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Editor’s Note what do you need to buy levitra. Me&My Doctor is launching a new monthly series, Medicine with a Med Student, which features blog posts written exclusively by medical students studying to become physicians. In this what do you need to buy levitra first post in a two-part series on voting, the authors discuss how to vote safely during the erectile dysfunction treatment levitra. For more information on the authors, visit below.

The 2020 election is here, and with early voting underway it’s important to vote – but very important to plan to do so safely – because we are still dealing with the erectile dysfunction treatment levitra. The U.S what do you need to buy levitra. Centers for Disease Control and Prevention and other organizations have created guidelines about how to make voting safer during the erectile dysfunction treatment levitra. Everyone needs to assess what level of risk they are comfortable accepting to vote and decide which voting method works best for them.

Texas is offering two different ways to vote this year, including voting by mail or voting in person at what do you need to buy levitra a polling location. The deadline to register to vote was Oct. 5, so if you did not make this deadline, you will not be able to vote in the November general election. The deadline to what do you need to buy levitra request a ballot by mail is Oct.

23. You can check whether you are registered to vote.Voting by Mail:Texas allows voting by mail if you meet certain criteria but are otherwise eligible to vote, that is, if you are:65 years of age or older,Sick or disabled,Out of the what do you need to buy levitra county on Election Day and during the early voting period, orIn jail.Voting by mail could be a safer alternative than voting in person because it doesn’t require you to be in confined spaces with other people. Remember to follow basic safety guidelines if you take your completed ballot to the post office to vote by mail, such as wearing a mask and washing your hands frequently. The same applies for people who hand-deliver their completed mail-in ballot at a county drop-off location rather than mailing it.The U.S.

Postal Service what do you need to buy levitra is encouraging everyone to plan ahead. Mail your ballot at least seven days before Election Day (Oct. 27). The last what do you need to buy levitra day to mail your ballot is Tuesday, Nov.

3 (must be postmarked by 7 pm).Voting in Person:Voting in person is the other option for voting in Texas. There are two opportunities to vote in person. Voting early what do you need to buy levitra or voting on Election Day (Nov. 3).

Either option you choose, physicians and other medical experts recommend these public health guidelines to keep you safe:Bring alcohol-based hand sanitizer with you in case there is none available at polling locations, and sanitize your hands before and what do you need to buy levitra after voting.Bring your own pen, pencil and stylus.Wear a mask.Socially distance. Keep at least 6 feet of distance from others including standing in line, even though you are wearing a mask.Try to vote during times when lines will be shorter, such as midmorning.Do not disinfect the voting equipment yourself, as this could damage the equipment.Cover your mouth with the inside of your elbow if you sneeze or cough, even while wearing a mask.Stay at home if you are sick.Early Voting – Oct. 13-30Early voting might be a safer alternative than voting on Election Day because you might encounter fewer people at the polls, which decreases the chance of spread of erectile dysfunction treatment. In addition, voting early helps to decrease lines on Election Day, which what do you need to buy levitra helps keep other people safe on a day when millions of people are expected to vote.

Early voting in Texas runs Oct. 13-Oct 30. Find out where to what do you need to buy levitra vote early and where to vote on Election Day. You can vote at any polling location in your county during the early voting period.

Election Day – Nov. 3Voting on Election Day, what do you need to buy levitra Nov. 3, often attracts more people, leading to longer lines. If this is the voting day that’s best for you, please make sure to follow the safety guidelines above.

On this day, you might be able to vote at any polling location in your county or you may be restricted what do you need to buy levitra to voting in your precinct, depending on the county where you live. Make sure to confirm your polling location before you go to vote!. Voting is important what do you need to buy levitra in every election cycle, and it is possible to do so safely even with a global levitra underway. It is essential to plan ahead and select the voting method that works best for you and is safest for you.

If you have any questions, please contact your county’s election authority.Stay tuned for Part 2 of our voting series on MeAndMyDoctor.com.Sarah MillerMedical Student at UTRGV School of MedicineChair, Texas Medical Association Medical Student Section Executive CouncilSwetha MaddipudiMedical Student at UT Health San Antonio Long School of MedicineVice Chair, TMA Medical Student Section Executive CouncilRyan WealtherMedical Student at UT Health San Antonio Long School of MedicineReporter, TMA Texas Medical Association Medical Student Section Executive CouncilAlyssa Greenwood FrancisMedical Student at Texas Tech University Health Sciences Center Paul L. Foster School of what do you need to buy levitra Medicine, El PasoTMA Delegate Co-Chair, TMA Medical Student Section Executive CouncilWith flu season starting as erectile dysfunction treatment continues to spread, many health experts fear a "twindemic."Getting a flu shot can help avoid that. Photo by Brent AnnearFall is here, and so is the flu. With erectile dysfunction treatment still a threat, it’s more important than ever to protect yourself from preventable illnesses, like the flu.

treatments prevent sickness and make it easier for us to go about our everyday what do you need to buy levitra lives. Here are ten reasons getting the flu shot is so important. 1. Save money what do you need to buy levitra.

A flu shot is usually free or low cost, whether you have insurance, Medicaid, Medicare, or work for a company that provides the shot to prevent employees from getting sick. For employees’ what do you need to buy levitra sake, not getting the flu means no lost wages or missed work. 2. Less chance of a heart attack.

Getting the flu shot reduces your risk of having a heart attack, which occurs what do you need to buy levitra more frequently in the weeks following the flu. A recent study that examined more than 80,000 U.S. Adults hospitalized with the flu over eight flu seasons found that one in eight flu patients experienced sudden, serious heart complications. 3.

Protect pregnant women. The flu treatment protects pregnant women who are at risk for complications from the flu. Every pregnant woman deserves a pregnancy without fearing for the health of herself and her baby. Women who plan to get pregnant should also get the flu shot.

treatments strengthen our ability to fight diseases, and studies show the shot works best among women of childbearing age. 4. Protect newborn babies. The flu shot also helps protect babies under six months who are not yet eligible for a flu shot.

When an expectant mom gets a flu shot, the protection gets passed on to her newborn until he or she is old enough to be immunized. 5. Protect older people. It will protect your elderly relatives, who are less likely to receive as much protection from the flu shot as younger people get.

If you don’t get the flu, you can’t pass it on to someone. By getting a flu shot, you help increase your area's herd immunity. Photo by Brent Annear6. Protect people with chronic health conditions.

You’ll also protect people who have conditions which can make the flu more serious for them. These include people with asthma, heart disease, cancer, chronic kidney disease, diabetes, and HIV/AIDS. 7. Help defend your community from illness.

The more people that get the flu shot, the stronger your area’s community immunity, or herd immunity is. Herd immunity is achieved when a large enough portion of the community becomes able to fight off a disease and is therefore less likely to spread it from person-to-person. This protects the whole community, especially those who are less able to fight illness or have chronic diseases. 8.

Avoid a hospital stay or doctor visit. treatments make you less likely to have to go to the doctor or end up in the hospital. Thanks to the flu shot, doctors and other health experts estimate two out of five older adults won’t have to be hospitalized this flu season because of the flu. 9.

Protect children. Influenza can be especially dangerous for children because they can develop complications like pneumonia, dehydration, brain dysfunction, sinus problems, and ear s. According to the Centers for Disease Control and Prevention, in the past 10 years between 7,000 and 26,000 children younger than 5 years of age were hospitalized with the flu. Although it is rare, kids can die from the flu as well.

If your child is afraid of needles, there is a nasal spray flu treatment available for everyone six months and older with no underlying health issues. Talk to your child’s doctor about which treatment is best.10. Stay active. The flu treatment helps keep you moving.

It may not always prevent the flu, but it can lessen symptoms and shorten sick time. This means fewer missed work and school days, and more time to do the things you enjoy. Because erectile dysfunction treatment is still spreading as flu season starts, many health experts fear a “twindemic.” While we wait for a erectile dysfunction treatment, there is one for the flu. For more information on the flu shot, view this downloadable poster created in both English and Spanish by the Texas Medical Association’s Be Wise Immunize℠ program.

Be Wise – Immunize is funded in 2020 by the TMA Foundation, thanks to major support from H-E-B and Permian Basin Youth Chavarim.Be Wise – Immunize is a service mark of the Texas Medical Association..

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

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

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

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

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

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

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

They explain Dworkin’s account of 'associative obligations' which occur within a what do you need to buy levitra group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The erectile dysfunction treatment levitra is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts..

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It's important to keep in http://www.wordsandbones.uni-tuebingen.de/symposium2017/?page_id=34 mind that not everyone will experience all these stages, and the order of how you experience them can be unpredictable, normal dose of levitra too. However, the five stages are quite useful for improving self-awareness of how you or a loved one may be coping with a diagnosis of hearing loss. That anger you may feel?. Quite normal dose of levitra normal. So is sadness.

Stage 1. Denial In many situations, especially with older normal dose of levitra adults, hearing loss occurs gradually. You may not realize you haven't heard the birds sing outside your bedroom window lately. Can you remember the last time you heard the sound your vehicle's turn signal makes?. Do you keep thinking everyone normal dose of levitra around you is mumbling?.

In other words, you may think your hearing is just fine until a friend or family member calls it to your attention that's it not them, it's you. Even then, it's normal to want to deny the obvious. You may tell yourself normal dose of levitra "My hearing isn't that bad" or "I've had a cold lately. My ears must be stuffy." You may tell yourself "My hearing isn't that bad" or "I've had a cold lately. My ears must be stuffy." Even those who relent and see an audiologist for a hearing test wait an average of seven years after their hearing loss is diagnosed before purchasing their first set of hearing aids.

Stage 2 normal dose of levitra. Anger Once you can no longer deny you're not hearing well, you may move into the second stage of grief—anger. You might be upset about having to add another doctor to your growing list or the money you have to spend on tests and medical devices. You may become angry with family members who continually normal dose of levitra ask you to down the volume on the television or insist you have your hearing checked by a health professional. Realize that your family members may be angry, too.

They may think you're ignoring them on purpose—or have a hard time understanding why you won't make an appointment to see the doctor. In the case of hearing loss, it's important to realize the stages of grief can apply to all family members as well as the one who's normal dose of levitra lost their hearing. This is especially true in this particular stage. Realize that your family members may be angry, too. They may think you're ignoring normal dose of levitra them on purpose—or have a hard time understanding why you won't make an appointment to see the doctor.

Regardless, it's important for all affected parties to work through the anger. If you're the one with hearing loss, consider talking to a trusted friend or counselor about what you're feeling, writing in a journal or exercising to release stress and tension. Stage 3 normal dose of levitra. Bargaining After the anger has passed, it's common to enter the bargaining stage and search for ways to restore normal hearing. Maybe it's a promise you make to yourself to wear hearing protection when you're pushing the lawn mower or turn down the volume on your car stereo.

After the normal dose of levitra anger has passed, it's common to enter the bargaining stage and search for ways to restore normal hearing. Depending on the type of hearing loss you're experiencing, the reality is you may never hear normally again. The good news. If your normal dose of levitra hearing loss is associated with presbycusis (old age hearing loss) or another sensorineural condition, you are most likely a perfect candidate for hearing aids. Your audiologist can make that determination following an extensive hearing test.

Stage 4. Depression If you're feeling a bit depressed about your hearing loss, you're not alone—especially if normal dose of levitra you're an older adult. When it becomes difficult and exhausting to participate in daily conversations with friends and loved ones, it's natural to want to avoid those situations. Knowing we've lost something valuable, like our hearing, can make us sad—no matter what our age. Not only does hearing loss mean one of your normal dose of levitra five senses isn't as sharp as it used to be, it may also contribute to a loss identity.

Knowing we've lost something extremely valuable, like our hearing, can make us sad—no matter what our age. Hearing health professionals know untreated hearing loss can lead to anxiety, depression, paranoia and social isolation. It's one of the reasons they stress the importance of maintaining contact with friends and family as we age normal dose of levitra. Stage 5. Acceptance The final stage of grief is acceptance.

In the case of normal dose of levitra those with a hearing impairment, that means you've accepted your physical limitations. Hopefully, you've elected to consult with a hearing health professional and are a candidate for one of the numerous ways of improving your ability to hear. If your audiologist has recommended hearing aids and you've decided not to purchase them, you may want to reconsider. If your hearing loss is severe or profound, you may also be a candidate for cochlear implants (even if normal dose of levitra you're older). Once you've accepted your hearing loss, hopefully you've elected to consult with a hearing health professional to receive help.

Many treatment options exist. Recent research confirms a direct link between hearing normal dose of levitra aid usage and improved quality of life. Most hearing aid users report higher levels of happiness and say hearing aids have significantly improved their relationships with family and friends and given them a greater sense of independence. Research also shows that hearing aids also have health benefits, such as reduced rates of depression, social isolation and the risk of falls.When you live with bothersome tinnitus, having the right coping tools close at hand can make a big difference in the quality of your day. But if you have a smartphone, you already own one of normal dose of levitra the most powerful tinnitus coping toolkits ever created.

There are many apps that can help you to better manage tinnitus in a variety of different ways. The only problem is that there are quite a lot of apps to choose from, and not all of them are created equal. So I’m normal dose of levitra here to help. I’ve put together a list of my favorite tinnitus-related apps across many different categories, all to help you find relief from the ringing in your ears. From sound masking, guided meditation and breathing techniques, to educational content, habituation assistance, and sensorineural hearing loss improvement, there is an app for every need.

Despite what your doctor might have told you or what you might have read online, if you suffer from tinnitus, you do not “just have to live with it.” There are many ways to find tinnitus relief, and these apps normal dose of levitra are just one more toolset available to every tinnitus patient. I hope you find them helpful!. Best apps for sound masking myNoise (Android and iOS) NatureSpace (Android and iOS) At its best, sound masking is one the most powerful coping tools available to tinnitus sufferers. The strategy is remarkably simple normal dose of levitra. You just use various types of background noise to partially cover the sound of your tinnitus.

For most sufferers, the right background noise can often provide immediate (though temporary) relief. Smartphone apps normal dose of levitra for tinnitus can help calm theringing in your ears. It’s an effective way to cope, but in practice it can get tricky, because not all sound masking sounds are created equal, and there are a seemingly endless number of sound masking/sound therapy apps available in the app store. Here are published here my top two app recommendations, available for both Android and iOS devices. MyNoise (Android and iOS).

MyNoise features a massive library of soundscapes and ambiances, including various experimental sounds specifically created for tinnitus patients normal dose of levitra. Best of all, every soundscape is completely customizable via sliders that let you control the individual volume of various elements of the soundscape. Want more birds, but less rain, stronger wind, and no chimes?. Simple normal dose of levitra. Or maybe you want the sound of more chatter in the café ambiance, but less clinking of cups and silverware?.

Two clicks and it’s done. MyNoise makes it easy to dial in the normal dose of levitra perfect soundscape to mask the sound of your tinnitus. NatureSpace (Android and iOS). Naturespace has been one of my favorite masking apps for a long time for one very specific reason. No other app can hold a candle normal dose of levitra to the quality of their nature soundscapes.

And that’s because all of the soundscapes are actual high-fidelity audio recordings of real nature. According to NatureSpace, “Our specialized team of audio engineers record outdoor environments in 3D using proprietary holographic microphone techniques drawn from binaural, classical, and field recording practices. The results are astonishing normal dose of levitra. Naturespace recordings preserve the entire hemispheric sound field, including the sounds that occur in front, behind, beside, and above the listener over headphones.” The app itself is free, along with 6 included soundscapes, with the remaining 120+ recordings available via in-app purchases a la carte. Runner up.

Relax Melodies (Android and iOS) Best apps for comprehensive tinnitus relief and habituation Rewiring Tinnitus Relief Project Quieten (Android and iOS) There may not currently be a cure for tinnitus, normal dose of levitra but lasting relief is entirely possible through a mental process called habituation. And only a select few apps are specifically designed to help you habituate to the sound of your tinnitus. The human brain is fully capable of tuning out the sound of tinnitus (even when it’s loud) just like it does all other meaningless background noise. The problem is that when tinnitus becomes severe, it triggers a normal dose of levitra powerful and progressively worsening fight-or-flight stress response that never fully ends because the tinnitus doesn’t just magically go away. And it’s this reaction that prevents the brain from being able to ignore the sound.

We are evolutionarily hardwired to focus on sounds that our brain and nervous system interpret as the sound of something dangerous. But you can completely change your underlying emotional, psychological and physiological reaction normal dose of levitra to the sound of your tinnitus. And when you do, your brain can start to automatically tune out and ignore the sound of your tinnitus more and more of the time. Here are two apps whose sole purpose is to help you habituate and find lasting relief. Rewiring Tinnitus Relief Project normal dose of levitra.

First I have to disclose that this is my app that I created to help tinnitus sufferers habituate and find relief as quickly as possible. It was originally designed to accompany my book (Rewiring Tinnitus. How I finally Found Relief from the Ringing in my Ears), normal dose of levitra but ultimately evolved into a standalone program for tinnitus habituation. The 54-track album feature a powerful audio technology called Brainwave Entrainment that can change your mental state in minutes, and all you have to do is press play. It features guided tinnitus meditation tracks, sleep induction tracks, guided tinnitus spike relief techniques, relaxation tracks, and more, all embedded with various masking sounds and brainwave entrainment to put you in a sedated state of relaxation automatically.

I may be biased, but as an experienced tinnitus coach, I know what normal dose of levitra works. Quieten (Android and iOS). Quieten is an excellent new app from author, therapist, and tinnitus expert Julian Cowan Hill. It features a wide variety of free audio and video educational content to help you habituate and better understand tinnitus, as well as meditations, normal dose of levitra coping tools, relaxation techniques and more!. Runner up.

Beltone Tinnitus Calmer (Android and iOS) Best paid app for meditation Waking Up (Android and iOS) When it comes to tinnitus coping, it’s important to reduce your stress and anxiety levels as much as possible, and mindfulness meditation is one of the most powerful tools at your disposal. Mindfulness has been shown to be helpful normal dose of levitra for tinnitus coping, but it’s also a remarkably effective way to better manage your mind. There are a ton of excellent mindfulness meditation apps on the market, but for me, the Waking Up meditation app from author Sam Harris stands above the rest. The app itself is not marketed or built for tinnitus patients specifically, but mindfulness is an important tool that should be every tinnitus sufferer's toolkit. I’ve personally used Waking Up on a daily basis for more than normal dose of levitra a year now and it has had a profoundly positive impact on my quality of life with tinnitus on almost every level.

I cannot recommend this app enough!. Runners up. 10% App, Headspace, Calm Best free app for meditation Insight Timer (Android and iOS) Insight Timer is the most popular free meditation app by far, and for good reason. It features more than 60,000 free guided meditations, breathing exercises, and music tracks. It’s not just traditional meditation either, Insight Timer features guided meditations for better sleep, relaxation, anxiety relief, focus, and more, making it an excellent option for tinnitus sufferers who want to experiment with different types of meditation to help them cope.

Insight Timer also includes a great meditation timer feature built into the app that allows you to set up custom meditation sessions. This is a focus training tool that plays a soft chime (or whatever sound you select) at preset intervals to help keep you focused while you meditate. This way, if your mind is wandering, and the chime goes off, it instantly brings you back to the meditation. You can also incorporate various background sounds into your meditation sessions, such as ambient music, nature sounds, and white noise. Best apps for breathing techniques Breathwrk (iOS only) Prana Breath.

Calm &. Meditate (Android only) Breathing techniques are a powerful way to cope with tinnitus, especially during spikes and on difficult days. Fortunately, there are a handful of excellent apps featuring guided breathing exercises to help you learn and practice the most effective techniques, of which there are many. Some breathing techniques can trigger a relaxation response in the nervous system very quickly, while other techniques can help with everything from falling asleep faster, lowering stress levels, improving emotional regulation, increasing energy and focus, and so much more!. Here my top two app recommendations for learning the most powerful breathing techniques.

Breathwrk (iOS only). Breathwrk is one of the top breathing exercise apps for iOS, featuring thousands of positive reviews in the app store, with a combined 4.9/5 star rating. As far features, Breathwrk includes 10+ guided breathing techniques, visual, audio, and vibration cues, breathing lessons, progress tracking, and so much more. Prana Breath. Calm &.

Meditate (Android only). Prana Breath is one of the most popular and powerful free guided breathing apps for Android, featuring 8 preset breathing protocols, visual, audio, and vibration cues to make it easy to follow along, as well as the ability to set up custom breathing sessions with timing intervals of your choosing. Prana Breath also allows you to increase the difficulty and complexity level of each technique as you practice, while recording of all of your breathing sessions so you can see your results and track progress over time. The app itself is free and ad-free, though there is a premium “Guru” version of the app (that I highly recommend) that can be unlocked via in-app purchase that adds an additional 50 breathing techniques. Best app for improving hearing loss AudioCardio (Android and iOS) Many patients with tinnitus also have hearing loss.

It's a difficult combination, but it opens the door to additional treatment strategies, because improving a person's hearing can often improve their tinnitus as well. AudioCardio delivers a new type of sound therapy that functions kind of like physical therapy for hearing, and one that could actually improve and strengthen hearing in patients with sensorineural hearing loss, based on preliminary data.

However, the five stages like it are quite useful for what do you need to buy levitra improving self-awareness of how you or a loved one may be coping with a diagnosis of hearing loss. That anger you may feel?. Quite normal. So is what do you need to buy levitra sadness.

Stage 1. Denial In many situations, especially with older adults, hearing loss occurs gradually. You may not realize you haven't heard the birds sing outside your bedroom what do you need to buy levitra window lately. Can you remember the last time you heard the sound your vehicle's turn signal makes?.

Do you keep thinking everyone around you is mumbling?. In other words, you may what do you need to buy levitra think your hearing is just fine until a friend or family member calls it to your attention that's it not them, it's you. Even then, it's normal to want to deny the obvious. You may tell yourself "My hearing isn't that bad" or "I've had a cold lately.

My ears must be stuffy." You may tell yourself "My hearing isn't that bad" or "I've had a cold what do you need to buy levitra lately. My ears must be stuffy." Even those who relent and see an audiologist for a hearing test wait an average of seven years after their hearing loss is diagnosed before purchasing their first set of hearing aids. Stage 2. Anger Once you can no longer deny you're not hearing what do you need to buy levitra well, you may move into the second stage of grief—anger.

You might be upset about having to add another doctor to your growing list or the money you have to spend on tests and medical devices. You may become angry with family members who continually ask you to down the volume on the television or insist you have your hearing checked by a health professional. Realize that your family members may what do you need to buy levitra be angry, too. They may think you're ignoring them on purpose—or have a hard time understanding why you won't make an appointment to see the doctor.

In the case of hearing loss, it's important to realize the stages of grief can apply to all family members as well as the one who's lost their hearing. This is especially true what do you need to buy levitra in this particular stage. Realize that your family members may be angry, too. They may think you're ignoring them on purpose—or have a hard time understanding why you won't make an appointment to see the doctor.

Regardless, it's important what do you need to buy levitra for all affected parties to work through the anger. If you're the one with hearing loss, consider talking to a trusted friend or counselor about what you're feeling, writing in a journal or exercising to release stress and tension. Stage 3. Bargaining After the anger has passed, it's common to enter the bargaining what do you need to buy levitra stage and search for ways to restore normal hearing.

Maybe it's a promise you make to yourself to wear hearing protection when you're pushing the lawn mower or turn down the volume on your car stereo. After the anger has passed, it's common to enter the bargaining stage and search for ways to restore normal hearing. Depending on the type of hearing loss you're experiencing, the reality is you may never hear normally what do you need to buy levitra again. The good news.

If your hearing loss is associated with presbycusis (old age hearing loss) or another sensorineural condition, you are most likely a perfect candidate for hearing aids. Your audiologist can make that determination following an extensive hearing what do you need to buy levitra test. Stage 4. Depression If you're feeling a bit depressed about your hearing loss, you're not alone—especially if you're an older adult.

When it becomes difficult what do you need to buy levitra and exhausting to participate in daily conversations with friends and loved ones, it's natural to want to avoid those situations. Knowing we've lost something valuable, like our hearing, can make us sad—no matter what our age. Not only does hearing loss mean one of your five senses isn't as sharp as it used to be, it may also contribute to a loss identity. Knowing we've lost something extremely valuable, like our hearing, can make what do you need to buy levitra us sad—no matter what our age.

Hearing health professionals know untreated hearing loss can lead to anxiety, depression, paranoia and social isolation. It's one of the reasons they stress the importance of maintaining contact with friends and family as we age. Stage 5 what do you need to buy levitra. Acceptance The final stage of grief is acceptance.

In the case of those with a hearing impairment, that means you've accepted your physical limitations. Hopefully, you've elected to consult with a hearing health professional and are a candidate for one what do you need to buy levitra of the numerous ways of improving your ability to hear. If your audiologist has recommended hearing aids and you've decided not to purchase them, you may want to reconsider. If your hearing loss is severe or profound, you may also be a candidate for cochlear implants (even if you're older).

Once you've accepted your hearing loss, hopefully you've elected to consult with a hearing health professional what do you need to buy levitra to receive help. Many treatment options exist. Recent research confirms a direct link between hearing aid usage and improved quality of life. Most hearing aid users report higher levels of happiness and say hearing aids have significantly improved their relationships with family and what do you need to buy levitra friends and given them a greater sense of independence.

Research also shows that hearing aids also have health benefits, such as reduced rates of depression, social isolation and the risk of falls.When you live with bothersome tinnitus, having the right coping tools close at hand can make a big difference in the quality of your day. But if you have a smartphone, you already own one of the most powerful tinnitus coping toolkits ever created. There are many apps that can help you what do you need to buy levitra to better manage tinnitus in a variety of different ways. The only problem is that there are quite a lot of apps to choose from, and not all of them are created equal.

So I’m here to help. I’ve put what do you need to buy levitra together a list of my favorite tinnitus-related apps across many different categories, all to help you find relief from the ringing in your ears. From sound masking, guided meditation and breathing techniques, to educational content, habituation assistance, and sensorineural hearing loss improvement, there is an app for every need. Despite what your doctor might have told you or what you might have read online, if you suffer from tinnitus, you do not “just have to live with it.” There are many ways to find tinnitus relief, and these apps are just one more toolset available to every tinnitus patient.

I hope you what do you need to buy levitra find them helpful!. Best apps for sound masking myNoise (Android and iOS) NatureSpace (Android and iOS) At its best, sound masking is one the most powerful coping tools available to tinnitus sufferers. The strategy is remarkably simple. You just use various types of background noise to partially cover the what do you need to buy levitra sound of your tinnitus.

For most sufferers, the right background noise can often provide immediate (though temporary) relief. Smartphone apps for tinnitus can help calm theringing in your ears. It’s an effective way to cope, but in practice it can get tricky, because not all sound masking sounds are created equal, and there are a seemingly endless number of sound masking/sound therapy apps available in the what do you need to buy levitra app store. Here are my top two app recommendations, available for both Android and iOS devices.

MyNoise (Android and iOS). MyNoise features a massive library of soundscapes and ambiances, including various experimental sounds specifically created for tinnitus patients. Best of all, every soundscape is completely customizable via sliders that let you control the individual volume of various elements of what do you need to buy levitra the soundscape. Want more birds, but less rain, stronger wind, and no chimes?.

Simple. Or maybe you want the sound of more chatter in the café what do you need to buy levitra ambiance, but less clinking of cups and silverware?. Two clicks and it’s done. MyNoise makes it easy to dial in the perfect soundscape to mask the sound of your tinnitus.

NatureSpace (Android what do you need to buy levitra and iOS). Naturespace has been one of my favorite masking apps for a long time for one very specific reason. No other app can hold a candle to the quality of their nature soundscapes. And that’s because all of the soundscapes are actual high-fidelity audio recordings of real nature what do you need to buy levitra.

According to NatureSpace, “Our specialized team of audio engineers record outdoor environments in 3D using proprietary holographic microphone techniques drawn from binaural, classical, and field recording practices. The results are astonishing. Naturespace recordings preserve the entire hemispheric sound field, including the what do you need to buy levitra sounds that occur in front, behind, beside, and above the listener over headphones.” The app itself is free, along with 6 included soundscapes, with the remaining 120+ recordings available via in-app purchases a la carte. Runner up.

Relax Melodies (Android and iOS) Best apps for comprehensive tinnitus relief and habituation Rewiring Tinnitus Relief Project Quieten (Android and iOS) There may not currently be a cure for tinnitus, but lasting relief is entirely possible through a mental process called habituation. And only a select few apps are specifically designed to help you habituate to the sound of your tinnitus what do you need to buy levitra. The human brain is fully capable of tuning out the sound of tinnitus (even when it’s loud) just like it does all other meaningless background noise. The problem is that when tinnitus becomes severe, it triggers a powerful and progressively worsening fight-or-flight stress response that never fully ends because the tinnitus doesn’t just magically go away.

And it’s this reaction that prevents the brain what do you need to buy levitra from being able to ignore the sound. We are evolutionarily hardwired to focus on sounds that our brain and nervous system interpret as the sound of something dangerous. But you can completely change your underlying emotional, psychological and physiological reaction to the sound of your tinnitus. And when you do, your brain can start to automatically tune out and ignore the sound of your tinnitus more what do you need to buy levitra and more of the time.

Here are two apps whose sole purpose is to help you habituate and find lasting relief. Rewiring Tinnitus Relief Project. First I have to disclose that this is my app what do you need to buy levitra that I created to help tinnitus sufferers habituate and find relief as quickly as possible. It was originally designed to accompany my book (Rewiring Tinnitus.

How I finally Found Relief from the Ringing in my Ears), but ultimately evolved into a standalone program for tinnitus habituation. The 54-track album feature a powerful audio technology called Brainwave Entrainment that can change your mental state in minutes, and what do you need to buy levitra all you have to do is press play. It features guided tinnitus meditation tracks, sleep induction tracks, guided tinnitus spike relief techniques, relaxation tracks, and more, all embedded with various masking sounds and brainwave entrainment to put you in a sedated state of relaxation automatically. I may be biased, but as an experienced tinnitus coach, I know what works.

Quieten what do you need to buy levitra (Android and iOS). Quieten is an excellent new app from author, therapist, and tinnitus expert Julian Cowan Hill. It features a wide variety of free audio and video educational content to help you habituate and better understand tinnitus, as well as meditations, coping tools, relaxation techniques and more!. Runner up what do you need to buy levitra.

Beltone Tinnitus Calmer (Android and iOS) Best paid app for meditation Waking Up (Android and iOS) When it comes to tinnitus coping, it’s important to reduce your stress and anxiety levels as much as possible, and mindfulness meditation is one of the most powerful tools at your disposal. Mindfulness has been shown to be helpful for tinnitus coping, but it’s also a remarkably effective way to better manage your mind. There are a ton of excellent mindfulness what do you need to buy levitra meditation apps on the market, but for me, the Waking Up meditation app from author Sam Harris stands above the rest. The app itself is not marketed or built for tinnitus patients specifically, but mindfulness is an important tool that should be every tinnitus sufferer's toolkit.

I’ve personally used Waking Up on a daily basis for more than a year now and it has had a profoundly positive impact on my quality of life with tinnitus on almost every level. I cannot recommend what do you need to buy levitra this app enough!. Runners up. 10% App, Headspace, Calm Best free app for meditation Insight Timer (Android and iOS) Insight Timer is the most popular free meditation app by far, and for good reason.

It features what do you need to buy levitra more than 60,000 free guided meditations, breathing exercises, and music tracks. It’s not just traditional meditation either, Insight Timer features guided meditations for better sleep, relaxation, anxiety relief, focus, and more, making it an excellent option for tinnitus sufferers who want to experiment with different types of meditation to help them cope. Insight Timer also includes a great meditation timer feature built into the app that allows you to set up custom meditation sessions. This is a focus training tool that plays a soft chime (or whatever sound you select) what do you need to buy levitra at preset intervals to help keep you focused while you meditate.

This way, if your mind is wandering, and the chime goes off, it instantly brings you back to the meditation. You can also incorporate various background sounds into your meditation sessions, such as ambient music, nature sounds, and white noise. Best apps for what do you need to buy levitra breathing techniques Breathwrk (iOS only) Prana Breath. Calm &.

Meditate (Android only) Breathing techniques are a powerful way to cope with tinnitus, especially during spikes and on difficult days. Fortunately, there are a handful of excellent apps featuring guided breathing exercises to help you learn and practice the most effective techniques, of which there are what do you need to buy levitra many. Some breathing techniques can trigger a relaxation response in the nervous system very quickly, while other techniques can help with everything from falling asleep faster, lowering stress levels, improving emotional regulation, increasing energy and focus, and so much more!. Here my top two app recommendations for learning the most powerful breathing techniques.

Breathwrk (iOS what do you need to buy levitra only). Breathwrk is one of the top breathing exercise apps for iOS, featuring thousands of positive reviews in the app store, with a combined 4.9/5 star rating. As far features, Breathwrk includes 10+ guided breathing techniques, visual, audio, and vibration cues, breathing lessons, progress tracking, and so much more. Prana Breath what do you need to buy levitra.

Calm &. Meditate (Android only). Prana Breath is one what do you need to buy levitra of the most popular and powerful free guided breathing apps for Android, featuring 8 preset breathing protocols, visual, audio, and vibration cues to make it easy to follow along, as well as the ability to set up custom breathing sessions with timing intervals of your choosing. Prana Breath also allows you to increase the difficulty and complexity level of each technique as you practice, while recording of all of your breathing sessions so you can see your results and track progress over time.

The app itself is free and ad-free, though there is a premium “Guru” version of the app (that I highly recommend) that can be unlocked via in-app purchase that adds an additional 50 breathing techniques. Best app for improving hearing loss AudioCardio (Android and iOS) Many patients with tinnitus also have hearing loss. It's a difficult combination, but it opens the door to additional treatment strategies, because improving a person's hearing can often improve their tinnitus as well. AudioCardio delivers a new type of sound therapy that functions kind of like physical therapy for hearing, and one that could actually improve and strengthen hearing in patients with sensorineural hearing loss, based on preliminary data.

In a clinical trial at Stanford University, more than 70% of 42 study participants experienced at least a 10-decibel improvement in their hearing at the targeted frequency after two weeks of using AudioCardio’s algorithmically generated sound therapy for one hour per day.

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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 super levitra 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 super levitra 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 super levitra 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 super levitra 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 super levitra 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 super levitra 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 super levitra. 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 super levitra 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 super levitra 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 super levitra 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 super levitra 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 super levitra (pg 8).

Pickle &. 1619B. 5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit.

The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences.

MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B.

It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7).

Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy.

If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS.

Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program. The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS). Unfortunately, the notice is not consumer-friendly and may be confusing.

See attached sample for what to look for. Health Insurance Premium Payment Program (HIPP) HIPP is a sister program to MIPP and will reimburse consumers for private third party health insurance when deemed “cost effective.” Directives:Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in QMB receive additional subsidies for Medicare costs.

See 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. N.Y.

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

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

(b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind.

(c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE.

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

EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work.

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

Under these rules, Bob is now eligible for an MSP. When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a).

(Link is to NYC HRA form, can be adapted for other counties). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021.)) 3.

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

Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, More about 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.

Instead, these url consumers can have their Part B what do you need to buy levitra premium reimbursed through the MIPP program. 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra 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 $1,288 what do you need to buy levitra (2021) 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra. 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra 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 what do you need to buy levitra C (pg 8). Pickle &. 1619B.

5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021).

They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences.

MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check.

MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only.

Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &.

Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy.

If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov.

If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program.

The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS). Unfortunately, the notice is not consumer-friendly and may be confusing. See attached sample for what to look for.

Health Insurance Premium Payment Program (HIPP) HIPP is a sister program to MIPP and will reimburse consumers for private third party health insurance when deemed “cost effective.” Directives:Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in QMB receive additional subsidies for Medicare costs.

See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y. Soc.

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. N.Y.

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.

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.