation. The chapter in the Dutch-Flemish guideline summarises the various clinical presentations that a DSD can have and provides information on how to communicate with parents and/or patients about the findings of the physical examination, the first-line investigations and the need for prompt referral to a specialised centre for further evaluation. Clinical examples are offered to illustrate some of these recurring situations.

The medical issues in DSD can be very challenging, and the social and psychological impact is high. For neonates with ambiguous genitalia, sex assignment is an urgent and crucial issue, and it is mandatory that parents are informed that it is possible to postpone registration of their child’s sex. In cases where sex assignment has already taken place, the message that the development of the gonads or genitalia is still atypical is complicated and distressing for patients and parents or carers. A list of contact details for DSD centres and patient organisations in the Netherlands and Flanders is attached to the Dutch-Flemish guideline. Publishing such a list, either in guidelines or online, can help healthcare professionals find the nearest centres for consultations and provide patients and patient organisations with an overview of the centres where expertise is available.Timing and place of genetic testing using NGS-based gene panelsThe diagnostic workup that is proposed for 46,XX and 46,XY DSD is shown in figures 2 and 3, respectively.

Even with the rapidly expanding molecular possibilities, a (family) history and a physical examination remain the essential first steps in the diagnostic process. Biochemical and hormonal screening aim at investigating serum electrolytes, renal function and the hypothalamic-pituitary-gonadal and hypothalamic-pituitary-adrenal axes. Ultrasound screening of kidneys and internal genitalia, as well as establishing genotypic sex, should be accomplished within 48 hours and complete the baseline diagnostic work-up of a child born with ambiguous genitalia.1 16 32 3346,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing.

CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone." data-icon-position data-hide-link-title="0">Figure 2 46,XX disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia.

AMH, Anti-Müllerian Hormone.46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. * SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing." data-icon-position data-hide-link-title="0">Figure 3 46,XY disorders/differences of sex development (DSD) in the postnatal setting. A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

NGS, next-generation sequencing.Very recently, a European position paper has been published focusing on the genetic workup of DSD.16 It highlights the limitations and drawbacks of NGS-based tests, which include the chance of missing subtle structural variants such as CNVs and mosaicism and the fact that NGS cannot detect methylation defects or other epigenetic changes.16 28 31 Targeted DNA analysis is preferred in cases where hormonal investigations suggest a block in steroidogenesis (eg, 11-β-hydroxylase deficiency, 21-hydroxylase deficiency), or in the context of a specific clinical constellation such as the often coincidental finding of Müllerian structures in a boy with normal external genitalia or cryptorchidism, that is, persistent Müllerian duct syndrome.33 34 Alternative tests should also be considered depending on the available information. Sometimes, a simple mouth swab for FISH analysis can detect mosaic XY/X in a male with hypospadias or asymmetric gonadal development or in a female with little or no Turner syndrome stigmata and a normal male molecular karyotyping profile or peripheral blood karyotype. Such targeted testing avoids incidental findings and is cheaper and faster than analysis of a large NGS-based panel, although the cost difference is rapidly declining.However, due to the genetic and phenotypic heterogeneity of DSD conditions, the most cost-effective next steps in the majority of cases are whole exome sequencing followed by panel analysis of genes involved in genital development and function or trio-analysis of a large gene panel (such as a Mendeliome).16 35–38 Pretest genetic counselling involves discussing what kind of information will be reported to patients or parents and the chance of detecting VUS, and the small risk of incidental findings when analysing a DSD panel should be mentioned. Laboratories also differ in what class of variants they report.39 In our experience, the fear of incidental findings is a major reason why some parents refrain from genetic testing.Timing of the DSD gene panel analysis is also important. While some patients or parents prefer that all diagnostic procedures be performed as soon as possible, others need time to reflect on the complex information related to more extensive genetic testing and on its possible consequences.

If parents or patients do not consent to panel-based genetic testing, analysis of specific genes, such as WT1, should be considered when appropriate in view of the clinical consequences if a mutation is present (eg, clinical surveillance of renal function and screening for Wilms’ tumour in the case of WT1 mutations). Genes that are more frequently involved in DSD (eg, SRY, NR5A1) and that match the specific clinical and hormonal features in a given patient could also be considered for sequencing. Targeted gene analysis may also be preferred in centres located in countries that do not have the resources or technical requirements to perform NGS panel-based genetic testing. Alternatively, participation by these centres in international collaborative networks may allow them to outsource the molecular genetic workup abroad.Gene panels differ between centres and are regularly updated based on scientific progress. A comparison of DSD gene panels used in recent studies can be found at https://www.nature.com/articles/s41574-018-0010-8%23Sec46.15 The panels currently used at the coauthors’ institutions can be found on their respective websites.

Given the pace of change, it is important to regularly consider repeating analysis in patients with an unexplained DSD, for example, when they transition into adult care or when they move from one centre to another. This also applies to patients in whom a clinical diagnosis has never been genetically confirmed. Confusion may arise when the diagnosis cannot be confirmed or when a mutation is identified in a different gene, for example, NR5A1 in someone with a clinical diagnosis of CAIS that has other consequences for relatives. Hence, new genetic counselling should always accompany new diagnostic endeavours.Class 3 variants and histopathological examinationsThe rapidly evolving diagnostic possibilities raise new questions. What do laboratories report?.

How should we deal with the frequent findings of mainly unique VUS or class 3 variants (ACMG recommendation) in the many different DSD-related genes in the diagnostic setting?. Reporting VUS can be a source of uncertainty for parents, but not reporting these variants precludes further investigations to determine their possible pathogenicity. It can also be difficult to prove variant pathogenicity, both on gene-level and variant-level.39 Moreover, given the gonad-specific expression of some genes and the variable phenotypic spectrum and reduced penetrance, segregation analysis is not always informative. A class 3 variant that does not fit the clinical presentation may be unrelated to the observed phenotype, but it could also represent a newly emerging phenotype. This was recently demonstrated by the identification of the NR5A1 mutation, R92W, in individuals with 46,XX testicular and ovotesticular DSD.40 This gene had previously been associated with 46,XY DSD.

In diagnostic laboratories, there is usually no capacity or expertise to conduct large-scale functional studies to determine pathogenicity of these unique class 3 VUS in the different genes involved in DSD. Functional validation of variants identified in novel genes may be more attractive in a research context. However, for individual families with VUS in well-established DSD genes such as AR or HSD17B3, functional analysis may provide a confirmed diagnosis that implies for relatives the option of undergoing their own DNA analysis and estimating the genetic risk of their own future offspring. This makes genetic follow-up important in these cases and demonstrates the usefulness of international databases and networks and the centralisation of functional studies of genetic variants in order to reduce costs and maximise expertise.The same is true for histopathological description, germ-cell tumour risk assessment in specific forms of DSD and classification of gonadal samples. Germ-cell tumour risk is related to the type of DSD (among other factors), but it is impossible to make risk estimates in individual cases.41–44 Gonadectomy may be indicated in cases with high-risk dysgenetic abdominal gonads that cannot be brought into a stable superficial (ie, inguinal, labioscrotal) position that allows clinical or radiological surveillance, or to avoid virilisation due to 5-alpha reductase deficiency in a 46,XY girl with a stable female gender identity.45 Pathological examination of DSD gonads requires specific expertise.

For example, the differentiation between benign germ cell abnormalities, such as delayed maturation and (pre)malignant development of germ cells, is crucial for clinical management but can be very troublesome.46 Centralised pathological examination of gonadal biopsy and gonadectomy samples in one centre, or a restricted number of centres, on a national scale can help to overcome the problem of non-uniform classification and has proven feasible in the Netherlands and Belgium. We therefore believe that uniform assessment and classification of gonadal differentiation patterns should also be addressed in guidelines on DSD management.International databases of gonadal tissues are crucial for learning more about the risk of malignancy in different forms of DSD, but they are only reliable if uniform criteria for histological classification are strictly applied.46 These criteria could be incorporated in many existing networks such as the I-DSD consortium, the Disorders of Sex Development Translational Research Network, the European Reference Network on Urogenital Diseases (eUROGEN), the EndoERN and COST actions.15–17 47Communication at the transition from paediatric to adult carePaediatric and adult teams need to collaborate closely to facilitate a well-organised transition from paediatric to adult specialist care.15 48–50 Both teams need to exchange information optimally and should consider transition as a longitudinal process rather than a fixed moment in time. Age-appropriate information is key at all ages, and an overview of topics to be discussed at each stage is described by Cools et al.15 Table 1 shows an example of how transition can be organised.View this table:Table 1 Example of transition table as used in the DSD clinic of the Erasmus Medical CenterPsychological support and the continued provision of information remains important for individuals with a DSD at all ages.15 22 In addition to the information given by the DSD team members, families and patients can benefit from resources such as support groups and information available on the internet.47 Information available online should be checked for accuracy and completeness when referring patients and parents to internet sites.Recommendations for future actionsMost guidelines and articles on the diagnosis and management of DSD are aimed at specialists and are only published in specialist journals or on websites for endocrinologists, urologists or geneticists. Yet there is a need for guidelines directed towards first-line and second-line healthcare workers that summarise the recommendations about the first crucial steps in the management of DSD. These should be published in widely available general medical journals and online, along with a national list of DSD centres.

Furthermore, DSD (expert) centres should provide continuous education to all those who may be involved in the identification of individuals with a DSD in order to enable these healthcare professionals to recognise atypical genitalia, to promptly refer individuals who have a DSD and to inform the patient and parents about this and subsequent diagnostic procedures.As DSD continues to be a rare condition, it will take time to evaluate the effects of having such a guideline on the preparedness of first-line and second-line healthcare workers to recognise DSD conditions. One way to evaluate this might be the development and use of questionnaires asking patients, carers and families and referring physicians how satisfied they were with the initial medical consultation and referral and what could be improved. A helpful addition to existing international databases that collect information on genetic variations would be a list of centres that offer suitable functional studies for certain genes, ideally covering the most frequently mutated genes (at minimum).Patient organisations can also play an important role in informing patients about newly available diagnostic or therapeutic strategies and options, and their influence and specific role has now been recognised and discussed in several publications.17 47 However, it should be kept in mind that these organisations do not represent all patients, as a substantial number of patients and parents are not member of such an organisation.Professionals have to provide optimal medical care based on well-established evidence, or at least on broad consensus. Yet not everything can be regulated by recommendations and guidelines. Options, ideas and wishes should be openly discussed between professionals, patients and families within their confidential relationship.

This will enable highly individualised holistic care tailored to the patient’s needs and expectations. Once they are well-informed of all available options, parents and/or patients can choose what they consider the optimal care for their children or themselves.15 16ConclusionThe Dutch-Flemish guideline uniquely addresses some topics that are under-represented in the literature, thus adding some key aspects to those addressed in recent consensus papers and guidelines.15–17 33 47As more children with a DSD are now being identified prenatally, and the literature on prenatal diagnosis of DSD remains scarce,20 21 we propose a prenatal diagnostic algorithm and emphasise the importance of having a prenatal specialist involved in or collaborating with DSD (expert) centres.We also stress that good communication between all involved parties is essential. Professionals should be well informed about protocols and communication. Collaboration between centres is necessary to optimise aspects of care such as uniform interpretation of gonadal pathology and functional testing of class 3 variants found by genetic testing. Guidelines can provide a framework within which individualised patient care should be discussed with all stakeholders.AcknowledgmentsThe authors would like to thank the colleagues of the DSD teams for their input in and critical reading of the Dutch-Flemish guideline.

Amsterdam University Center (AMC and VU), Maastricht University Medical Center, Erasmus Medical Center Rotterdam, Radboud University Medical Center Nijmegen, University Medical Center Groningen, University Medical Center Utrecht, Ghent University Hospital. The authors would like to thank Kate McIntyre for editing the revised manuscript and Tom de Vries Lentsch for providing the figures as a PDF. Three of the authors of this publication are members of the European Reference Network for rare endocrine diseases—Project ID 739543..

Cialis over the counter

Cialis
Forzest
Filitra professional
Viagra with fluoxetine
Kamagra
Best price in Great Britain
Yes
Yes
No
Yes
Yes
Best way to use
Yes
No
Yes
No
No
Online price
17h
15h
6h
5h
15h
Buy with Bitcoin
60mg 10 tablet $49.95
20mg 12 tablet $99.95
20mg 180 sublingual tablet $494.95
$
100mg 92 tablet $183.95

Those in QMB receive additional subsidies cialis over the counter for Medicare costs. See 2021 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 Note.

Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP. See this article for more info. TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A.

Summary Chart of MSP Programs 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 (2021) Single Couple Single Couple Single Couple $1,094 $1,472 $1,308 $1,762 $1,469 $1,980 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). 2021 FPL levels were released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II 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 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.

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

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

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

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

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

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

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

In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link.

(Updated 4/14/2021.)) 3. The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP).

The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people. Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits.

MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program. Note.

MSP limits are based on the federal poverty line (FPL). The new FPL is released by the federal government at the beginning of each year, but it takes some time for the state to implement them. Therefore, as of February 2021, the MSP limits are still based on the 2020 FPL. This article will be updated with the 2021 limits when they are released.

In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP. Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down.

Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example. Sam is age 50 and has Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity.

$ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,276 (2020) but she can still qualify for MIPP.

2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL.

MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3.

New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS.

The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c).

These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during erectile dysfunction treatment emergency their case may remain with NYSoH for more than 12 months. See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process.

Note. During the erectile dysfunction treatment emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on erectile dysfunction treatment eligibility changes 4.

Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN.

See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums. See page 96 of the Medicaid Reference Guide (Categorical Factors).

If their income is lower than the MSP SLIMB threshold, they can be added to MSP. If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11.

Soc where can you buy cialis cialis costco pharmacy. Serv. L. § 367-a(3)(a), (b), and (d) cialis costco pharmacy.

2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging Note. Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP. See this cialis costco pharmacy article for more info. TOPICS COVERED IN THIS ARTICLE 1.

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

The Three MSP Programs - What are they and how are they Different? cialis costco pharmacy. 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 cialis costco pharmacy 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 cialis costco pharmacy. 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! cialis costco pharmacy. 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 cialis costco pharmacy ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2021) Single Couple Single Couple Single Couple $1,094 $1,472 $1,308 $1,762 $1,469 $1,980 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 cialis costco pharmacy &.

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 cialis costco pharmacy applica-tion, but only within the current calendar year. (No retro for January application).

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

Cannot have both, not cialis costco pharmacy 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 cialis costco pharmacy limits are tied to the Federal Poverty Level (FPL).

2021 FPL levels were released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II 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 cialis costco pharmacy 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 2021 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 cialis costco pharmacy. Soc. Serv.

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

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

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

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

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

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

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

Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837.

(The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021.)) 3. The Three Medicare Savings Programs - what are they and how are they different?. 1.

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

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

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

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

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

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

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

Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason.

Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients.

In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2.

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

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

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

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

Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down.

Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification.

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

Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website.

Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below.

Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See http://freeonlinepoker.org.uk/review/betfred-poker/ 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.

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

18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year. 7.

QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid.

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

This article was authored by the Empire Justice Center.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP). The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people. Some people are not eligible for an MSP even though they have full Medicaid with no spend down.

This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits. MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program.

Note. MSP limits are based on the federal poverty line (FPL). The new FPL is released by the federal government at the beginning of each year, but it takes some time for the state to implement them. Therefore, as of February 2021, the MSP limits are still based on the 2020 FPL.

This article will be updated with the 2021 limits when they are released. In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP.

Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example. Sam is age 50 and has Medicare and MBI-WPD.

She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income.

This is above the SLIMB limit of $1,276 (2020) but she can still qualify for MIPP. 2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time.

This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP.

(See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3. New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age.

AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS. The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd.

4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during erectile dysfunction treatment emergency their case may remain with NYSoH for more than 12 months. See here.

See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note. During the erectile dysfunction treatment emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments.

See GIS 20 MA/04 or this article on erectile dysfunction treatment eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit.

If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums.

See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP. If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11.

Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &. 1619B.

What side effects may I notice from Cialis?

Side effects that you should report to your doctor or health care professional as soon as possible:

  • allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
  • breathing problems
  • changes in hearing
  • chest pain
  • fast, irregular heartbeat

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

  • back pain
  • dizziness
  • flushing
  • headache
  • indigestion
  • muscle aches
  • stuffy or runny nose

This list may not describe all possible side effects.

Cheapest place to buy cialis

5 and pregnant women have HIGHER how much does cialis cost at walgreens LIMITS than shown ESSENTIAL PLAN For MAGI-eligible people over MAGI income cheapest place to buy cialis limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All of the attachments with the various levels are posted here.

NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE cheapest place to buy cialis LEVELS?. Which household size applies?. The rules are complicated.

See cheapest place to buy cialis rules here. On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.

People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% cheapest place to buy cialis of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school.

42 cheapest place to buy cialis C.F.R. § 435.4. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <.

Age 1, cheapest place to buy cialis 154% FPL for children age 1 - 19. CAUTION. What is counted as income may not be what you think.

For the NON-MAGI Disabled/Aged 65+/Blind, income will cheapest place to buy cialis still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and bad changes.

GOOD cheapest place to buy cialis. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD.

There is no more "spousal" or parental refusal for this population cheapest place to buy cialis (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person.

HOWEVER, Medicaid rules about how to calculate cheapest place to buy cialis the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid. Here are the 2 basic categories and the rules for calculating their household size.

People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - cheapest place to buy cialis See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population.

Their household size will be determined using federal income tax rules, which are very cheapest place to buy cialis complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size.

See slides cheapest place to buy cialis 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category.

Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility cheapest place to buy cialis. See 18 NYCRR 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION.

Different people in the same cheapest place to buy cialis household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid.

Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% cheapest place to buy cialis FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples.

This category had lower income limits than DAB/ADC-related, but cheapest place to buy cialis had no asset limits. It did not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL.

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

PAST INCOME cheapest place to buy cialis &. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order. These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs in NYS.

This article was authored by the Evelyn Frank cheapest place to buy cialis Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care. The special income standard for housing expenses helps pay for housing expenses to help certain nursing home or adult home residents to safely transition back to the community with MLTC.

Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult cheapest place to buy cialis homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income Standard.

September 2018 NEWS -- Those already cheapest place to buy cialis enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify. "Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan.

Once an individual has been cheapest place to buy cialis accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community. Questions regarding the special income standard may be directed to DOH at 518-474-8887.

Who is eligible for this special income cheapest place to buy cialis standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC. How much is the allowance?.

The rates vary by region and change cheapest place to buy cialis yearly. Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $483 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates.

The guidance on how the standardized cheapest place to buy cialis amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS. 2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N.

Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 cheapest place to buy cialis HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!.

HOW TO OBTAIN THE HOUSING DISREGARD cheapest place to buy cialis. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it.

The procedures cheapest place to buy cialis in NYC are explained in this Troubleshooting guide. NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest).

NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy. References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard.

GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept. 28, 2018 - this finally implements the most recent Special Terms &. Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan.

19 in cialis costco pharmacy http://iconographymag.com/lanvin-h-m-interative-video/ school) 138% FPL*** Children <. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All of the attachments with the cialis costco pharmacy various levels are posted here. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?.

Which household size applies?. The rules are cialis costco pharmacy complicated. See rules here. On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- cialis costco pharmacy The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.

People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI cialis costco pharmacy INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R. § 435.4.

Certain populations have cialis costco pharmacy an even higher income limit - 224% FPL for pregnant women and babies <. Age 1, 154% FPL for children age 1 - 19. CAUTION. What is cialis costco pharmacy counted as income may not be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards.

However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes cialis costco pharmacy and bad changes. GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD cialis costco pharmacy.

There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits cialis costco pharmacy - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid.

Here are the 2 basic categories and the rules cialis costco pharmacy for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, cialis costco pharmacy including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated.

New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine cialis costco pharmacy the Household Size. See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the cialis costco pharmacy 1st "DAB" category.

Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p. 573, cialis costco pharmacy NYS GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.

The following programs were available prior to 2014, but are now discontinued because they are folded cialis costco pharmacy into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in cialis costo 5mg the household. It was sometimes known as "S/CC" category for Singles cialis costco pharmacy and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits.

It did not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group cialis costco pharmacy whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified cialis costco pharmacy Health Plans on the Exchange.

PAST INCOME &. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order. These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs cialis costco pharmacy in NYS. This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care.

The special income standard for cialis costco pharmacy housing expenses helps pay for housing expenses to help certain nursing home or adult home residents to safely transition back to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this cialis costco pharmacy Special Income Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below.

"How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify. "Nursing home administrators, cialis costco pharmacy nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan. Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community. Questions regarding the special income standard may be directed to DOH at cialis costco pharmacy 518-474-8887.

Who is eligible for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC. How much is the cialis costco pharmacy allowance?. The rates vary by region and change yearly. Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St.

Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $483 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS. 2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?.

Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!. HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it.

The procedures in NYC are explained in this Troubleshooting guide. NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest). NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy.

References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept. 28, 2018 - this finally implements the most recent Special Terms &. Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan.

Buy cialis online without prescription

Explore the full-page map Fifteen states have completely vaccinated more than 40% of their rural buy cialis online without prescription population, up from seven states can you buy over the counter cialis two weeks ago. Massachusetts led the way, with 59.7% of its rural residents completely vaccinated. The other top five states were Connecticut, New Hampshire, buy cialis online without prescription Maine, and Hawaii.

Nationally, 32.5% of the 46 million residents who live in nonmetropolitan counties are completely vaccinated, according to data from the Centers for Disease Control and Prevention and selected state health departments. In metropolitan counties, 40.0% of the population has been vaccinated, according to the Daily Yonder’s buy cialis online without prescription analysis of state and federal data. The gap between the rural and metropolitan vaccination rates was 7.5 percentage points as of June 7.

That’s down slightly from two weeks ago, when the gap was 8 percentage points. But that improvement is primarily from a buy cialis online without prescription change in how the Daily Yonder has collected data for this report, rather than an increase in vaccination activity on the ground in rural areas. This week, our analysis includes Texas and Hawaii, which the CDC has omitted in its reports.

We gathered Texas and Hawaii vaccination data buy cialis online without prescription directly from the Texas and Hawaii state departments of health. We also substituted state health department data for Massachusetts because of reporting anomalies identified in CDC data by the Provincetown Independent in Barnstable County. (For example, buy cialis online without prescription for several weeks in a row, the CDC has reported that Barnstable County’s rate of completed vaccinations was 4%.

State data show 63% of the county’s population has been completely vaccinated.) Like this story?. Sign up for our newsletter. The addition of state data buy cialis online without prescription from Texas alone added 1.24 million completed rural vaccinations.

That’s about 8% of the nation’s entire count of rural completed vaccinations, which stood at 14.9 million as of June 7. Texas has completely vaccinated 40.2% buy cialis online without prescription of its rural residents, according to state data. The graph below shows the percentage of rural and metropolitan populations that have completed erectile dysfunction treatment vaccinations.

(Data note buy cialis online without prescription. The percentage is calculated based on the size of the population for which we have vaccination data. Prior to June 7, the calculations excluded both the vaccinations and population figures for Texas and Hawaii.) The county-level map at the top of the story shows the completed vaccination rates by county.

County rates are compared to a national adjusted average, which buy cialis online without prescription this week is 38.9%. The map confirms the state rural vaccination rankings. New England, where most states are compact buy cialis online without prescription compared to the rest of the U.S., leads the way in rural vaccinations.

Maine, which faces considerably more geographic challenges than its New England neighbors is also a high performer, with all its rural and urban counties coming in at above the national adjusted average. Other states at the top of the vaccination-rate list are spread across buy cialis online without prescription the country in diverse geographies. Hawaii has completed vaccination rates over 40% for both its rural areas like the Big Island and Kauai and the urban center of Honolulu.

Much of the upper Midwest such as Wisconsin, Minnesota, buy cialis online without prescription and Iowa, plus Michigan’s Upper Peninsula, are above the national average. Another set of above-average counties are located in northern Arizona and New Mexico, where tribal efforts are part of the equation. McKinley County, New Mexico, which experienced some of the nation’s worst rates of erectile dysfunction treatment-related deaths, now has a completed vaccination rate of 77.2%, one of the highest in the nation.

The border region of Texas, which also experienced high rates of erectile dysfunction treatment s and deaths, also have several buy cialis online without prescription counties with above-average levels of vaccination. Below-average rates of vaccination are clustered in the South and the Great Plains, from Texas to North Dakota. The map below indicates buy cialis online without prescription the statewide rural vaccination rate.

Click on the state for information on the metropolitan rate, total number of completed vaccinations, and the number of new vaccinations that were completed since June 1. You Might Also Like.

Explore the full-page map Fifteen states have completely vaccinated cialis safe online more than 40% of their rural population, up cialis costco pharmacy from seven states two weeks ago. Massachusetts led the way, with 59.7% of its rural residents completely vaccinated. The other cialis costco pharmacy top five states were Connecticut, New Hampshire, Maine, and Hawaii. Nationally, 32.5% of the 46 million residents who live in nonmetropolitan counties are completely vaccinated, according to data from the Centers for Disease Control and Prevention and selected state health departments.

In metropolitan counties, 40.0% of the population has been vaccinated, according cialis costco pharmacy to the Daily Yonder’s analysis of state and federal data. The gap between the rural and metropolitan vaccination rates was 7.5 percentage points as of June 7. That’s down slightly from two weeks ago, when the gap was 8 percentage points. But that improvement is primarily from a change in how the Daily Yonder cialis costco pharmacy has collected data for this report, rather than an increase in vaccination activity on the ground in rural areas.

This week, our analysis includes Texas and Hawaii, which the CDC has omitted in its reports. We gathered Texas and Hawaii vaccination data directly from the Texas cialis costco pharmacy and Hawaii state departments of health. We also substituted state health department data for Massachusetts because of reporting anomalies identified in CDC data by the Provincetown Independent in Barnstable County. (For example, for cialis costco pharmacy several weeks in a row, the CDC has reported that Barnstable County’s rate of completed vaccinations was 4%.

State data show 63% of the county’s population has been completely vaccinated.) Like this story?. Sign up for our newsletter. The addition of cialis costco pharmacy state data from Texas alone added 1.24 million completed rural vaccinations. That’s about 8% of the nation’s entire count of rural completed vaccinations, which stood at 14.9 million as of June 7.

Texas has cialis costco pharmacy completely vaccinated 40.2% of its rural residents, according to state data. The graph below shows the percentage of rural and metropolitan populations that have completed erectile dysfunction treatment vaccinations. (Data note cialis costco pharmacy. The percentage is calculated based on the size of the population for which we have vaccination data.

Prior to June 7, the calculations excluded both the vaccinations and population figures for Texas and Hawaii.) The county-level map at the top of the story shows the completed vaccination rates by county. County rates cialis costco pharmacy are compared to a national adjusted average, which this week is 38.9%. The map confirms the state rural vaccination rankings. New England, where most states are compact compared to the rest of the U.S., leads the way cialis costco pharmacy in rural vaccinations.

Maine, which faces considerably more geographic challenges than its New England neighbors is also a high performer, with all its rural and urban counties coming in at above the national adjusted average. Other states at the top of the vaccination-rate cialis costco pharmacy list are spread across the country in diverse geographies. Hawaii has completed vaccination rates over 40% for both its rural areas like the Big Island and Kauai and the urban center of Honolulu. Much of the upper Midwest such cialis costco pharmacy as Wisconsin, Minnesota, and Iowa, plus Michigan’s Upper Peninsula, are above the national average.

Another set of above-average counties are located in northern Arizona and New Mexico, where tribal efforts are part of the equation. McKinley County, New Mexico, which experienced some of the nation’s worst rates of erectile dysfunction treatment-related deaths, now has a completed vaccination rate of 77.2%, one of the highest in the nation. The border region cialis costco pharmacy of Texas, which also experienced high rates of erectile dysfunction treatment s and deaths, also have several counties with above-average levels of vaccination. Below-average rates of vaccination are clustered in the South and the Great Plains, from Texas to North Dakota.

The map below indicates the statewide rural vaccination rate. Click on the state for information on the metropolitan rate, total number of completed vaccinations, and the number of new vaccinations that were completed since June 1. You Might Also Like.

Does daily cialis lower blood pressure

Why Are More Black Kids sites Suicidal? does daily cialis lower blood pressure. A Search for Answers.Mental health experts assumed that people of all races had the same risk factors for self-harm. Emerging evidence does daily cialis lower blood pressure suggests that is not the case.Credit...Supported byContinue reading the main storyNov.

18, 2021Updated 3:28 p.m. ETJoe was 17 does daily cialis lower blood pressure when he decided life wasn’t worth living.He was tired of the violence in his Boston neighborhood, where his older brother had spent more than a year recovering from a gunshot wound to his leg. And he was especially tired of the comments about his weight.“You think you can sit on that chair?.

€ his classmates would ask.Other does daily cialis lower blood pressure times they were more direct, saying simply. €œYou’re fat.”“Sometimes I’d be so depressed I wouldn’t eat for three days,” said Joe, now 25, who was a lineman on his high school’s football team.(Joe’s surname and that of another young person interviewed for this article are being withheld to protect their privacy. Joe is being identified by his middle does daily cialis lower blood pressure name.)He thought about ending his life if the bullying didn’t stop.

Those thoughts eventually became so pervasive that one day he came home from school and took a small handful of pills. But it was enough only to produce a bad stomachache.Months does daily cialis lower blood pressure later, he was still feeling depressed. €œLet me go see a therapist.

My head’s not right,” does daily cialis lower blood pressure he told his father. €œI’m having these thoughts of killing myself — that you’d all be better without me here.”Joe still remembers his father’s response. €œThat’s not does daily cialis lower blood pressure true.

We love you. But you does daily cialis lower blood pressure want to talk to somebody and tell someone that?. They’re going to think you’re crazy.”Over the past generation, a mental health crisis has been brewing among Black youths like Joe, one that very few people — including Black families — have spoken about publicly.

Self-reported suicide attempts rose nearly 80 percent among Black adolescents from 1991 to 2019, while does daily cialis lower blood pressure the prevalence of attempts did not change significantly among those of other races and ethnicities. Legislators and academics are now pushing for better research to understand why, especially in light of new evidence that suggests Black children may have unique risk factors for self-harm.‘I Didn’t Necessarily Want to Die’One study of high school students, published in September, found that the Black teenagers surveyed were more likely than the white teenagers to have attempted suicide without first having suicidal thoughts or plans. Because suicide screening questionnaires typically ask whether people are having suicidal thoughts or have made plans to hurt does daily cialis lower blood pressure themselves, the authors speculated that the questionnaires might fail to identify some Black youths who are at risk of suicide, or that there could be additional factors that might indicate a need for intervention.More research is needed, but a government study conducted last year suggested that Black children and adolescents who died by suicide were more likely than white youths to have experienced a crisis in the two weeks before they died.

They were also more likely to have had a family relationship problem, argument or conflict, or a history of suicide attempts.Jordan Burnham, who survived a jump from a ninth-story window when he was 18, said that if he had been asked whether he was planning to kill himself that day, the answer would have been no.“I couldn’t even think that far ahead,” he said.The fall broke his pelvis, shattered his left leg and fractured his wrist, skull and jaw. It would be four years before he could walk again.“I does daily cialis lower blood pressure didn’t necessarily want to die,” added Mr. Burnham, who is now 32 and visits as many as 60 schools a year to speak about suicide prevention and mental illness.

€œBut the part of me that had depression and shame does daily cialis lower blood pressure and sadness everyday — I wanted that pain to die. I wanted that part to go away.”On the day of his suicide attempt, he was confronted by his parents about a stash of alcohol that they had found in his car. Although Mr does daily cialis lower blood pressure.

Burnham was diagnosed with depression as a teenager, he became so good at hiding it that even his own family members, who were loving and supportive, did not fully understand how much pain he held inside — or the extent to which he felt like an outsider as one of the few Black students at a mostly white school in suburban Philadelphia.Suicide and mental illness are often thought of as a “white phenomenon,” said Michael A. Lindsey, the executive director of the McSilver Institute for Poverty Policy and Research at New York University, who studies the mental health of Black adolescents.Looking at the raw numbers, it’s easy to understand why does daily cialis lower blood pressure. White deaths by suicide far outnumber those of Black people.

But when taking into account youth suicide rates — the number of suicides per 100,000 individuals under age does daily cialis lower blood pressure 25 — a different picture emerges.“I think the statistics are shocking,” said Dr. Lindsey, who was the first to document trends in rising suicide attempts among Black adolescents.A 2018 study found that while the suicide rate of Black children 5 to 12 was low, it was nearly twice that of white children in the same age group. In one of does daily cialis lower blood pressure the most recent examples, a 10-year-old Black girl with autism died by suicide in Utah in early November.

Her parents said she had been subjected to racist bullying by her classmates.Among teenagers and young adults, suicide rates remain highest among whites, Native Americans and Alaska Natives. But while does daily cialis lower blood pressure the suicide rate has recently declined among those groups, it has continued to rise among Black youths. From 2013 to 2019 the suicide rate of Black boys and men 15 to 24 years old rose by 47 percent, and by 59 percent for Black girls and women of the same age.Adolescents of color who identify as L.G.B.T.Q.

May be especially at risk of a suicide attempt, does daily cialis lower blood pressure according to a national survey conducted by the Trevor Project, a suicide prevention group for L.G.B.T.Q. Youth.Despite the racial disparities — and the fact that suicide is the second leading cause of death among all adolescents — there has been a dearth of research examining the racial and ethnic differences in youth suicidal ideation, plans or suicide attempts.This is partly because Black researchers who examine health disparities have been underfunded — in March the director of the National Institutes of Health issued a public apology for “structural racism in biomedical research” — but also because there are only a handful of academics who study these topics.“You have to bring culture into this, you have to talk about racism, you have to talk about discrimination,” said Arielle Sheftall, a principal investigator at the Center for Suicide Prevention and Research at Nationwide Children’s Hospital in Columbus, Ohio. €œIt is something that Black youth experience every single day.”A report presented to Congress in 2019 identified gaps in research and policy and has resulted in more research dollars flowing to studies related to Black youth suicide, including a program to teach middle schoolers about mental health and a suicide prevention intervention called Success Over Stress, which touches on themes like systemic racism and police brutality to help ninth-grade students at predominantly Black schools develop coping skills.“These kids have stressors that are uniquely different than other kids,” said LaVome Robinson, the lead investigator of the Success Over Stress study and a professor of psychology at DePaul University in Chicago.‘Nothing to Stress About’Deaths by suicide are does daily cialis lower blood pressure more common among boys than girls overall, but a study published in September found that suicide rates among Black girls increased by an average of 6.6 percent each year from 2003 to 2017 — more than twice the increase for Black boys.

A diagnosis of depression or anxiety was more common among the girls. Additionally, nearly 20 percent of the girls had engaged in an argument does daily cialis lower blood pressure within 24 hours of their deaths.Denise (her middle name), 19, a high school senior in Cleveland, lives with her mother and six siblings. She struggles with depression and anxiety, largely driven by conflict at home and the lingering trauma of a sexual assault.“When I told Mom how I was feeling, she didn’t seem to care,” Denise said, adding.

€œShe said I had nothing to stress about because I’m a kid.”“I does daily cialis lower blood pressure just felt like there was nothing nobody could do to change the situation.”One evening in September, after a disagreement with her mother, she texted one of her school counselors and told her. €œI don’t want to be here no more.”Her counselor insisted that she go to the hospital to get a psychiatric evaluation.“The first three nights I spent in the hospital, all I could do is cry,” said Denise, who received her first prescription for psychiatric medication while she was there. €œI just felt relieved that does daily cialis lower blood pressure somebody could actually understand what I’m going through.

It felt good to let it all out after holding it in for so long.”Suicidal behavior is already a well-known problem in Denise’s school district, which is about two-thirds Black. In 2019, data from the Centers for Disease Control and Prevention showed that 18 percent of Cleveland high school students had attempted suicide in the previous does daily cialis lower blood pressure 12 months, compared with about 9 percent nationally. Many students in Cleveland face chronic stressors, including neighborhood violence and food insecurity.

Researchers have found that young people are more likely to die by suicide in high-poverty communities.Lisa Ellis, a counselor at a high school in Cleveland, developed an eight-week program for first-year students at her school that aims to help reduce the stigma of mental illness, which she sees as a large barrier preventing students of color from getting the help they need.Tips for Parents to Help Their Struggling TeensCard 1 of 6Are you does daily cialis lower blood pressure concerned for your teen?. If you worry that your teen might be experiencing depression or suicidal thoughts, there are a few things you can do to help. Dr.

Christine Moutier, the chief medical officer of the American Foundation for Suicide Prevention, suggests these steps:Look for changes. Notice shifts in sleeping and eating habits in your teen, as well as any issues he or she might be having at school, such as slipping grades. Watch for angry outbursts, mood swings and a loss of interest in activities they used to love.

Stay attuned to their social media posts as well.Keep the lines of communication open. If you notice something unusual, start a conversation. But your child might not want to talk.

In that case, offer him or her help in finding a trusted person to share their struggles with instead.Seek out professional support. A child who expresses suicidal thoughts may benefit from a mental health evaluation and treatment. You can start by speaking with your child’s pediatrician or a mental health professional.In an emergency.

If you have immediate concern for your child’s safety, do not leave him or her alone. Call a suicide prevention lifeline. Lock up any potentially lethal objects.

Children who are actively trying to harm themselves should be taken to the closest emergency room.Resources If you’re worried about someone in your life and don’t know how to help, these resources can offer guidance:1. The National Suicide Prevention Lifeline. 1-800-273-8255 (TALK) 2.

The Crisis Text Line. Text TALK to 741741 3. The American Foundation for Suicide PreventionThe curriculum includes videos, like TED talks about mental health, as well as discussions about various mental health diagnoses and healthy coping mechanisms to help students regulate their emotions inside and outside the classroom.‘Keeping Your Business Out of the Street’An American Psychological Association report found that only 4 percent of psychologists in the United States in 2015 were Black, even though Black people represent 13 percent of the population.

A similar disparity exists among social workers and psychiatrists.“This is a deterrent,” said Dr. Kali D. Cyrus, a psychiatrist at Sibley Memorial Hospital in Washington, D.C., and an assistant professor at Johns Hopkins University.

Talking about your family’s business with a white person — much less an outsider — is often discouraged in the Black community, added Dr. Cyrus, who is Black.Most mental health care for children takes place in public schools via school psychologists or counselors. This is especially true in low-income districts where other resources are scarce.

But these professionals are also in short supply.Even when mental health professionals are available, research has shown that Black adolescents’ depression often goes untreated because of negative perceptions of services and providers or feelings of shame about experiencing depressive symptoms.“Black families don’t typically have literacy in discussing ‘feelings’ with each other,” Dr. Cyrus said in an email. €œThere is also the strong value of ‘keeping your business out of the street.’”Ever since Kathy Williams’s teenage son Torian Graves took his life in 1996, she has been teaching the people in her hometown, Durham, N.C., about the symptoms she missed and the importance of mental health treatment.

But the stigma is still strong, she said. Some parents are afraid of being judged and don’t trust therapists. Sometimes they say.

€œJust pray about it. It will go away.”Yes, she said, prayer is good. But treating mental illness requires more than that.After her son died, she found a poem in his room that he had written as a class assignment.It reads:Part of me is Carolina Blue,Full of Flavor and Excitement,Like a Wild RollercoasterOn the Loose.But, At times,I’m mean, dark, lonely,Black, mad at the world,Like a lost dog in the desert,Yet, they are both true,And they are both me.“Wow, this is the way my child was feeling,” she recalled thinking at the time.“I saw him angry at times and couldn’t figure out why,” she said of her son, who was 15 when he died.

€œI believe Torian was depressed and we didn’t know it.”To help remove the stigma associated with therapy, Dr. Lindsey has developed a pilot program at five New York City public middle and high schools that recruits Black youths who are experiencing symptoms of depression and enrolls them in therapy with a clinician at a school-based mental health clinic.When parents are informed that their children have mental health challenges, they often feel as if they did something wrong, Dr. Lindsey said.“The first thing we tell them is this is not your fault, this is not the result of bad parenting,” he added.As for Joe, who had been struggling with depression in Boston, he did eventually find a therapist with the help of his mother and his primary care doctor, and started therapy at the beginning of 12th grade.“Talking to someone every Wednesday for one hour, it just did something,” he said.

€œIt made me feel like a person, like I was wanted.”His father and the rest of his family noticed that he wasn’t as angry anymore.“It’s not that I was crazy,” Joe said. €œI needed someone to understand what I was going through, to give me a way to deal with it. Now, Joe said, “I love who I am.”If you’re worried about someone in your life and unsure of how to help, use one of these free, 24-7 resources:The National Suicide Prevention Lifeline.

1-800-273-8255 (TALK)The Crisis Text Line. Text TALK to 741741The American Foundation for Suicide PreventionThis article was produced as part of the USC Annenberg Center for Health Journalism’s 2021 National Fellowship.How to Talk to a Child Who Is StrugglingStrategies to help young children open up about tough emotions.AdvertisementContinue reading the main storyAdvertisementContinue reading the main storySupported byContinue reading the main storyNov. 18, 2021Mental Health Days Are Important.

Here’s How to Make Yours Worthwhile.Well readers share advice on how to get away from it all.CreditCredit...By Marine Buffard“How did relaxing for one day become so hard to do?. € Lena Poole, a primary care doctor in Austin, Texas, posed this question recently as she and her husband, who works in public health, decided to schedule a much-needed mental health day together. Then, she said, they went “round and round” trying to figure out how to spend it.

The cialis has pushed many of us to re-examine our priorities and become more attuned to our needs, so the idea of taking a mental health day away from work or school has begun to seem essential rather than daring. But what is the ideal way to fill those hours so that we walk away feeling refreshed and recharged?. We turned to our readers to find out what they do during a mental health day.

The replies poured in — and not just from those caught up in the rat race. Some said they had been retired for years, others were stay-at-home parents and some responded on behalf of their burned out teenagers. Here are their ideas:Starting in August, I began scheduling a once-a-month “play day” to do whatever I want.

I usually take the bus/train into New York City to a museum, a park, window shopping, etc., walking as much as I can. I buy lunch (eating outdoors) and usually a decadent sweet treat to savor alone. I come home just after dinner hour (so that I don’t feel obliged to cook that day) feeling refreshed and ready for the next daily grind.

Colleen Goidel, Hoboken, N.J.________I go to a matinee movie. I go alone. Get my own soda and popcorn and I immerse myself.

It’s a nice way to avoid all the competing demands on my attention for a couple hours.Candace Davis, Washington________CreditCredit...By Marine BuffardI usually take a mental health day because I need to just lay in bed all day and stare at the walls. The point is not what to do on these days or how to do it, but the sense of relief that comes from “I am OK beyond what I can do or produce. I am worthy and OK just because I am here.” Ilse Murdock, City Island, Bronx, N.Y.________During my last mental health day, I hiked up to the top of Flattop, a mountain in Anchorage, Alaska, that looks like an enormous tabletop overlooking the city.

I needed space and air. It was just hard enough to escape and get a thrill, but safe enough to not be stressful. There were some paragliders jumping off the top of it that day and it was beautiful.

I watched them float down into the mountain valley wondering how and where they would land.Elijah Haines, Anchorage, Alaska________Pull weeds in my yard. They don’t talk back, so it’s the perfect stress reliever. And the yard looks better when I’m done.Mary Ann Rood, Fernandina Beach, Fla.________CreditCredit...By Marine BuffardMy mom would let me take a “mental health day” when I was in high school in the ’90s, usually exhausted from a string of big projects and tests or just needing a break from teenage life.

I was to always treat it as a sick day, since we were telling everyone that was why, so a quiet day of reading, trash TV, movies, and maybe baking and kitchen experiments in comfy clothes. My mom said she knew if I had a day of rest I’d be able to stay well, but if I burned out, I’d be more likely to actually get sick.Elisabeth Leekley, Boston Area ________I have bipolar disorder, so I usually take a mental health day when I feel prone to a depressed, manic or mixed episode. Typically, I will listen to a new album, either one that has been recently released or one that is new to me.

Then, I’ll usually take a walk to a nearby park and just sit somewhere and observe everything around me — dogs being walked, children playing tag, couples going for picnics. Sunlight and fresh air can make me go from melancholic to balanced, or at least closer to balanced. Claire Goray, Glasgow________My 13-year-old soccer-obsessed son asked to miss school for a mental health day.

He spent the day in bed, sipping hot chocolate and working on a script for a musical. He said it was the best day of his life.Holly Roberson, Berkeley, Calif.________CreditCredit...By Marine BuffardThis is a bit sad, but when I take a mental health day I use it to clean the house, plan vacations, camp/child care and schedule appointments. Basically I use the time to catch up on things that are difficult to do during the regular work week.

Granted, I usually do this while still in my PJs, drinking hot coffee or tea, and possibly with a podcast or show playing in the background — and when the kids are all at school!. So it’s not all bad. Claire R., Seattle________My mental health days are usually triggered by feeling completely overwhelmed by my self-inflicted and overly ambitious to-do lists.

So I cross off items. I make that recipe, organize that corner of the apartment, find a YouTube video to help me fix the drafty window. Or at least I pretend that I’m going to do these things.

Instead, I spend a few hours doing something mindless in front of a screen, maybe do one or two things, then silently erase half the remaining items from the list. Lauren Gledhill, New Britain, Conn. ________CreditCredit...By Marine BuffardI do what I want to do.

Period. Swimming outside on a warm summer day at 6 a.m., then to Starbucks. Then go bike riding for 50 miles.

Sure, I check my work email now and then. But what made a difference was that I had told everyone in advance I was taking a mental health day. So no one was expecting me to be online and I knew there wouldn’t be anything pressing.Rob Hill, Minneapolis ________I moved from N.Y.C.

To Vancouver, B.C., in 2019 and live in the small, quiet village of Deep Cove. Any break I get, I spend on the trails in the woods outside my home. I can’t believe this is where I live and where I am raising my daughters.

Who knew ferns were so spectacular and make you feel like you’re walking the Earth in prehistoric times?. The strain of the cialis mixed with postpartum depression and not seeing my family has definitely taken its toll. In N.Y.C., I would have spent the day at the spa or time in the spin studio and nail salon.

Having easy access to the forest and these quiet trails has been way more restorative.Rebecca C., North Vancouver, B.C., Canada________I call it museum swimming. We’re so fortunate as Americans to have access to incredible museums across the U.S., with many hosting free days for the public. To go museum swimming requires only a museum and one rule.

Try not to read the placards on the wall. (Although very comfortable shoes are also helpful.) Paige McAfee, Philadelphia________CreditCredit...By Marine BuffardI am a therapist who assesses and treats PTSD at the Memphis V.A. My mental health days (few and far between) are often spent pulling weeds and tidying my garden beds — clearing the clutter that I can and letting some spaces exist as they are.

It’s a lot like my work but not as painful. Kitty Frazer, Memphis________I’ve been retired for 8 years. My wife still works.

That means I’m the “house manager.” As any caretaker in the world knows, taking care of the house and family is grueling. So a retired guy takes a mental health day, too. I close the blinds and get the house to 70 degrees.

I won’t take in news. I’ll binge watch funny shows. I’ll have a glass of wine.

A pot gummy bear perhaps. I “float” around my backyard garden trying to stay in the moment and appreciate how beautiful my garden has become. Maybe I’ll have pizza delivered.

I often stay in my pajamas all day. It’s wonderful.Jerry, Bay Area article h1 { font-size. 53px !.

Important;} @media (max-width. 740px) {article h1 { font-size. 40px !.

Important;}} AdvertisementContinue reading the main story.

Why Are cialis costco pharmacy More Black Can you buy amoxil without a prescription Kids Suicidal?. A Search for Answers.Mental health experts assumed that people of all races had the same risk factors for self-harm. Emerging evidence suggests that is cialis costco pharmacy not the case.Credit...Supported byContinue reading the main storyNov.

18, 2021Updated 3:28 p.m. ETJoe was 17 when he decided life wasn’t worth living.He was tired of the violence in his Boston neighborhood, where his older brother had spent more than a year recovering from a gunshot cialis costco pharmacy wound to his leg. And he was especially tired of the comments about his weight.“You think you can sit on that chair?.

€ his classmates would cialis costco pharmacy ask.Other times they were more direct, saying simply. €œYou’re fat.”“Sometimes I’d be so depressed I wouldn’t eat for three days,” said Joe, now 25, who was a lineman on his high school’s football team.(Joe’s surname and that of another young person interviewed for this article are being withheld to protect their privacy. Joe is being identified by his middle name.)He thought about ending cialis costco pharmacy his life if the bullying didn’t stop.

Those thoughts eventually became so pervasive that one day he came home from school and took a small handful of pills. But it was enough only to produce a bad stomachache.Months later, he cialis costco pharmacy was still feeling depressed. €œLet me go see a therapist.

My head’s cialis costco pharmacy not right,” he told his father. €œI’m having these thoughts of killing myself — that you’d all be better without me here.”Joe still remembers his father’s response. €œThat’s not cialis costco pharmacy true.

We love you. But you want to talk to somebody and tell someone cialis costco pharmacy that?. They’re going to think you’re crazy.”Over the past generation, a mental health crisis has been brewing among Black youths like Joe, one that very few people — including Black families — have spoken about publicly.

Self-reported suicide attempts rose nearly 80 percent among Black adolescents from 1991 to 2019, while the prevalence of attempts did not change significantly among those of other races cialis costco pharmacy and ethnicities. Legislators and academics are now pushing for better research to understand why, especially in light of new evidence that suggests Black children may have unique risk factors for self-harm.‘I Didn’t Necessarily Want to Die’One study of high school students, published in September, found that the Black teenagers surveyed were more likely than the white teenagers to have attempted suicide without first having suicidal thoughts or plans. Because suicide screening questionnaires typically ask whether people are having suicidal thoughts or have made plans to hurt themselves, the authors speculated that the questionnaires might fail to identify some Black youths who are at risk of suicide, or that there could be additional factors that cialis costco pharmacy might indicate a need for intervention.More research is needed, but a government study conducted last year suggested that Black children and adolescents who died by suicide were more likely than white youths to have experienced a crisis in the two weeks before they died.

They were also more likely to have had a family relationship problem, argument or conflict, or a history of suicide attempts.Jordan Burnham, who survived a jump from a ninth-story window when he was 18, said that if he had been asked whether he was planning to kill himself that day, the answer would have been no.“I couldn’t even think that far ahead,” he said.The fall broke his pelvis, shattered his left leg and fractured his wrist, skull and jaw. It would be four years before he could walk again.“I didn’t necessarily cialis costco pharmacy want to die,” added Mr. Burnham, who is now 32 and visits as many as 60 schools a year to speak about suicide prevention and mental illness.

€œBut the part cialis costco pharmacy of me that had depression and shame and sadness everyday — I wanted that pain to die. I wanted that part to go away.”On the day of his suicide attempt, he was confronted by his parents about a stash of alcohol that they had found in his car. Although Mr cialis costco pharmacy.

Burnham was diagnosed with depression as a teenager, he became so good at hiding it that even his own family members, who were loving and supportive, did not fully understand how much pain he held inside — or the extent to which he felt like an outsider as one of the few Black students at a mostly white school in suburban Philadelphia.Suicide and mental illness are often thought of as a “white phenomenon,” said Michael A. Lindsey, the executive director of the McSilver Institute for Poverty Policy and Research at New cialis costco pharmacy York University, who studies the mental health of Black adolescents.Looking at the raw numbers, it’s easy to understand why. White deaths by suicide far outnumber those of Black people.

But when taking into account youth suicide rates — the cialis costco pharmacy number of suicides per 100,000 individuals under age 25 — a different picture emerges.“I think the statistics are shocking,” said Dr. Lindsey, who was the first to document trends in rising suicide attempts among Black adolescents.A 2018 study found that while the suicide rate of Black children 5 to 12 was low, it was nearly twice that of white children in the same age group. In one of the most recent examples, a 10-year-old Black girl with autism cialis costco pharmacy died by suicide in Utah in early November.

Her parents said she had been subjected to racist bullying by her classmates.Among teenagers and young adults, suicide rates remain highest among whites, Native Americans and Alaska Natives. But while the suicide rate has recently declined among those groups, it has cialis costco pharmacy continued to rise among Black youths. From 2013 to 2019 the suicide rate of Black boys and men 15 to 24 years old rose by 47 percent, and by 59 percent for Black girls and women of the same age.Adolescents of color who identify as L.G.B.T.Q.

May be cialis costco pharmacy especially at risk of a suicide attempt, according to a national survey conducted by the Trevor Project, a suicide prevention group for L.G.B.T.Q. Youth.Despite the racial disparities — and the fact that suicide is the second leading cause of death among all adolescents — there has been a dearth of research examining the racial and ethnic differences in youth suicidal ideation, plans or suicide attempts.This is partly because Black researchers who examine health disparities have been underfunded — in March the director of the National Institutes of Health issued a public apology for “structural racism in biomedical research” — but also because there are only a handful of academics who study these topics.“You have to bring culture into this, you have to talk about racism, you have to talk about discrimination,” said Arielle Sheftall, a principal investigator at the Center for Suicide Prevention and Research at Nationwide Children’s Hospital in Columbus, Ohio. €œIt is something that Black youth experience every single day.”A report cialis costco pharmacy presented to Congress in 2019 identified gaps in research and policy and has resulted in more research dollars flowing to studies related to Black youth suicide, including a program to teach middle schoolers about mental health and a suicide prevention intervention called Success Over Stress, which touches on themes like systemic racism and police brutality to help ninth-grade students at predominantly Black schools develop coping skills.“These kids have stressors that are uniquely different than other kids,” said LaVome Robinson, the lead investigator of the Success Over Stress study and a professor of psychology at DePaul University in Chicago.‘Nothing to Stress About’Deaths by suicide are more common among boys than girls overall, but a study published in September found that suicide rates among Black girls increased by an average of 6.6 percent each year from 2003 to 2017 — more than twice the increase for Black boys.

A diagnosis of depression or anxiety was more common among the girls. Additionally, nearly 20 percent of the girls had engaged in an argument within cialis costco pharmacy 24 hours of their deaths.Denise (her middle name), 19, a high school senior in Cleveland, lives with her mother and six siblings. She struggles with depression and anxiety, largely driven by conflict at home and the lingering trauma of a sexual assault.“When I told Mom how I was feeling, she didn’t seem to care,” Denise said, adding.

€œShe said I had nothing to stress about because I’m a cialis costco pharmacy kid.”“I just felt like there was nothing nobody could do to change the situation.”One evening in September, after a disagreement with her mother, she texted one of her school counselors and told her. €œI don’t want to be here no more.”Her counselor insisted that she go to the hospital to get a psychiatric evaluation.“The first three nights I spent in the hospital, all I could do is cry,” said Denise, who received her first prescription for psychiatric medication while she was there. €œI just felt cialis costco pharmacy relieved that somebody could actually understand what I’m going through.

It felt good to let it all out after holding it in for so long.”Suicidal behavior is already a well-known problem in Denise’s school district, which is about two-thirds Black. In 2019, data from the Centers for Disease Control and Prevention showed that 18 percent of Cleveland high school students had attempted suicide in the previous cialis costco pharmacy 12 months, compared with about 9 percent nationally. Many students in Cleveland face chronic stressors, including neighborhood violence and food insecurity.

Researchers have found that young people are more likely to die by suicide in high-poverty communities.Lisa Ellis, a counselor at a high school in Cleveland, developed an eight-week program for first-year students at her school that aims to help reduce the stigma of mental cialis costco pharmacy illness, which she sees as a large barrier preventing students of color from getting the help they need.Tips for Parents to Help Their Struggling TeensCard 1 of 6Are you concerned for your teen?. If you worry that your teen might be experiencing depression or suicidal thoughts, there are a few things you can do to help. Dr.

Christine Moutier, the chief medical officer of the American Foundation for Suicide Prevention, suggests these steps:Look for changes. Notice shifts in sleeping and eating habits in your teen, as well as any issues he or she might be having at school, such as slipping grades. Watch for angry outbursts, mood swings and a loss of interest in activities they used to love.

Stay attuned to their social media posts as well.Keep the lines of communication open. If you notice something unusual, start a conversation. But your child might not want to talk.

In that case, offer him or her help in finding a trusted person to share their struggles with instead.Seek out professional support. A child who expresses suicidal thoughts may benefit from a mental health evaluation and treatment. You can start by speaking with your child’s pediatrician or a mental health professional.In an emergency.

If you have immediate concern for your child’s safety, do not leave him or her alone. Call a suicide prevention lifeline. Lock up any potentially lethal objects.

Children who are actively trying to harm themselves should be taken to the closest emergency room.Resources If you’re worried about someone in your life and don’t know how to help, these resources can offer guidance:1. The National Suicide Prevention Lifeline. 1-800-273-8255 (TALK) 2.

The Crisis Text Line. Text TALK to 741741 3. The American Foundation for Suicide PreventionThe curriculum includes videos, like TED talks about mental health, as well as discussions about various mental health diagnoses and healthy coping mechanisms to help students regulate their emotions inside and outside the classroom.‘Keeping Your Business Out of the Street’An American Psychological Association report found that only 4 percent of psychologists in the United States in 2015 were Black, even though Black people represent 13 percent of the population.

A similar disparity exists among social workers and psychiatrists.“This is a deterrent,” said Dr. Kali D. Cyrus, a psychiatrist at Sibley Memorial Hospital in Washington, D.C., and an assistant professor at Johns Hopkins University.

Talking about your family’s business with a white person — much less an outsider — is often discouraged in the Black community, added Dr. Cyrus, who is Black.Most mental health care for children takes place in public schools via school psychologists or counselors. This is especially true in low-income districts where other resources are scarce.

But these professionals are also in short supply.Even when mental health professionals are available, research has shown that Black adolescents’ depression often goes untreated because of negative perceptions of services and providers or feelings of shame about experiencing depressive symptoms.“Black families don’t typically have literacy in discussing ‘feelings’ with each other,” Dr. Cyrus said in an email. €œThere is also the strong value of ‘keeping your business out of the street.’”Ever since Kathy Williams’s teenage son Torian Graves took his life in 1996, she has been teaching the people in her hometown, Durham, N.C., about the symptoms she missed and the importance of mental health treatment.

But the stigma is still strong, she said. Some parents are afraid of being judged and don’t trust therapists. Sometimes they say.

€œJust pray about it. It will go away.”Yes, she said, prayer is good. But treating mental illness requires more than that.After her son died, she found a poem in his room that he had written as a class assignment.It reads:Part of me is Carolina Blue,Full of Flavor and Excitement,Like a Wild RollercoasterOn the Loose.But, At times,I’m mean, dark, lonely,Black, mad at the world,Like a lost dog in the desert,Yet, they are both true,And they are both me.“Wow, this is the way my child was feeling,” she recalled thinking at the time.“I saw him angry at times and couldn’t figure out why,” she said of her son, who was 15 when he died.

€œI believe Torian was depressed and we didn’t know it.”To help remove the stigma associated with therapy, Dr. Lindsey has developed a pilot program at five New York City public middle and high schools that recruits Black youths who are experiencing symptoms of depression and enrolls them in therapy with a clinician at a school-based mental health clinic.When parents are informed that their children have mental health challenges, they often feel as if they did something wrong, Dr. Lindsey said.“The first thing we tell them is this is not your fault, this is not the result of bad parenting,” he added.As for Joe, who had been struggling with depression in Boston, he did eventually find a therapist with the help of his mother and his primary care doctor, and started therapy at the beginning of 12th grade.“Talking to someone every Wednesday for one hour, it just did something,” he said.

€œIt made me feel like a person, like I was wanted.”His father and the rest of his family noticed that he wasn’t as angry anymore.“It’s not that I was crazy,” Joe said. €œI needed someone to understand what I was going through, to give me a way to deal with it. Now, Joe said, “I love who I am.”If you’re worried about someone in your life and unsure of how to help, use one of these free, 24-7 resources:The National Suicide Prevention Lifeline.

1-800-273-8255 (TALK)The Crisis Text Line. Text TALK to 741741The American Foundation for Suicide PreventionThis article was produced as part of the USC Annenberg Center for Health Journalism’s 2021 National Fellowship.How to Talk to a Child Who Is StrugglingStrategies to help young children open up about tough emotions.AdvertisementContinue reading the main storyAdvertisementContinue reading the main storySupported byContinue reading the main storyNov. 18, 2021Mental Health Days Are Important.

Here’s How to Make Yours Worthwhile.Well readers share advice on how to get away from it all.CreditCredit...By Marine Buffard“How did relaxing for one day become so hard to do?. € Lena Poole, a primary care doctor in Austin, Texas, posed this question recently as she and her husband, who works in public health, decided to schedule a much-needed mental health day together. Then, she said, they went “round and round” trying to figure out how to spend it.

The cialis has pushed many of us to re-examine our priorities and become more attuned to our needs, so the idea of taking a mental health day away from work or school has begun to seem essential rather than daring. But what is the ideal way to fill those hours so that we walk away feeling refreshed and recharged?. We turned to our readers to find out what they do during a mental health day.

The replies poured in — and not just from those caught up in the rat race. Some said they had been retired for years, others were stay-at-home parents and some responded on behalf of their burned out teenagers. Here are their ideas:Starting in August, I began scheduling a once-a-month “play day” to do whatever I want.

I usually take the bus/train into New York City to a museum, a park, window shopping, etc., walking as much as I can. I buy lunch (eating outdoors) and usually a decadent sweet treat to savor alone. I come home just after dinner hour (so that I don’t feel obliged to cook that day) feeling refreshed and ready for the next daily grind.

Colleen Goidel, Hoboken, N.J.________I go to a matinee movie. I go alone. Get my own soda and popcorn and I immerse myself.

It’s a nice way to avoid all the competing demands on my attention for a couple hours.Candace Davis, Washington________CreditCredit...By Marine BuffardI usually take a mental health day because I need to just lay in bed all day and stare at the walls. The point is not what to do on these days or how to do it, but the sense of relief that comes from “I am OK beyond what I can do or produce. I am worthy and OK just because I am here.” Ilse Murdock, City Island, Bronx, N.Y.________During my last mental health day, I hiked up to the top of Flattop, a mountain in Anchorage, Alaska, that looks like an enormous tabletop overlooking the city.

I needed space and air. It was just hard enough to escape and get a thrill, but safe enough to not be stressful. There were some paragliders jumping off the top of it that day and it was beautiful.

I watched them float down into the mountain valley wondering how and where they would land.Elijah Haines, Anchorage, Alaska________Pull weeds in my yard. They don’t talk back, so it’s the perfect stress reliever. And the yard looks better when I’m done.Mary Ann Rood, Fernandina Beach, Fla.________CreditCredit...By Marine BuffardMy mom would let me take a “mental health day” when I was in high school in the ’90s, usually exhausted from a string of big projects and tests or just needing a break from teenage life.

I was to always treat it as a sick day, since we were telling everyone that was why, so a quiet day of reading, trash TV, movies, and maybe baking and kitchen experiments in comfy clothes. My mom said she knew if I had a day of rest I’d be able to stay well, but if I burned out, I’d be more likely to actually get sick.Elisabeth Leekley, Boston Area ________I have bipolar disorder, so I usually take a mental health day when I feel prone to a depressed, manic or mixed episode. Typically, I will listen to a new album, either one that has been recently released or one that is new to me.

Then, I’ll usually take a walk to a nearby park and just sit somewhere and observe everything around me — dogs being walked, children playing tag, couples going for picnics. Sunlight and fresh air can make me go from melancholic to balanced, or at least closer to balanced. Claire Goray, Glasgow________My 13-year-old soccer-obsessed son asked to miss school for a mental health day.

He spent the day in bed, sipping hot chocolate and working on a script for a musical. He said it was the best day of his life.Holly Roberson, Berkeley, Calif.________CreditCredit...By Marine BuffardThis is a bit sad, but when I take a mental health day I use it to clean the house, plan vacations, camp/child care and schedule appointments. Basically I use the time to catch up on things that are difficult to do during the regular work week.

Granted, I usually do this while still in my PJs, drinking hot coffee or tea, and possibly with a podcast or show playing in the background — and when the kids are all at school!. So it’s not all bad. Claire R., Seattle________My mental health days are usually triggered by feeling completely overwhelmed by my self-inflicted and overly ambitious to-do lists.

So I cross off items. I make that recipe, organize that corner of the apartment, find a YouTube video to help me fix the drafty window. Or at least I pretend that I’m going to do these things.

Instead, I spend a few hours doing something mindless in front of a screen, maybe do one or two things, then silently erase half the remaining items from the list. Lauren Gledhill, New Britain, Conn. ________CreditCredit...By Marine BuffardI do what I want to do.

Period. Swimming outside on a warm summer day at 6 a.m., then to Starbucks. Then go bike riding for 50 miles.

Sure, I check my work email now and then. But what made a difference was that I had told everyone in advance I was taking a mental health day. So no one was expecting me to be online and I knew there wouldn’t be anything pressing.Rob Hill, Minneapolis ________I moved from N.Y.C.

To Vancouver, B.C., in 2019 and live in the small, quiet village of Deep Cove. Any break I get, I spend on the trails in the woods outside my home. I can’t believe this is where I live and where I am raising my daughters.

Who knew ferns were so spectacular and make you feel like you’re walking the Earth in prehistoric times?. The strain of the cialis mixed with postpartum depression and not seeing my family has definitely taken its toll. In N.Y.C., I would have spent the day at the spa or time in the spin studio and nail salon.

Having easy access to the forest and these quiet trails has been way more restorative.Rebecca C., North Vancouver, B.C., Canada________I call it museum swimming. We’re so fortunate as Americans to have access to incredible museums across the U.S., with many hosting free days for the public. To go museum swimming requires only a museum and one rule.

Try not to read the placards on the wall. (Although very comfortable shoes are also helpful.) Paige McAfee, Philadelphia________CreditCredit...By Marine BuffardI am a therapist who assesses and treats PTSD at the Memphis V.A. My mental health days (few and far between) are often spent pulling weeds and tidying my garden beds — clearing the clutter that I can and letting some spaces exist as they are.

It’s a lot like my work but not as painful. Kitty Frazer, Memphis________I’ve been retired for 8 years. My wife still works.

That means I’m the “house manager.” As any caretaker in the world knows, taking care of the house and family is grueling. So a retired guy takes a mental health day, too. I close the blinds and get the house to 70 degrees.

I won’t take in news. I’ll binge watch funny shows. I’ll have a glass of wine.

A pot gummy bear perhaps. I “float” around my backyard garden trying to stay in the moment and appreciate how beautiful my garden has become. Maybe I’ll have pizza delivered.

I often stay in my pajamas all day. It’s wonderful.Jerry, Bay Area article h1 { font-size. 53px !.

Important;} @media (max-width. 740px) {article h1 { font-size. 40px !.

Important;}} AdvertisementContinue reading the main story.

Share

No Comments

Cialis over the counter

Autodesk deployed it’s Octo-Copter in Africa for high resolution reality capture.  This was done in support of Louis Leakey in Kenya in search of our ancestral trails


Additonally, they deployed it on their head quarters in San Rafael.

From the Gizmag Website:

The Mikrokopter Octocopter is an 8-rotor flying platform which has a 2 kg (4.4 lbs) capacity to carry cameras. It can be flown using an internal camera to give the operator a copter-based vantage point on video glasses, or can be programmed to follow a GPS-controlled flight path. An Octocopter can fly autonomously at altitudes up to 1000 meters (3280 feet), or can be manually flown as high as 3500 meters (11,480 feet). In the Autodesk tests video was captured using a GOPro Hero 2 camera, and the still pictures from which the 3D model was later built were taken by a remotely triggered Canon SLR camera.

Autodesk 123D is a suite of programs which allow a user to create, manipulate, and construct 3D objects using a 3D printer. Catch is part of the 123D suite, and offers a standalone software package that helps you create 3D models from a series of 2D digital images of an object or a scene. The spatial resolution available using 123D Catch is about 1 part in 600, or 0.167% of the total size of the object pictured, so you would be able to accurately place individual windows on a 3D model of a Boeing 747.

Share

, , , , , , ,

No Comments

Cialis over the counter

Cialis over the counter

Get to the Beach and then Treat Yourself

Cranes Beach & Wingaersheek Beech, Head north on 128.  Enjoy the water, and then take the short drive to Essex and go get fried clams and soft serve, call in your fried clam order if you can.  Try Woodman’s, Farnham’s (they got picnic tables over looking the tidal marsh) or try the Village, and Essex Seafood, which has always been a solid go to.

Horseneck Beach, terrific beach going south on 24, Westport, MA almost always less traffic, then go to the Back Eddy for something to cold to drink and a snack.

You’re in and around the city.

Find a Roof Deck and/or Pool, a variety of posts on the subject from Boston.com, but it seems the Colonade for a pool stop is always mentioned. And outside of the city, Indigo in Newton is pretty nice stop.

Walk the Greenway, play in the fountains, get gelatto, try the Gelateria  in the North End.

Have a cold drink in a well air conditioned bar by the Garden, then walk over the river, across the locks into Charlestown and do the same thing there.  Your choice for locations, there are many.  But go ahead and stop at Emack and Bolio’s on the walk back.

Play in the Fountain at the Christian Science Center, walk into the Pru and Copley to soak in the air conditioning, play “how much are these shoes” at Nordstrom.  Have a friend stand back from the shoe tables, have them guess.  Most likely off by a factor of 10, go get a coolata at Dunkin.

If you are feeling particularly flush and it’s after 5, go get a martini at the Oak Room, used to come with side car sitting in ice.  That will frame the rest of your day.  Air Conditioning set on igloo.

Take your dog for a walk at the Middlesex Fells Reservation, or bring him/her to a pond, throw a stick. Jamaica Pond, Spy Pond, Fresh Pond, etc.  You might not get cool, but look at the dog, so happy.  And now I’ve seen Canoe and Kayak Rentals at Spy Pond.

So there’s a start, generally, a cold drink, cone or a slush, water, you get the idea.

 

Share

, , ,

No Comments

Cialis over the counter

With Microsoft’s announcement of Windows 8, and the unveiling of the Surface Tablet, it finally appears there will be a tablet form factor that will run Revit in the field.  According to the press release there will be two versions, one based on the ARM chip and another based on the Intel i5 chip running Windows 8 Pro.  The iPad, as much it is great for so many tasks, simply does not have the horsepower to run Revit in the field, and delivering the type of user experience one would want with heavyweight programs is a real limitation in the ‘cloud.’  I understand Autodesk is now counting solely on Citrix to provide its remote platform but even if you are driving Revit remotely would you want to rely on whatever internet connection you have?  That’s just not a funnel I would want to count on in the field.

At first glance you might say so what, not a big deal.  However, if I can have a device that toggles between my heavyweight AEC programs, and delivers content the way my my iPad does then I might have an iPad to sell you; because frankly I am sick of devices, I live between the Mac and Windows camp, I’m tired of it.  I used to be an Apple fanatic, even being the only kid in business school with a Mac, the disastrous PowerPC model, but what was not to like about Apple.  Now, how did we get to the point where Microsoft is the little guy, relatively speaking.  Now if they could get their content management into a spot that works the way you want.  Imagine the central Revit model up on the sky drive, you check it out in the field, do your work, update it, booyah.

I think single purpose, highly specific apps are great to digest data,  not for the creation of it so I am real interested in the melding of tablet like functionality with horsepower.  I’m rooting for the little guy, I’m rooting for Microsoft.

********************

BTW anyone else bother to notice the blending and vertical integration of software/hardware.  Apple, obviously.  Google buys Motorola. Microsoft with multiple attempts, Zune, XBox, etc.  and now Surface. And more germane to AEC Trimble buys Tekla and SketchUp.  Seems to be the biz strategy du jour, watch for more.

Share

, , , , ,

4 Comments

Cialis over the counter

Tweet about PKNail Pro’s Proven Field to BIM Technology, Get Entered Automatically

PointKnown is giving away a free Apple iPad to one lucky Twitterer…er, tweeter, i.e.  one who uses the service twitter to disseminate clever, witty, informative text burst in 140 characters or less.  PointKnown does not claim to be clever, witty or informative, but will claim producing kick ahh…whup ahh…Excellent productivity software tools for documenting existing buildings.

 

 

Cialis over the counter

To participate, simply tweet using the hash tags below:

#pknail #revit #bim and mention ‘PKNail Pro’

Cialis over the counter

PKNail Pro turbo charges Revit and modeling existing buildings #pknail #revit #bim

or “Capture Existing Buildings Directly In Revit with PKNail Pro, 5x-10x faster #pknail #revit #bim

less pertinent but still acceptable “We came, we saw, we conquered with PKNail Pro, #pknail, #bim , #revit

less pertinent verging to the non-sequitur but still acceptable…

beautiful software for happy people PKNail Pro, #pknail, #bim, #revit

or certainly and you are most welcome and encouraged to tweet your own stuff; as we will have a separate drawing of $100 VISA Card for best/most creative tweet as judged by anyone at our next BBQ.

Cialis over the counter


We are on the road with Microcad and have other excellent resellers including,  Seiler Instrument (ask for Harvey) and CADDFX

Cialis over the counter

Cialis over the counter

1. This giveaway is offered by PointKnown LLC and is open to anyone with a Twitter account who is at least 16 years of age. Employees of PointKnown, LLC. and/or its affiliated companies and family members of such employees may enter the contest but are not eligible to win.

2. The giveaway will begin at the time of this post and end 62 days after initial post, a winner will be randomly chosen, much like the number 62, and announced via twitter through @pointknown

3. One giveaway will be available: a 16GB Wi-Fi Apple iPad or $499 Apple Store Credit, winner’s choice.

4. You must prove ownership of the winning entry and provide your email address to collect the prize.

5. To enter the giveaway you must send out a tweet from your own Twitter account that includes the #hash tags above in your message.

6. Entries using automated tweets will be disqualified, however there is no limit on the number of tweets you may enter.

7. PointKnown LLC will choose a winner randomly from all the entries within the specified period. The winner will be announced from our twitter account (@pointknown) once the contest ends.

8. Entrants agree to allow @pointknown to use their twitter handles and entry tweets for marketing purposes.

9. Neither PointKnown LLC. nor its affiliated companies shall have any liability for (i) any technical failures of any kind, including but not limited to malfunctions, interruptions or disconnections in phone lines or network hardware or software; (ii) technical or human error which may occur in the administration of the giveaway; (iii) any malfunction of or damage to the prize; (iv) any corruption, typos or hacking of prize winners email accounts; or (v) any restrictions or delays imposed by any customs authorities or any import or other taxes of any kind imposed by any taxation authority in respect of the prizes.

Share

, , , ,

No Comments

Cialis over the counter

Announced today, Autodesk Acquires Vela Systems.  If you are developing products within the Building Life Cycle somewhere between and including design to demolition, you are in play.  Trimble has been going on an acquisition rampage with its acquisition of Tekla and Sketch Up and Autodesk never one to be a wallflower has just acquired Vela.  This is almost 2 years to the date that Vela was unveiled publicly.  No idea of their market size but their own press releases state that they are more than ‘twice as big’ as any competitive Field BIM Systems.  Regardless, market penetration means little at this point now that the Autodesk marketing/sales system is behind it.  How big was Revit in 2006 when they were purchased.  A primer of Vela’s Key Features below.  Congrats Vela folks, job well done.

Vela Field Management Suite Key Features
The Vela Field Management Suite of Web, Mobile and Reports enables everyone throughout the enterprise to access documents, field activities and reports in the office and in the field. Since its release a year ago, and to further broaden the usability throughout the enterprise, Vela Systems has expanded upon the following features:

  • Field BIM® for commissioning and handover that ties BIM to the field for data and document exchange
  • Company-level checklist and issue template capabilities to implement and enforce quality and safety programs
  • Increased accessibility via the Internet on multiple devices like iPads and Smart Phones
  • Better web-based reporting that turns field data into powerful information for managing quality, safety and risk at the project and company level
Share

, , , ,

No Comments

Cialis over the counter

As reported by Industry Week, ‘The world’s most sophisticated malware had a ‘high interest in AutoCAD drawings,’ Kaspersky Lab said.  The Flame Virus, which mainly affected computers in the Middle East used a loophole in Microsoft software tricking computers into thinking they are downloading a legitimate Windows update.  This fact, being reported by Reuters, The Times, CNET, and others. CNN reported that Flame can turn on your microphone, webcam, log e-mails, etc.  I have not read if it can do anything malicious itself as the Stuxnet Virus did to Iran Uranium enrichment facilities by having centrifuges essentially tear themselves apart.  However, going after CAD, essentially engineering and building documents can let whoever is collecting this information know what you are designing and building, and possibly have the blueprints of the building you are designing and building in.  And you thought google knowing that you smoke cigars and eat ice cream on your back porch at 5:23 PM was intrusive.

Share

, ,

No Comments

Cialis over the counter

File under cool.   The City of New York has unveiled an initiative for the electronic submission of BIM safety plans; you can learn more here; and a  Turner Press Release yesterday stated they used both 2D and 3D BIM submissions to get approval for their construction project at the Energy Building at NYU Langone Medical Center.

“The digital submission of 3D, BIM-based site safety plans reduced the approval times from weeks to days,” said Di Fillipo, Turner Senior Vice President.

Share

, ,

No Comments

Cialis over the counter

The more demos I go on, the more I get asked about our field kit, so I wanted to post what’s in my bag and what we use on a day to day basis when surveying/modeling in the field with PKNail Pro.  Those of you not interested in the day-in day-out particulars of surveying buildings may want to hit your back button now… Anyway an individual equally equipped will be ready for knocking out BIM Building Surveys, and this kit, all in, costs a fraction of most other technology solutions, plus the added benefit of surveying/modeling directly in the platform you or your clients are most likely working in.  However, always choose the tool/service that fits your needs.  In fact, we’ll be posting shortly where we combined workflows of PKNail Pro and pointclouds.  But here you go, what’s in my bag or my complete kit.

So it might seem like a lot but all fits in the bag except for the tripods.  The laptop tripod is excellent when mobility/portability with your gear is at a premium but I will use a laptop cart with wheels if the space allows;  it is easier with wheels and has more surface area to put stuff.

The real minimum you need to have with you is a laptop/tablet PC running the appropriate software, a Disto D8 or 330i, a measuring tape, and something to use for a target when needed, like an outside corner.  Stickynotes (larger size) are excellent for shorter distances, a reflective Leica Target attached with Painter’s Tape is better for longer ones.  Rechargeable batteries for both the laptop and Disto.  I prefer an external battery pack for the laptop as it can be used on any laptop and it is self contained unlike an extra battery for a specific laptop.

I  like Eneloop rechargeables for devices, my preference, they come preloaded with a charge, and seem to carry it longer when not being used.  You need a measuring tape on occasion for distances to short or sometimes nice to hook something with a tape when finding a distance manually.  I like thick banded measuring tapes because they will extend longer without ‘breaking’ but find they are just as prone to wear down as any other so sometimes not worth the expense.  LED flashlight because they are bright and do not use as much juice as others, and are always nice to have.  I also have an LED light that you can wear on your head, which is my preferred.  Diameter tape is a luxury but one side is graduated the other will measure the diameter of any round column which is helpful.

The tripod attachment from Leica allows it to pivot properly on the its axis so the measurements stay as accurate as possible.  This is great to have for exterior work  when you might not have access to the interior of the building.  Building chalk or a marking crayon can be helpful but usually would want to mark with painters tape or sticky pad because they are easily removed, however, the former comes in handy sometimes, especially in basements.

And bring food and drink, nothing clouds your mind like being hungry, so eat.

Share

, , , ,

2 Comments

Cialis over the counter

Interioreview, utilized PKNail Pro, an add in to Revit, combined with Leica Disto D8 laser range finders as the main surveying tool and software for capturing and modeling the 28 Story DuBois Library at UMass Amherst.  The structure designed by Durell Stone in 1966 is tallest library in the United States.  While intially considering combining LIDAR and creating a pointcloud for the exterior and utilizing PKNail Pro for the interior it turned out the exterior was the easiest part of the job and it was interior that was the most difficult.  Every 3rd floor contained  90+ rooms  with study carrels combined with classrooms where very few technologies would work well.  Nico Martinez, a Project Manager with Interioreview, commented,”Without PKNail the survey work could have taken  5 times, 10 times what it was.”

The project was completed to support the design and retrofitting a fire protection system.

Interioreview, an architecural surveying firm founded in 2003 specialzies in documenting the built environment in both 2D CAD and 3D Revit formats.

PointKnown, a software firm, founded in 2008 develops productivity tools for the built environment / AEC (Architectural, Engineering, and Construction) Industry

PKNail Pro, allows a user to measure and model objects in real time directly in Revit.

Autodesk® Revit® software is specifically built for Building Information Modeling (BIM), helping building professionals design, build, and maintain higher-quality, more energy-efficient buildings.

Share

, , , ,

No Comments