Can i get viagra over the counter

Starting in 2022, there are new protections can i get viagra over the counter that prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills. If you’re uninsured or you decide not to use your health insurance for a service, under these protections, you can often get a good faith estimate of the cost of your care up front, before your can i get viagra over the counter visit. If you disagree with your bill, you may be able to dispute the charges.

According to CMS Fact Sheet (https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills). If you get health coverage through your employer, a Health Insurance Marketplace, or an individual health insurance plan can i get viagra over the counter you purchase directly from an insurance company, these new rules will. Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization). Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services.

You can’t be charged more than in-network can i get viagra over the counter cost-sharing for these services. Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility. Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if can i get viagra over the counter you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider). What if my state has a surprise billing law?.

The No Surprises Act supplements state surprise billing laws. It does can i get viagra over the counter not supplant them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does can i get viagra over the counter the No Surprises Act and its implementing regulations, the state law generally will apply.

For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process. As another example, if your state has an All-payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate. Overview of Rules &. Fact Sheets.

Https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get a good faith estimate of how much your care will cost before you receive it. For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of the date on your bill. Https://www.cms.gov/nosurprises/consumers/medical-bill-disagreements-if-you-are-uninsured You can submit a complaint about a medical billing experience you had, whether you’re insured or uninsured. Https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing This article was authored by the Empire Justice Center..

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June 1, 2022Our file how can i get viagra number. 22-104423-584Health Canada is informing hospitals of additional products that may fall under serious adverse drug reaction reporting requirements that are already in place.As noted in our 2019 proposal, the Department is moving forward with a new set of regulations for public and military health emergencies. These regulations will be set out under the Food and Drug Regulations, entitled "Public or Canadian Armed Forces Health Emergencies - Drugs for Immediate Use or Stockpiling", otherwise known as the block release regulations.These regulations would allow Chief Medical Officers of Health, referred to as Public Health Officials, to stockpile and use drugs that are not authorized in Canada or available through other emergency channels to address a public health emergency in Canada.The regulations were proposed in May 2019 for a 70-day comment period.In that proposal, Public Health Officials would have been how can i get viagra required to report serious adverse drug reactions to the Minister of Health. However, it is anticipated that Canadians would present themselves at a hospital should they experience a serious adverse drug reaction with one of these drugs. Since hospitals are currently how can i get viagra required to report serious adverse drug reactions to Health Canada, the proposed block release regulations have been changed to be consistent with this reporting.

Hospitals would be informed, by the Public Health Official authorized by Health Canada to stockpile and use the drug. It is how can i get viagra anticipated that use of these drugs would be a rare event, and only to address a public health emergency. Hospitals would be expected to report according to the procedures already in place for mandatory reporting and as outlined in the guidance document entitled "Mandatory reporting of serious adverse drug reactions and medical device incidents by hospitals". This proposed framework is necessary to ensure drugs not normally available in Canada through how can i get viagra existing channels could be made available if needed to address a public health emergency. Although, the Urgent Public Health Need List is available for use in a public health emergency, it only allows drugs that are authorized for sale in the United States, the European Union, or Switzerland.

There are how can i get viagra cases however, where a drug that could address a public health emergency is one that is not authorized in any of those countries. As such, the block release regulation will be an additional mechanism to allow access to drugs in a public health emergency should one not be sold in Canada.These new regulations are expected to come into effect early 2023. Hospitals will be informed when the regulations come into effect.For additional information please contact:.

June 1, 2022Our file can i get viagra over the counter number. 22-104423-584Health Canada is informing hospitals of additional products that may fall under serious adverse drug reaction reporting requirements that are already in place.As noted in our 2019 proposal, the Department is moving forward with a new set of regulations for public and military health emergencies. These regulations will be set out under the Food and Drug Regulations, entitled "Public or Canadian Armed Forces Health Emergencies - Drugs for Immediate Use or Stockpiling", otherwise known as the block release regulations.These regulations would allow Chief Medical Officers of Health, referred to as can i get viagra over the counter Public Health Officials, to stockpile and use drugs that are not authorized in Canada or available through other emergency channels to address a public health emergency in Canada.The regulations were proposed in May 2019 for a 70-day comment period.In that proposal, Public Health Officials would have been required to report serious adverse drug reactions to the Minister of Health. However, it is anticipated that Canadians would present themselves at a hospital should they experience a serious adverse drug reaction with one of these drugs. Since hospitals are currently required to report serious adverse drug reactions to Health Canada, the proposed block can i get viagra over the counter release regulations have been changed to be consistent with this reporting.

Hospitals would be informed, by the Public Health Official authorized by Health Canada to stockpile and use the drug. It is anticipated that use of these drugs would be a rare event, and only can i get viagra over the counter to address a public health emergency. Hospitals would be expected to report according to the procedures already in place for mandatory reporting and as outlined in the guidance document entitled "Mandatory reporting of serious adverse drug reactions and medical device incidents by hospitals". This proposed framework is can i get viagra over the counter necessary to ensure drugs not normally available in Canada through existing channels could be made available if needed to address a public health emergency. Although, the Urgent Public Health Need List is available for use in a public health emergency, it only allows drugs that are authorized for sale in the United States, the European Union, or Switzerland.

There are cases however, where a drug that could address a public health emergency can i get viagra over the counter is one that is not authorized in any of those countries. As such, the block release regulation will be an additional mechanism to allow access to drugs in a public health emergency should one not be sold in Canada.These new regulations are expected to come into effect early 2023. Hospitals will be informed when the regulations come into effect.For additional information please contact:.

What may interact with Viagra?

Do not take Viagra with any of the following:

• cisapride
• methscopolamine nitrate
• nitrates like amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin
• nitroprusside
• other sildenafil products (Revatio)

Viagra may also interact with the following:

• certain drugs for high blood pressure
• certain drugs for the treatment of HIV or AIDS
• certain drugs used for fungal or yeast s, like fluconazole, itraconazole, ketoconazole, and voriconazole
• cimetidine
• erythromycin
• rifampin

This list may not describe all possible interactions. Give your health care providers a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

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An out-of-state man wanted for assaulting a woman was nabbed by police in the Hudson paul thorn viagra Valley.The man was apprehended in Ulster County while officers were conducting a warrant investigation on Tuesday, Aug. 23.While conducting the investigation, officers located AJ Brown, age unknown, of Gloucester, Massachusetts, living in the hamlet of Glasco, in the town of Saugerties, Saugerties Police Chief Joseph Sinagra said.Brown was wanted out of Maryland on a warrant paul thorn viagra from Baltimore County for felony assault of a woman on I-95 in December 2021, Sinagra said.He was taken into custody by officers without incident. Brown was processed and arraigned paul thorn viagra in the Town of Saugerties Justice Court on the charge of being a fugitive from justice. He was sent to the Ulster County Jail without bail, awaiting extradition proceedings.

Click here to follow Daily Voice Somers and receive free news updates.A brand-new forecast for the winter of 2022-23 is calling for a cold, snowy winter.It's in the 231st edition of the Old Farmer's Almanac, which says it has an 80-percent accuracy rate with its weather forecasts.“Depending on where you live, this will be the best of winters or paul thorn viagra memorable for all the wrong reasons,” said Janice Stillman, editor of The Old Farmer’s Almanac. €œOne half of the country will deal with bone-chilling cold and loads of snow, while the other half may feel like winter never really arrives.”Most of the Northeast will paul thorn viagra see a “cold, snowy” winter, according to the almanac's forecast graphic. "The coldest periods paul thorn viagra will be in early and late January and late February," the Old Farmer's Almanac says. "Precipitation will be above normal.

Snowfall will be below normal in the north and above normal in the south, paul thorn viagra with the snowiest periods in early to mid-December and the first half of January."Areas in the country that will see milder conditions are mainly in the southwest and west, according to the Old Farmer's Almanac.A separate, unaffiliated outlet, Farmers' Almanac, earlier released its outlook, calling for a harsh winter.The Old Farmer's Almanac said it uses three scientific disciplines to make long-range predictions. Meteorology, the study of the atmosphere;Climatology, the study of prevailing weather patterns.Solar science, the study of paul thorn viagra sunspots and other solar activity.Check back to Daily Voice for updates. Click here to follow Daily Voice Somers and receive free news updates..

An out-of-state man wanted for assaulting a woman was can i get viagra over the counter nabbed by police in the Hudson Valley.The man was apprehended in Ulster County while officers were conducting a warrant investigation on Tuesday, Aug Propecia online canada. 23.While conducting the investigation, officers located AJ Brown, age unknown, of Gloucester, Massachusetts, living in the hamlet of Glasco, in the town of Saugerties, Saugerties Police Chief Joseph Sinagra said.Brown was wanted out of Maryland on a warrant from Baltimore County for felony can i get viagra over the counter assault of a woman on I-95 in December 2021, Sinagra said.He was taken into custody by officers without incident. Brown was can i get viagra over the counter processed and arraigned in the Town of Saugerties Justice Court on the charge of being a fugitive from justice.

He was sent to the Ulster County Jail without bail, awaiting extradition proceedings. Click here to follow Daily Voice Somers and receive free can i get viagra over the counter news updates.A brand-new forecast for the winter of 2022-23 is calling for a cold, snowy winter.It's in the 231st edition of the Old Farmer's Almanac, which says it has an 80-percent accuracy rate with its weather forecasts.“Depending on where you live, this will be the best of winters or memorable for all the wrong reasons,” said Janice Stillman, editor of The Old Farmer’s Almanac. €œOne half of the country will deal with bone-chilling cold and loads of snow, while the other half may feel like winter never really arrives.”Most of the Northeast will see a “cold, snowy” winter, according can i get viagra over the counter to the almanac's forecast graphic.

"The coldest periods will be in early and late January and can i get viagra over the counter late February," the Old Farmer's Almanac says. "Precipitation will be above normal. Snowfall will be below normal in the north and above normal in the south, with the snowiest periods in early to mid-December and the first half of January."Areas in the country that will see milder conditions are mainly in the southwest and west, according to the Old Farmer's Almanac.A separate, unaffiliated outlet, Farmers' Almanac, earlier released its outlook, can i get viagra over the counter calling for a harsh winter.The Old Farmer's Almanac said it uses three scientific disciplines to make long-range predictions.

Meteorology, the study of the atmosphere;Climatology, the study of prevailing weather patterns.Solar science, the study can i get viagra over the counter of sunspots and other solar activity.Check back to Daily Voice for updates. Click here to follow Daily Voice Somers and receive free news updates..

Sex viagra tablets for female

Jennifer Smithfield felt weak and http://wilcolquhoun.com/can-you-buy-cialis-over-the-counter/ still had trouble breathing in sex viagra tablets for female February after nearly two weeks with erectile dysfunction treatment. It was sex viagra tablets for female a Sunday, and her doctor’s office was closed. So her primary care physician suggested going to an emergency room to be safe.Smithfield went to HCA Healthcare’s flagship hospital, near its corporate headquarters in Nashville, Tennessee, and thought she would be checked out and sent home. But that’s not what happened.“Even though I did not feel well, I didn’t think it was bad enough to be hospitalized, especially not multiple days,” Smithfield said.Over three days, Smithfield racked up $40,000 in charges for her inpatient stay sex viagra tablets for female and received a bill for $6,000 under the terms of her health insurance policy.

€œI could have sex viagra tablets for female walked out,” Smithfield said. €œI wish I had walked out.”While she was in the hospital, she said, the doctor who had directed her to the ER texted her repeatedly, asking why she’d been admitted.For more than a decade, large health systems have faced scrutiny for admitting patients to costly hospital stays when less expensive treatments or short periods of observation in the ER would have been appropriate.Not a Modern Healthcare subscriber?. Sign up today.Commercial insurers pay handsomely for inpatient care, sex viagra tablets for female with room rates often hitting several thousand dollars a day — and that doesn’t include the charges that inevitably follow for bloodwork, consultations, and other exams that typically occur. Hospitals, like hotels, maximize revenue by keeping their beds full.Critics allege that HCA sought to keep occupancy rates high by creating incentives for doctors to admit ER patients — whether those patients required admission or not sex viagra tablets for female.

The accusation is particularly surprising because admission rates nationally have generally been declining as more conditions can be safely treated with telemedicine and home monitoring.U.S. Rep. Bill Pascrell (D-N.J.) and the Service Employees International Union have been pressing the Department of Health and Human Services to investigate allegations against HCA as potential Medicare fraud. A spokesperson for the Centers for Medicare &.

Medicaid Services, Bruce Alexander, said the agency is reviewing a September letter from Pascrell that details the claims that HCA forced doctors to meet unofficial quotas, or targets, for the number of patients admitted to the hospital. And a previously sealed whistleblower case is shedding new light on such internal policies.“Improper hospital admissions can have cascading effects on patients and workers,” Pascrell, chair of the House Ways and Means oversight subcommittee, wrote to HHS Secretary Xavier Becerra. €œUnnecessary admissions expose patients to unnecessary treatments. This creates an added potential risk of complications and the possibility of new s for patients.”HCA spokesperson Harlow Sumerford refuted the accusations.

€œWe categorically reject any allegation that physicians admit patients to our hospitals on the basis of anything other than their independent medical judgment and their patients’ individual conditions and medical needs,” he told KHN in a statement.Pascrell’s concerns are based largely on a 58-page investigative report from the SEIU published in February. The national labor union has been challenging health systems on admissions for more than a decade as it attempts to organize in more for-profit hospitals and advocates for its members who work on the front lines. The SEIU estimates HCA overcharged the Medicare program at least $1.8 billion over roughly a decade through excessive admissions, according to the report.The claims against HCA are similar to those the SEIU made that led to a $98 million settlement with Community Health Systems in 2014 and a $262 million settlement in 2018 with Health Management Associations. The government alleged that hospitals knowingly billed for inpatient services when lower-paying outpatient or observational services were warranted.The government is in the best position to prove such claims, said Jacob Tubbs, an attorney based in Birmingham, Alabama, whose law firm, Price Armstrong, has represented plaintiffs in similar cases against hospitals.

But he noted that proving that doctors willingly and systematically departed from today’s standard of care is difficult. It is particularly hard to show that a patient was overtreated.Lawyers still have “a healthy amount of skepticism” about the potential for winning these cases, he said. €œWe know that what we’re going to have to ultimately prove is that the medical care was objectively unnecessary.”In a 141-page court filing from 2018, Dr. Camilo Ruiz, a whistleblower at a 400-bed HCA hospital in suburban Miami, accused the health system of threatening his job if he didn’t admit more patients, instead of sending them home from the ER.

HCA supervisors hounded him with warnings to start meeting established targets, he said in the court documents.Ruiz’s attorneys used publicly available Medicare data to show that HCA hospitals nationwide routinely admitted patients for low-level maladies such as abdominal pain, lower respiratory problems, dizziness, and nausea while non-HCA hospitals sent patients with the same conditions home.At 41 HCA hospitals with the highest admission rates — located in Florida, Texas, Nevada, Virginia, and California — the attorneys found that from 2013 through 2016, 84% of Medicare patients were admitted for eight common diagnoses, compared with 55% at non-HCA hospitals.The Ruiz case was unsealed in 2020 when the federal government declined to take on the investigation. The Justice Department — which has intervened in similar cases that led to settlements — did not explain in court records why it passed on the Ruiz case and declined to comment to KHN.Ken Nolan is an attorney with Nolan Auerbach &. White, a firm that is based in Fort Lauderdale, Florida, and has successfully represented whistleblowers alleging fraudulent hospital admissions. Nolan said the government sometimes declines cases for reasons other than a lack of evidence.The SEIU is continuing to push the government to investigate its broader allegations against HCA.

The union incorporated data from the Ruiz suit in the report it’s been shopping around to government agencies, including the Securities and Exchange Commission.Download Modern Healthcare’s app to stay informed when industry news breaks.In addition to asking HHS to investigate, Pascrell sent a letter directly to HCA’s CEO, Sam Hazen, demanding an explanation for elevated admissions numbers.As the nation’s largest hospital company, HCA sets the pace for the U.S. Healthcare system. Its profits approached $7 billion in 2021 even as other health systems struggled through the tail wind of the viagra.For Smithfield, her costly hospitalization not only threatened her wallet. It also broke her trust in a system in which she has long gotten care, including treatment for leukemia.

She is disputing her bill.Now, when she seeks medical care, she wonders whether her “best interests are being taken into account versus some other motive that the hospital administration might have.”This article is from a partnership that includes Nashville Public Radio and KHN.Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente..

Jennifer Smithfield felt weak and still had trouble breathing in February after read this nearly two weeks can i get viagra over the counter with erectile dysfunction treatment. It was a Sunday, and her can i get viagra over the counter doctor’s office was closed. So her primary care physician suggested going to an emergency room to be safe.Smithfield went to HCA Healthcare’s flagship hospital, near its corporate headquarters in Nashville, Tennessee, and thought she would be checked out and sent home.

But that’s not what happened.“Even though I did not can i get viagra over the counter feel well, I didn’t think it was bad enough to be hospitalized, especially not multiple days,” Smithfield said.Over three days, Smithfield racked up $40,000 in charges for her inpatient stay and received a bill for $6,000 under the terms of her health insurance policy. €œI could have can i get viagra over the counter walked out,” Smithfield said. €œI wish I had walked out.”While she was in the hospital, she said, the doctor who had directed her to the ER texted her repeatedly, asking why she’d been admitted.For more than a decade, large health systems have faced scrutiny for admitting patients to costly hospital stays when less expensive treatments or short periods of observation in the ER would have been appropriate.Not a Modern Healthcare subscriber?.

Sign up today.Commercial insurers pay handsomely for inpatient care, with room rates often hitting several thousand dollars a day — and that doesn’t include the charges that inevitably can i get viagra over the counter follow for bloodwork, consultations, and other exams that typically occur. Hospitals, like hotels, maximize revenue by keeping their beds full.Critics allege that HCA sought can i get viagra over the counter to keep occupancy rates high by creating incentives for doctors to admit ER patients — whether those patients required admission or not. The accusation is particularly surprising because admission rates nationally have generally been declining as more conditions can be safely treated with telemedicine and home monitoring.U.S.

Rep. Bill Pascrell (D-N.J.) and the Service Employees International Union have been pressing the Department of Health and Human Services to investigate allegations against HCA as potential Medicare fraud. A spokesperson for the Centers for Medicare &.

Medicaid Services, Bruce Alexander, said the agency is reviewing a September letter from Pascrell that details the claims that HCA forced doctors to meet unofficial quotas, or targets, for the number of patients admitted to the hospital. And a previously sealed whistleblower case is shedding new light on such internal policies.“Improper hospital admissions can have cascading effects on patients and workers,” Pascrell, chair of the House Ways and Means oversight subcommittee, wrote to HHS Secretary Xavier Becerra. €œUnnecessary admissions expose patients to unnecessary treatments.

This creates an added potential risk of complications and the possibility of new s for patients.”HCA spokesperson Harlow Sumerford refuted the accusations. €œWe categorically reject any allegation that physicians admit patients to our hospitals on the basis of anything other than their independent medical judgment and their patients’ individual conditions and medical needs,” he told KHN in a statement.Pascrell’s concerns are based largely on a 58-page investigative report from the SEIU published in February. The national labor union has been challenging health systems on admissions for more than a decade as it attempts to organize in more for-profit hospitals and advocates for its members who work on the front lines.

The SEIU estimates HCA overcharged the Medicare program at least $1.8 billion over roughly a decade through excessive admissions, according to the report.The claims against HCA are similar to those the SEIU made that led to a $98 million settlement with Community Health Systems in 2014 and a $262 million settlement in 2018 with Health Management Associations. The government alleged that hospitals knowingly billed for inpatient services when lower-paying outpatient or observational services were warranted.The government is in the best position to prove such claims, said Jacob Tubbs, an attorney based in Birmingham, Alabama, whose law firm, Price Armstrong, has represented plaintiffs in similar cases against hospitals. But he noted that proving that doctors willingly and systematically departed from today’s standard of care is difficult.

It is particularly hard to show that a patient was overtreated.Lawyers still have “a healthy amount of skepticism” about the potential for winning these cases, he said. €œWe know that what we’re going to have to ultimately prove is that the medical care was objectively unnecessary.”In a 141-page court filing from 2018, Dr. Camilo Ruiz, a whistleblower at a 400-bed HCA hospital in suburban Miami, accused the health system of threatening his job if he didn’t admit more patients, instead of sending them home from the ER.

HCA supervisors hounded him with warnings to start meeting established targets, he said in the court documents.Ruiz’s attorneys used publicly available Medicare data to show that HCA hospitals nationwide routinely admitted patients for low-level maladies such as abdominal pain, lower respiratory problems, dizziness, and nausea while non-HCA hospitals sent patients with the same conditions home.At 41 HCA hospitals with the highest admission rates — located in Florida, Texas, Nevada, Virginia, and California — the attorneys found that from 2013 through 2016, 84% of Medicare patients were admitted for eight common diagnoses, compared with 55% at non-HCA hospitals.The Ruiz case was unsealed in 2020 when the federal government declined to take on the investigation. The Justice Department — which has intervened in similar cases that led to settlements — did not explain in court records why it passed on the Ruiz case and declined to comment to KHN.Ken Nolan is an attorney with Nolan Auerbach &. White, a firm that is based in Fort Lauderdale, Florida, and has successfully represented whistleblowers alleging fraudulent hospital admissions.

Nolan said the government sometimes declines cases for reasons other than a lack of evidence.The SEIU is continuing to push the government to investigate its broader allegations against HCA. The union incorporated data from the Ruiz suit in the report it’s been shopping around to government agencies, including the Securities and Exchange Commission.Download Modern Healthcare’s app to stay informed when industry news breaks.In addition to asking HHS to investigate, Pascrell sent a letter directly to HCA’s CEO, Sam Hazen, demanding an explanation for elevated admissions numbers.As the nation’s largest hospital company, HCA sets the pace for the U.S. Healthcare system.

Its profits approached $7 billion in 2021 even as other health systems struggled through the tail wind of the viagra.For Smithfield, her costly hospitalization not only threatened her wallet. It also broke her trust in a system in which she has long gotten care, including treatment for leukemia. She is disputing her bill.Now, when she seeks medical care, she wonders whether her “best interests are being taken into account versus some other motive that the hospital administration might have.”This article is from a partnership that includes Nashville Public Radio and KHN.Kaiser Health News is a national health policy news service.

It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente..

Mandy flores viagra

IntroductionDespite widespread implementation of interventions aimed at reducing HIV transmission, such as condom mandy flores viagra use, regular testing and treatment with antiretroviral therapy (ART) as prevention (eg, undetectable=untransmittable (U=U)),1 2 HIV transmission continues. Globally, around 1.7 million people were newly diagnosed with HIV in 2019, and risk of acquiring HIV is higher in men who have sex with men (MSM).3 4 Recently, pre-exposure prophylaxis (PrEP) has become available, which is a highly effective intervention to prevent mandy flores viagra HIV .5 6 In the Netherlands, PrEP use and intention to use PrEP have increased over the past years and are expected to keep increasing in the future.7 8HIV incidence in the population may decrease significantly due to PrEP,5 6 but the impact of PrEP on the transmission of other STIs, such as chlamydia, gonorrhoea and syphilis, is unclear. Previous studies showed that condomless anal intercourse increased among MSM after PrEP initiation,9 10 which may increase STI risk.

Furthermore, sexual behaviour trends before PrEP were already moving towards higher risk.11 12 Since PrEP is available for MSM at high risk of acquiring HIV based on their behaviour, it is likely that PrEP users are disproportionally affected by STI as well (ie, STI positivity rates are usually higher in this high risk group compared with lower risk groups).Here, we aimed to quantify how STI diagnoses are distributed among MSM in the Netherlands based on their sexual behaviour, using longitudinal data from the Amsterdam Cohort Studies (ACS).13 In economics, measuring disparity in distributions (ie, inequalities in income distribution) is often done using the Gini coefficient computed from a Lorenz curve.14 mandy flores viagra Since these inequalities have been shown to exist in the distribution of STI/HIV diagnoses,15–17 we used these disparity measures to examine the distribution of chlamydia, gonorrhoea and syphilis diagnoses across sexual behaviour risk strata in the MSM population. Furthermore, as risk behaviour and STI diagnoses may increase as a result of PrEP, these measures could be useful to quantify the impact of PrEP on changes in sexual behaviour and STI distribution in the MSM population. Therefore, we examined possible changes in sexual behaviour and Gini coefficients over time under the influence of PrEP and PrEP-related STI screening.MethodsDataThe ACS is an open and ongoing prospective cohort study on sexual behaviour, psychosocial characteristics, course of and pathogenesis of HIV among MSM in mandy flores viagra Amsterdam.13 Men are eligible to participate if they live in or around Amsterdam and had sex with other men in the past 6 months.

MSM were included in the present study if they visited the ACS at least once between January 2009 and December 2019, and if they were HIV negative at their first visit during this period. Follow-up ended after the last ACS visit in the study period, HIV seroconversion or death.ACS participants completed questionnaires about their sexual behaviour in the preceding 6 months and were tested for STI/HIV, including urogenital, anal and mandy flores viagra pharyngeal testing for gonorrhoea and chlamydia, and syphilis testing, at the Public Health Service of Amsterdam every 6 months. We calculated positivity rates, defined as the percentage of all visits with an STI diagnosis for gonorrhoea, chlamydia and syphilis s separately and for combinations of these diagnoses (STI).Sexual behaviour risk scoreSince sexual behaviour is more likely to change over time compared with other more stable predictors of STI diagnosis, such as demographic characteristics (eg, migration background and education level), only behavioural variables were included in the risk score.

Data on sexual behaviour collected in the mandy flores viagra biannual questionnaires included number of casual partners, type of partnership (steady/casual), condomless insertive and/or receptive sex (yes/no), anal intercourse during group sex (yes/no) and chemsex (yes/no). Definitions of behavioural variables are provided in online supplemental text S1. With these variables, we developed a sexual behaviour mandy flores viagra risk score predictive of STI acquisition.

We created a combined STI diagnosis variable, where STI diagnosis was defined as gonorrhoea, chlamydia and/or syphilis diagnoses at one or more anatomical locations (ie, any STI). Continuous behavioural mandy flores viagra variables that were not normally distributed were log-transformed. Missing data were, when possible, extrapolated from the next ACS visit of this unique individual (see online supplemental material, text S2, for a detailed description of dealing with missing data).Supplemental materialWe used univariable and multivariable logistic regression analyses to identify behavioural predictors of STI diagnosis.

If behavioural variables were statistically significant in the mandy flores viagra univariable analyses (p<0.05), they were included in multivariable analysis. All variables that remained in the multivariable model were used to calculate the sexual behaviour risk score. The calculation of this risk score was based on previous work, which explored longitudinal trajectories of sexual behaviour.18 The risk score mandy flores viagra was calculated for each individual at each visit using the regression coefficients from the multivariable model.

To assess the performance of the sexual behaviour risk score in predicting STI diagnosis, we calculated the area under the curve (AUC), with values >0.7 considered acceptable.19Gini coefficients and Lorenz curvesWe used the sexual behaviour risk score to study how STI are distributed in the MSM population using Lorenz curves. Gini coefficients mandy flores viagra and Lorenz curves were calculated and plotted similar to methods used in a previous study.15 A Lorenz curve is the cumulative proportion of visits with STI diagnosis plotted as a function of the proportion of all visits from lower to higher risk score. Gini coefficients are defined as the area between the line of equality (ie, the diagonal line), and the Lorenz curve is divided by the total area below the line of equality.

Gini coefficients close to zero indicate homogeneous distribution of STI diagnoses over the population mandy flores viagra regardless of the sexual behaviour risk score, which is equal to the line of equality in the Lorenz curve. Gini coefficients close to one indicate that STI diagnoses are concentrated in parts of the population with higher sexual behaviour risk scores. We computed Lorenz curves and estimated Gini coefficients and 95% CIs for gonorrhoea, chlamydia and syphilis s and for any STI (ie, chlamydia and/or gonorrhoea and/or syphilis diagnoses at the current visit), including mandy flores viagra all visits from 2009 to 2019.

Furthermore, a Gini coefficient was computed for anal gonorrhoea and for any anal STI.Introduction of PrEPIn the Netherlands, PrEP was made available by the government for eligible MSM in 2019, which includes HIV-negative MSM who either report to have had condomless anal intercourse with a male partner with unknown HIV status or with a known HIV-positive partner with detectable viral load, or at least one syphilis or anal STI diagnosis, or to have used postexposure prophylaxis in the past 6 months. However, some healthcare institutions had already been providing PrEP to MSM before 2019 mandy flores viagra. For example, the Amsterdam Pre-Exposure Prophylaxis (AMPrEP) project is a prospective demonstration study that started in June 2015 and aimed to assess STI/HIV incidence and sexual behaviour among PrEP users in Amsterdam.9 As ACS participants were able to participate in this project, we used 31 May 2015 as a cut-off to compare Gini coefficients in a time period before PrEP (2009 to mid-2015) and after PrEP (mid-2015 to 2019).MSM who had no ACS visit before PrEP or no visit after PrEP were excluded from this analysis.

We also computed Gini coefficients and sexual behaviour risk scores per year (ie, for 2009–2019) mandy flores viagra to examine pre-existing trends in the distribution of STI diagnoses and sexual behaviour over time, irrespective of PrEP. Furthermore, sensitivity analyses were done excluding visits in the year 2019, mandy flores viagra because after 2019, no data were available to extrapolate for visits with missing data, which could possibly introduce bias. All statistical analyses were done using R V.3.6.1.20ResultsStudy populationIn total, data from 14 787 visits were available in the ACS dataset in the period between 2009 and 2019.

For 2350 of these visits, behavioural variable values were missing, and values were extrapolated from the mandy flores viagra next ACS visit of the same person within the dataset (online supplemental figure S1), and 1269 visits were excluded because extrapolation was not possible (ie, no next ACS visit available). As expected, STI positivity rates and risk scores were higher in extrapolated and excluded visits (online supplemental material, text S2). Furthermore, 45 visits were mandy flores viagra excluded after HIV seroconversion (n=39, 4% of all MSM).

Thus, 971 MSM with 13 473 ACS visits (91%) in the period between 2009 and 2019 were included in the final statistical analyses (online supplemental table S1 and figure S1). The majority of MSM was Dutch (69%) and highly educated mandy flores viagra (77%). The mean age at first visit was 35 years (SD 10 years), and the mean age at sexual debut with a man was 18 years (SD 4 years).

PrEP use mandy flores viagra was reported by 232 MSM (24% of all participants) at 758 visits (5% of all visits), all after June 2015.Lorenz curves representing the cumulative proportion of STI diagnoses among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274) as a function of the cumulative proportion of all visits from lowest to highest risk score. Curves are shown for any STI , and for gonorrhoea, chlamydia and syphilis separately. ACS, Amsterdam mandy flores viagra Cohort Studies.

Created by the authors." data-icon-position data-hide-link-title="0">Figure 1 Lorenz curves representing the cumulative proportion of STI diagnoses among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274) as a function of the cumulative proportion of all visits from lowest to highest risk score. Curves are shown for mandy flores viagra any STI , and for gonorrhoea, chlamydia and syphilis separately. ACS, Amsterdam Cohort Studies.

Created by the authors.Sexual behaviour risk scoreAll mandy flores viagra behavioural variables were significant in the univariable logistic regression analyses (table 1) and were, thus, all included in the multivariable model. In the multivariable analysis, 959 MSM with 12 274 visits (83%) were included, after excluding 1199 visits with one or more missing values. Regression coefficients from the multivariable model were used to calculate the mandy flores viagra sexual behaviour risk score.

The sexual behaviour risk score varied between 0.00 (lowest risk score) and 3.61 (highest risk score), and the mean risk score was 0.82 (SD=0.74). The risk score performed reasonably well for gonorrhoea (AUC=0.73), chlamydia (AUC=0.71) and syphilis (AUC=0.72) s mandy flores viagra separately and for any STI (AUC=0.72). The mean risk score gradually increased over time, with a lowest mean risk score of 0.63 (SD=0.62) in 2009 and highest mean risk score of 1.01 (SD=0.81) in 2018 (online supplemental table S3).

The mean risk score was higher at visits when PrEP use in the past 6 months was reported (mean=1.27, SD=0.70) compared with visits without recent PrEP use (mean=0.73, SD=0.57).View this table:Table 1 Logistic univariable and multivariable regression analysis of factors associated with STI acquisition among MSM participating in the Amsterdam Cohort Studies between 2009 and 2019Lorenz curves and Gini coefficients for STIPositivity rates (% positive of all 12 274 visits) for gonorrhoea (5.1%) and chlamydia (4.6%) were higher compared with the positivity rate for syphilis (0.7%) (online supplemental mandy flores viagra table S2). The Lorenz curves for gonorrhoea, chlamydia and syphilis s separately and any STI were relatively similar (figure 1). The gonorrhoea curve is slightly further away from the diagonal line (ie, from the homogeneous distribution of STI diagnoses over the mandy flores viagra population regardless of the sexual behaviour risk score) compared with the curves for chlamydia, syphilis and the any STI variable, which indicates that the association between gonorrhoea and the sexual behaviour risk score may be stronger than for the other STI.To increase interpretability of the Lorenz curve, we added a figure plotting STI positivity over different segments of the continuous risk score (figure 2, online supplemental figure S2), which showed that positivity rates increased along with the risk score.

Gini coefficients for gonorrhoea at any location, anal gonorrhoea and anal STI were slightly higher than Gini coefficients for chlamydia, syphilis and any STI (table 2). These results indicate that (anal) gonorrhoea and anal STI were more mandy flores viagra concentrated in MSM with a higher sexual behaviour risk score.Distribution of STI diagnoses among MSM with different risk scores based on sexual behaviour among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274). The width of the bars represents the proportion of visits with a specific risk score (the legend shows the distribution of the risk score over the population), and the height of the bars indicates the percentage of STI diagnoses in each risk score segment.

Overall, STI positivity is given by mandy flores viagra the dashed line. ACS, Amsterdam Cohort Studies mandy flores viagra. MSM, men who have sex with men.

Created by the authors." data-icon-position data-hide-link-title="0">Figure 2 Distribution of STI mandy flores viagra diagnoses among MSM with different risk scores based on sexual behaviour among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274). The width of the bars represents the proportion of visits with a specific risk score (the legend shows the distribution of the risk score over the population), and the height of the bars indicates the percentage of STI diagnoses in each risk score segment. Overall, STI positivity mandy flores viagra is given by the dashed line.

ACS, Amsterdam Cohort Studies. MSM, men mandy flores viagra who have sex with men. Created by the authors.View this table:Table 2 Mean risk scores, positivity rates, estimated Gini coefficients and corresponding 95% CIs for gonorrhoea, chlamydia and syphilis in MSM participating in the Amsterdam Cohort Studies between 2009 and 2019 (n=959, n visits=12 274)Before and after PrePGini coefficients were computed again for 630 MSM with 10 677 ACS visits (online supplemental figure S1, figure 3), who had ≥1 visit before and ≥1 visit after PrEP.

Positivity rates for chlamydia and syphilis remained relatively stable before and after PrEP, but the mandy flores viagra positivity rate for (anal) gonorrhoea and (anal) STI was significantly increased after PrEP (figure 3, online supplemental table S2). Gini coefficients for chlamydia, syphilis, anal gonorrhoea and (anal) STI increased from before to after PrEP and were thus more concentrated in the population with a higher risk score (figure 3, online supplemental table S2). However, the Gini coefficient for gonorrhoea mandy flores viagra at all anatomical locations remained stable.

When looking at the Gini coefficients for gonorrhoea and chlamydia at all anatomical locations per year (number of diagnoses for syphilis were too small to stratify per year), no clear increasing or decreasing trends were observed (online supplemental table S3). Sensitivity analyses excluding visits in 2019 showed that the Gini coefficients remained the same as in the computations with 2019 (data not shown).Gini coefficients and STI positivity rates in MSM participating in the ACS before PrEP (n visits=5997, 56%) and mandy flores viagra after PrEP (n visits=4680, 44%) between 2009 and 2019 (n=630, n visits=10 677). Estimated Gini coefficients for gonorrhoea, chlamydia and syphilis, and STI, and the corresponding 95% CIs for these coefficients are shown on the left y-axis (bars).

STI positivity rates before and after PrEP are shown mandy flores viagra on the right y-axis (black dots). ACS, Amsterdam Cohort Studies. CT, chlamydia mandy flores viagra.

GO, gonorrhoea. MSM, men who have sex with mandy flores viagra men. PrEP, pre-exposure prophylaxis.

SYPH, syphilis mandy flores viagra. Created by the authors." data-icon-position data-hide-link-title="0">Figure 3 Gini coefficients and STI positivity rates in MSM participating in the ACS before PrEP (n visits=5997, 56%) and after PrEP (n visits=4680, 44%) between 2009 and 2019 (n=630, n visits=10 677). Estimated Gini coefficients for gonorrhoea, chlamydia and syphilis, and STI, and the corresponding 95% CIs for these coefficients are shown on the left mandy flores viagra y-axis (bars).

STI positivity rates before and after PrEP are shown on the right y-axis (black dots). ACS, Amsterdam Cohort Studies mandy flores viagra. CT, chlamydia.

GO, gonorrhoea mandy flores viagra. MSM, men who have sex with mandy flores viagra men. PrEP, pre-exposure prophylaxis.

SYPH, syphilis mandy flores viagra. Created by the authors.DiscussionWe found that the distribution of gonorrhoea diagnoses over the population according to a sexual behaviour risk score was more concentrated in a higher risk subpopulation, compared with chlamydia and syphilis diagnoses in 2009–2019. Furthermore, although the gonorrhoea positivity rate increased after the introduction of PrEP, the distribution of diagnoses over the population mandy flores viagra remained the same.

In contrast, the positivity rates for chlamydia and syphilis were similar before and after the introduction of PrEP, but the distribution of diagnoses over the population became more concentrated in a higher risk subpopulation after 2015.The increase in STI positivity rates observed after the introduction of PrEP may be explained by increased STI testing frequency among PrEP users (ie, the more you test, the more you find). However, whereas gonorrhoea mandy flores viagra positivity rates increased after PrEP, the distribution of gonorrhoea diagnoses over the population did not change, in contrast to chlamydia and syphilis. This might be explained by pre-existing inequalities in STI distribution before PrEP.

Possibly, gonorrhoea was already more common among MSM with higher mandy flores viagra risk sexual behaviour before the introduction of PrEP, compared with chlamydia and syphilis, which has been found in the national STI surveillance data as well.7 However, Gini coefficients for all STIs and differences in coefficients between different STIs found in this study were small (ie, more homogeneous STI distribution in this study population irrespective of risk score). This may be explained by participant characteristics, because the ACS already includes a more high risk MSM subpopulation.To our knowledge, this is the first study to examine how heterogeneity in sexual behaviour and STI distribution changed in the MSM population after the introduction of PrEP using Lorenz curves and Gini coefficients. A strength of mandy flores viagra this study is the large sample size and the availability of longitudinal data on sexual behaviour, PrEP use and STI/HIV diagnoses.There were also a few limitations.

First, ACS data might not be representative for the entire MSM population in the Netherlands, as participants are predominantly Dutch and highly educated. Nevertheless, these characteristics are similar to the MSM population visiting STI clinics in the Netherlands,7 which is a key population for PrEP mandy flores viagra use. Second, the number of syphilis diagnoses was low, which resulted in wide CIs for the estimated Gini coefficients.

Last, for 17% mandy flores viagra of all visits behavioural data was extrapolated, which may have introduced bias. For example, STI positivity rates were higher at visits with extrapolated behavioural data. Nonetheless, as behavioural data at the next ACS visit is reported retrospectively (eg, number of partners in the past 6 months), the extrapolated data may still be a good reflection of the actual behaviour, which was supported by the higher risk scores mandy flores viagra in the extrapolated visits.Our results suggested that gonorrhoea s were more concentrated in a specific high-risk subpopulation of MSM compared with chlamydia distribution, which was found in previous studies among heterosexuals as well.17 21 Also, Gini coefficients for syphilis among MSM are likely to be lower (ie, more homogeneous distribution of s) compared with the heterosexual population17 21 22 and may be more susceptible to changes over time compared with gonorrhoea.22 This was also found in our study, as the Gini coefficient for syphilis increased after the introduction of PrEP, whereas the Gini coefficient for gonorrhoea remained stable before and after PrEP.We found that the sexual behaviour risk score and STI positivity rates increased over time.

This was consistent with other studies exploring sexual behaviour and STI incidence in a similar time period.23–26 In addition, even when STI positivity rates did not increase after PrEP introduction in the total MSM population,11 27 there might be a specific group of high risk MSM (ie, PrEP users) in which STI positivity rates do increase. This was shown by mandy flores viagra the increased Gini coefficients for chlamydia and syphilis after PrEP in our study. Thus, a specific high-risk subgroup may view PrEP as the ultimate prevention measure and increase risk behaviour, whereas others may use PrEP as a prevention measure in addition to other measures (eg, condom use).

It should be kept in mind that an increasing trend in risk behaviour and STI incidence was already mandy flores viagra observed before the introduction of PrEP in 2015.12 Therefore, it is not possible to conclude that changes after 2015 were a result of PrEP. Other developments in HIV prevention and treatment (ie, U=U) may have influenced sexual behaviour in the time period between 2009 and 2019 as well.28 Nonetheless, the results of this study underline the importance of closely monitoring sexual behaviour and STI diagnoses in both PrEP users and non-PrEP users during the national roll-out of the PrEP programme, which started in 2019.The methods used in this study may be valuable for the monitoring of sexual behaviour and STI diagnoses in the national PrEP programme. We showed that even though STI positivity rates remained stable, STI diagnoses may become more concentrated in a high-risk subpopulation mandy flores viagra.

The methodology of this study could also be applied to characterise populations in other settings/countries, including demographic and sexual health-related characteristics and subsequent STI distribution as well. Targeting interventions, such as increased frequency of STI testing, to a high-risk subpopulation may reduce STI mandy flores viagra transmission. However, more frequent STI testing and subsequent antibiotic treatment could also increase antimicrobial resistance,29 30 which has been rising for STI in the past years, especially for gonorrhoea.7 Therefore, interventions aimed at reducing sexual risk behaviour may be an important strategy as well.

As Gini coefficients and Lorenz curves can be used as a quantitative indicator for the impact of interventions on population level,15 future research could use these measures to investigate mandy flores viagra the impact of varying PrEP coverage, testing and behavioural interventions on STI/HIV distribution in the population.To conclude, high-risk sexual behaviour and gonorrhoea diagnoses increased after PrEP was introduced, and the distribution of chlamydia and syphilis diagnoses has become more concentrated in a high-risk subgroup. Monitoring the impact of increasing PrEP coverage on sexual behaviour and STI incidence is of great importance, and improved STI prevention is needed, especially for high-risk MSM.Key messagesThis study quantified the distribution of STI diagnoses among men who have sex with men (MSM) in the Netherlands based on their sexual behaviour before and after the introduction of pre-exposure prophylaxis (PrEP).MSM engaged in more high-risk sexual behaviour and gonorrhoea diagnoses increased after PrEP was introduced.Gonorrhoea diagnoses were concentrated in high risk MSM, and chlamydia and syphilis diagnoses have become more concentrated in a high-risk subgroup after PrEP .Monitoring the impact of increasing PrEP coverage on behaviour and STI incidence is important, and improved STI prevention is needed, especially for high-risk MSM.Abstract translationThis web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content..

IntroductionDespite widespread implementation of interventions aimed at reducing HIV transmission, such as can i get viagra over the counter condom use, regular testing and treatment with antiretroviral therapy (ART) as prevention (eg, undetectable=untransmittable (U=U)),1 2 HIV transmission continues. Globally, around 1.7 million people were newly diagnosed with HIV in 2019, and risk of acquiring HIV is higher in men who have sex with men (MSM).3 4 Recently, pre-exposure prophylaxis (PrEP) has become available, which is a can i get viagra over the counter highly effective intervention to prevent HIV .5 6 In the Netherlands, PrEP use and intention to use PrEP have increased over the past years and are expected to keep increasing in the future.7 8HIV incidence in the population may decrease significantly due to PrEP,5 6 but the impact of PrEP on the transmission of other STIs, such as chlamydia, gonorrhoea and syphilis, is unclear. Previous studies showed that condomless anal intercourse increased among MSM after PrEP initiation,9 10 which may increase STI risk.

Furthermore, sexual behaviour trends before PrEP were already moving can i get viagra over the counter towards higher risk.11 12 Since PrEP is available for MSM at high risk of acquiring HIV based on their behaviour, it is likely that PrEP users are disproportionally affected by STI as well (ie, STI positivity rates are usually higher in this high risk group compared with lower risk groups).Here, we aimed to quantify how STI diagnoses are distributed among MSM in the Netherlands based on their sexual behaviour, using longitudinal data from the Amsterdam Cohort Studies (ACS).13 In economics, measuring disparity in distributions (ie, inequalities in income distribution) is often done using the Gini coefficient computed from a Lorenz curve.14 Since these inequalities have been shown to exist in the distribution of STI/HIV diagnoses,15–17 we used these disparity measures to examine the distribution of chlamydia, gonorrhoea and syphilis diagnoses across sexual behaviour risk strata in the MSM population. Furthermore, as risk behaviour and STI diagnoses may increase as a result of PrEP, these measures could be useful to quantify the impact of PrEP on changes in sexual behaviour and STI distribution in the MSM population. Therefore, we examined possible changes in sexual behaviour and Gini coefficients over time under the influence of PrEP and PrEP-related STI screening.MethodsDataThe ACS is an open and ongoing prospective cohort study on sexual behaviour, psychosocial characteristics, course of and pathogenesis of HIV among MSM in Amsterdam.13 Men are eligible to participate if they live can i get viagra over the counter in or around Amsterdam and had sex with other men in the past 6 months.

MSM were included in the present study if they visited the ACS at least once between January 2009 and December 2019, and if they were HIV negative at their first visit during this period. Follow-up ended after the last ACS visit in the study period, HIV seroconversion or death.ACS participants completed questionnaires about their sexual behaviour in the preceding 6 months and were tested for STI/HIV, including urogenital, anal and pharyngeal testing for gonorrhoea and chlamydia, and syphilis testing, at the Public can i get viagra over the counter Health Service of Amsterdam every 6 months. We calculated positivity rates, defined as the percentage of all visits with an STI diagnosis for gonorrhoea, chlamydia and syphilis s separately and for combinations of these diagnoses (STI).Sexual behaviour risk scoreSince sexual behaviour is more likely to change over time compared with other more stable predictors of STI diagnosis, such as demographic characteristics (eg, migration background and education level), only behavioural variables were included in the risk score.

Data on sexual behaviour collected in the biannual questionnaires included number of casual partners, type of partnership (steady/casual), condomless insertive and/or receptive sex (yes/no), anal intercourse during group can i get viagra over the counter sex (yes/no) and chemsex (yes/no). Definitions of behavioural variables are provided in online supplemental text S1. With these can i get viagra over the counter variables, we developed a sexual behaviour risk score predictive of STI acquisition.

We created a combined STI diagnosis variable, where STI diagnosis was defined as gonorrhoea, chlamydia and/or syphilis diagnoses at one or more anatomical locations (ie, any STI). Continuous behavioural variables that were not normally distributed were log-transformed can i get viagra over the counter. Missing data were, when possible, extrapolated from the next ACS visit of this unique individual (see online supplemental material, text S2, for a detailed description of dealing with missing data).Supplemental materialWe used univariable and multivariable logistic regression analyses to identify behavioural predictors of STI diagnosis.

If behavioural variables were statistically significant in the univariable analyses (p<0.05), they can i get viagra over the counter were included in multivariable analysis. All variables that remained in the multivariable model were used to calculate the sexual behaviour risk score. The calculation of this risk score was based on previous work, which explored longitudinal trajectories of sexual behaviour.18 The risk score was calculated for each individual at can i get viagra over the counter each visit using the regression coefficients from the multivariable model.

To assess the performance of the sexual behaviour risk score in predicting STI diagnosis, we calculated the area under the curve (AUC), with values >0.7 considered acceptable.19Gini coefficients and Lorenz curvesWe used the sexual behaviour risk score to study how STI are distributed in the MSM population using Lorenz curves. Gini coefficients and Lorenz curves were calculated can i get viagra over the counter and plotted similar to methods used in a previous study.15 A Lorenz curve is the cumulative proportion of visits with STI diagnosis plotted as a function of the proportion of all visits from lower to higher risk score. Gini coefficients are defined as the area between the line of equality (ie, the diagonal line), and the Lorenz curve is divided by the total area below the line of equality.

Gini coefficients close to zero indicate homogeneous distribution of STI diagnoses over the population regardless can i get viagra over the counter of the sexual behaviour risk score, which is equal to the line of equality in the Lorenz curve. Gini coefficients close to one indicate that STI diagnoses are concentrated in parts of the population with higher sexual behaviour risk scores. We computed Lorenz curves and estimated Gini coefficients and 95% CIs for can i get viagra over the counter gonorrhoea, chlamydia and syphilis s and for any STI (ie, chlamydia and/or gonorrhoea and/or syphilis diagnoses at the current visit), including all visits from 2009 to 2019.

Furthermore, a Gini coefficient was computed for anal gonorrhoea and for any anal STI.Introduction of PrEPIn the Netherlands, PrEP was made available by the government for eligible MSM in 2019, which includes HIV-negative MSM who either report to have had condomless anal intercourse with a male partner with unknown HIV status or with a known HIV-positive partner with detectable viral load, or at least one syphilis or anal STI diagnosis, or to have used postexposure prophylaxis in the past 6 months. However, some healthcare institutions had already been providing PrEP can i get viagra over the counter to MSM before 2019. For example, the Amsterdam Pre-Exposure Prophylaxis (AMPrEP) project is a prospective demonstration study that started in June 2015 and aimed to assess STI/HIV incidence and sexual behaviour among PrEP users in Amsterdam.9 As ACS participants were able to participate in this project, we used 31 May 2015 as a cut-off to compare Gini coefficients in a time period before PrEP (2009 to mid-2015) and after PrEP (mid-2015 to 2019).MSM who had no ACS visit before PrEP or no visit after PrEP were excluded from this analysis.

We also computed Gini coefficients and sexual behaviour risk scores per year (ie, for 2009–2019) to examine pre-existing trends in the distribution of STI diagnoses and sexual behaviour over time, irrespective of can i get viagra over the counter PrEP. Furthermore, sensitivity analyses were done excluding visits in the year 2019, because can i get viagra over the counter after 2019, no data were available to extrapolate for visits with missing data, which could possibly introduce bias. All statistical analyses were done using R V.3.6.1.20ResultsStudy populationIn total, data from 14 787 visits were available in the ACS dataset in the period between 2009 and 2019.

For 2350 of can i get viagra over the counter these visits, behavioural variable values were missing, and values were extrapolated from the next ACS visit of the same person within the dataset (online supplemental figure S1), and 1269 visits were excluded because extrapolation was not possible (ie, no next ACS visit available). As expected, STI positivity rates and risk scores were higher in extrapolated and excluded visits (online supplemental material, text S2). Furthermore, 45 can i get viagra over the counter visits were excluded after HIV seroconversion (n=39, 4% of all MSM).

Thus, 971 MSM with 13 473 ACS visits (91%) in the period between 2009 and 2019 were included in the final statistical analyses (online supplemental table S1 and figure S1). The majority can i get viagra over the counter of MSM was Dutch (69%) and highly educated (77%). The mean age at first visit was 35 years (SD 10 years), and the mean age at sexual debut with a man was 18 years (SD 4 years).

PrEP use was reported by 232 MSM (24% of all participants) at 758 visits (5% of all visits), all after June 2015.Lorenz curves representing the cumulative proportion of STI diagnoses among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274) as a function of can i get viagra over the counter the cumulative proportion of all visits from lowest to highest risk score. Curves are shown for any STI , and for gonorrhoea, chlamydia and syphilis separately. ACS, Amsterdam Cohort Studies can i get viagra over the counter.

Created by the authors." data-icon-position data-hide-link-title="0">Figure 1 Lorenz curves representing the cumulative proportion of STI diagnoses among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274) as a function of the cumulative proportion of all visits from lowest to highest risk score. Curves are shown for any STI , and for gonorrhoea, can i get viagra over the counter chlamydia and syphilis separately. ACS, Amsterdam Cohort Studies.

Created by the authors.Sexual behaviour risk scoreAll behavioural variables were significant can i get viagra over the counter in the univariable logistic regression analyses (table 1) and were, thus, all included in the multivariable model. In the multivariable analysis, 959 MSM with 12 274 visits (83%) were included, after excluding 1199 visits with one or more missing values. Regression coefficients from the multivariable model were used to calculate the can i get viagra over the counter sexual behaviour risk score.

The sexual behaviour risk score varied between 0.00 (lowest risk score) and 3.61 (highest risk score), and the mean risk score was 0.82 (SD=0.74). The risk score performed reasonably well for gonorrhoea (AUC=0.73), chlamydia can i get viagra over the counter (AUC=0.71) and syphilis (AUC=0.72) s separately and for any STI (AUC=0.72). The mean risk score gradually increased over time, with a lowest mean risk score of 0.63 (SD=0.62) in 2009 and highest mean risk score of 1.01 (SD=0.81) in 2018 (online supplemental table S3).

The mean risk score was can i get viagra over the counter higher at visits when PrEP use in the past 6 months was reported (mean=1.27, SD=0.70) compared with visits without recent PrEP use (mean=0.73, SD=0.57).View this table:Table 1 Logistic univariable and multivariable regression analysis of factors associated with STI acquisition among MSM participating in the Amsterdam Cohort Studies between 2009 and 2019Lorenz curves and Gini coefficients for STIPositivity rates (% positive of all 12 274 visits) for gonorrhoea (5.1%) and chlamydia (4.6%) were higher compared with the positivity rate for syphilis (0.7%) (online supplemental table S2). The Lorenz curves for gonorrhoea, chlamydia and syphilis s separately and any STI were relatively similar (figure 1). The gonorrhoea curve is slightly further away from the diagonal line (ie, from the homogeneous distribution of STI diagnoses over the population regardless of the sexual behaviour risk score) compared with the curves for chlamydia, syphilis and the any STI variable, which indicates that the association between gonorrhoea and the sexual behaviour can i get viagra over the counter risk score may be stronger than for the other STI.To increase interpretability of the Lorenz curve, we added a figure plotting STI positivity over different segments of the continuous risk score (figure 2, online supplemental figure S2), which showed that positivity rates increased along with the risk score.

Gini coefficients for gonorrhoea at any location, anal gonorrhoea and anal STI were slightly higher than Gini coefficients for chlamydia, syphilis and any STI (table 2). These results indicate that (anal) gonorrhoea and anal STI were more concentrated in MSM with a can i get viagra over the counter higher sexual behaviour risk score.Distribution of STI diagnoses among MSM with different risk scores based on sexual behaviour among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274). The width of the bars represents the proportion of visits with a specific risk score (the legend shows the distribution of the risk score over the population), and the height of the bars indicates the percentage of STI diagnoses in each risk score segment.

Overall, STI positivity is given by the dashed line can i get viagra over the counter. ACS, Amsterdam Cohort can i get viagra over the counter Studies. MSM, men who have sex with men.

Created by the authors." data-icon-position data-hide-link-title="0">Figure 2 Distribution of STI diagnoses among MSM with different risk scores based on sexual behaviour can i get viagra over the counter among MSM participating in the ACS between 2009 and 2019 (n=959, n visits=12 274). The width of the bars represents the proportion of visits with a specific risk score (the legend shows the distribution of the risk score over the population), and the height of the bars indicates the percentage of STI diagnoses in each risk score segment. Overall, STI positivity is given by the dashed can i get viagra over the counter line.

ACS, Amsterdam Cohort Studies. MSM, men who have can i get viagra over the counter sex with men. Created by the authors.View this table:Table 2 Mean risk scores, positivity rates, estimated Gini coefficients and corresponding 95% CIs for gonorrhoea, chlamydia and syphilis in MSM participating in the Amsterdam Cohort Studies between 2009 and 2019 (n=959, n visits=12 274)Before and after PrePGini coefficients were computed again for 630 MSM with 10 677 ACS visits (online supplemental figure S1, figure 3), who had ≥1 visit before and ≥1 visit after PrEP.

Positivity rates for chlamydia and syphilis remained relatively stable before and can i get viagra over the counter after PrEP, but the positivity rate for (anal) gonorrhoea and (anal) STI was significantly increased after PrEP (figure 3, online supplemental table S2). Gini coefficients for chlamydia, syphilis, anal gonorrhoea and (anal) STI increased from before to after PrEP and were thus more concentrated in the population with a higher risk score (figure 3, online supplemental table S2). However, the Gini coefficient for gonorrhoea at all anatomical locations remained stable can i get viagra over the counter.

When looking at the Gini coefficients for gonorrhoea and chlamydia at all anatomical locations per year (number of diagnoses for syphilis were too small to stratify per year), no clear increasing or decreasing trends were observed (online supplemental table S3). Sensitivity analyses excluding visits in 2019 showed that the Gini coefficients remained the same as in the computations with 2019 (data not shown).Gini coefficients and STI positivity rates in MSM can i get viagra over the counter participating in the ACS before PrEP (n visits=5997, 56%) and after PrEP (n visits=4680, 44%) between 2009 and 2019 (n=630, n visits=10 677). Estimated Gini coefficients for gonorrhoea, chlamydia and syphilis, and STI, and the corresponding 95% CIs for these coefficients are shown on the left y-axis (bars).

STI positivity can i get viagra over the counter rates before and after PrEP are shown on the right y-axis (black dots). ACS, Amsterdam Cohort Studies. CT, chlamydia can i get viagra over the counter.

GO, gonorrhoea. MSM, men can i get viagra over the counter who have sex with men. PrEP, pre-exposure prophylaxis.

SYPH, syphilis can i get viagra over the counter. Created by the authors." data-icon-position data-hide-link-title="0">Figure 3 Gini coefficients and STI positivity rates in MSM participating in the ACS before PrEP (n visits=5997, 56%) and after PrEP (n visits=4680, 44%) between 2009 and 2019 (n=630, n visits=10 677). Estimated Gini coefficients for gonorrhoea, chlamydia and syphilis, and STI, and the corresponding 95% can i get viagra over the counter CIs for these coefficients are shown on the left y-axis (bars).

STI positivity rates before and after PrEP are shown on the right y-axis (black dots). ACS, Amsterdam can i get viagra over the counter Cohort Studies. CT, chlamydia.

GO, gonorrhoea can i get viagra over the counter. MSM, men can i get viagra over the counter who have sex with men. PrEP, pre-exposure prophylaxis.

SYPH, syphilis can i get viagra over the counter. Created by the authors.DiscussionWe found that the distribution of gonorrhoea diagnoses over the population according to a sexual behaviour risk score was more concentrated in a higher risk subpopulation, compared with chlamydia and syphilis diagnoses in 2009–2019. Furthermore, although the gonorrhoea positivity rate increased after the introduction of PrEP, the distribution of diagnoses over can i get viagra over the counter the population remained the same.

In contrast, the positivity rates for chlamydia and syphilis were similar before and after the introduction of PrEP, but the distribution of diagnoses over the population became more concentrated in a higher risk subpopulation after 2015.The increase in STI positivity rates observed after the introduction of PrEP may be explained by increased STI testing frequency among PrEP users (ie, the more you test, the more you find). However, whereas gonorrhoea positivity rates increased after PrEP, the distribution of can i get viagra over the counter gonorrhoea diagnoses over the population did not change, in contrast to chlamydia and syphilis. This might be explained by pre-existing inequalities in STI distribution before PrEP.

Possibly, gonorrhoea was already can i get viagra over the counter more common among MSM with higher risk sexual behaviour before the introduction of PrEP, compared with chlamydia and syphilis, which has been found in the national STI surveillance data as well.7 However, Gini coefficients for all STIs and differences in coefficients between different STIs found in this study were small (ie, more homogeneous STI distribution in this study population irrespective of risk score). This may be explained by participant characteristics, because the ACS already includes a more high risk MSM subpopulation.To our knowledge, this is the first study to examine how heterogeneity in sexual behaviour and STI distribution changed in the MSM population after the introduction of PrEP using Lorenz curves and Gini coefficients. A strength of this study is the large sample size and the availability of longitudinal data on sexual behaviour, PrEP use and STI/HIV can i get viagra over the counter diagnoses.There were also a few limitations.

First, ACS data might not be representative for the entire MSM population in the Netherlands, as participants are predominantly Dutch and highly educated. Nevertheless, these characteristics are similar to the MSM population visiting STI clinics in can i get viagra over the counter the Netherlands,7 which is a key population for PrEP use. Second, the number of syphilis diagnoses was low, which resulted in wide CIs for the estimated Gini coefficients.

Last, for 17% of all visits behavioural data was extrapolated, which may have can i get viagra over the counter introduced bias. For example, STI positivity rates were higher at visits with extrapolated behavioural data. Nonetheless, as behavioural data at the next ACS visit is reported retrospectively (eg, number of partners in the past 6 months), the extrapolated data may still be a good reflection of the actual behaviour, which was supported by the higher risk scores in the extrapolated visits.Our results suggested that gonorrhoea s were more concentrated in a specific high-risk subpopulation of MSM compared with chlamydia distribution, which was found in previous studies among heterosexuals as well.17 21 Also, Gini coefficients for syphilis among MSM are likely to be lower (ie, more homogeneous can i get viagra over the counter distribution of s) compared with the heterosexual population17 21 22 and may be more susceptible to changes over time compared with gonorrhoea.22 This was also found in our study, as the Gini coefficient for syphilis increased after the introduction of PrEP, whereas the Gini coefficient for gonorrhoea remained stable before and after PrEP.We found that the sexual behaviour risk score and STI positivity rates increased over time.

This was consistent with other studies exploring sexual behaviour and STI incidence in a similar time period.23–26 In addition, even when STI positivity rates did not increase after PrEP introduction in the total MSM population,11 27 there might be a specific group of high risk MSM (ie, PrEP users) in which STI positivity rates do increase. This was shown by the can i get viagra over the counter increased Gini coefficients for chlamydia and syphilis after PrEP in our study. Thus, a specific high-risk subgroup may view PrEP as the ultimate prevention measure and increase risk behaviour, whereas others may use PrEP as a prevention measure in addition to other measures (eg, condom use).

It should be kept in mind that an increasing trend can i get viagra over the counter in risk behaviour and STI incidence was already observed before the introduction of PrEP in 2015.12 Therefore, it is not possible to conclude that changes after 2015 were a result of PrEP. Other developments in HIV prevention and treatment (ie, U=U) may have influenced sexual behaviour in the time period between 2009 and 2019 as well.28 Nonetheless, the results of this study underline the importance of closely monitoring sexual behaviour and STI diagnoses in both PrEP users and non-PrEP users during the national roll-out of the PrEP programme, which started in 2019.The methods used in this study may be valuable for the monitoring of sexual behaviour and STI diagnoses in the national PrEP programme. We showed that even though STI can i get viagra over the counter positivity rates remained stable, STI diagnoses may become more concentrated in a high-risk subpopulation.

The methodology of this study could also be applied to characterise populations in other settings/countries, including demographic and sexual health-related characteristics and subsequent STI distribution as well. Targeting interventions, such as increased frequency of STI testing, to a high-risk can i get viagra over the counter subpopulation may reduce STI transmission. However, more frequent STI testing and subsequent antibiotic treatment could also increase antimicrobial resistance,29 30 which has been rising for STI in the past years, especially for gonorrhoea.7 Therefore, interventions aimed at reducing sexual risk behaviour may be an important strategy as well.

As Gini coefficients and Lorenz curves can be used as a quantitative indicator for the impact of interventions on population can i get viagra over the counter level,15 future research could use these measures to investigate the impact of varying PrEP coverage, testing and behavioural interventions on STI/HIV distribution in the population.To conclude, high-risk sexual behaviour and gonorrhoea diagnoses increased after PrEP was introduced, and the distribution of chlamydia and syphilis diagnoses has become more concentrated in a high-risk subgroup. Monitoring the impact of increasing PrEP coverage on sexual behaviour and STI incidence is of great importance, and improved STI prevention is needed, especially for high-risk MSM.Key messagesThis study quantified the distribution of STI diagnoses among men who have sex with men (MSM) in the Netherlands based on their sexual behaviour before and after the introduction of pre-exposure prophylaxis (PrEP).MSM engaged in more high-risk sexual behaviour and gonorrhoea diagnoses increased after PrEP was introduced.Gonorrhoea diagnoses were concentrated in high risk MSM, and chlamydia and syphilis diagnoses have become more concentrated in a high-risk subgroup after PrEP .Monitoring the impact of increasing PrEP coverage on behaviour and STI incidence is important, and improved STI prevention is needed, especially for high-risk MSM.Abstract translationThis web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content..

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Rules what is generic viagra and Household Size 3. The Three MSP Programs - What are they and how are they Different?. 4. FOUR what is generic viagra 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 what is generic viagra People who Have Medicare WHO IS AUTOMATICALLY ENROLLED IN AN MSP Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP Enrolling in an MSP if you have Medicaid and Just Became Eligible for Medicare MIPPA - SSA Notifies Social Security recipients that they may be eligible for MSP based on their income. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How what is generic viagra 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 what is generic viagra. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2022) Single Couple Single Couple Single Couple $1,133 $1,526 $1,359 $1,831 $1,529 $2,060 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement.

See “Part A what is generic viagra 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 what is generic viagra 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 what is generic viagra. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between what is generic viagra 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 what is generic viagra different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). The figures in the chart are based on a document issued by HRA in March 2022 (Box 7) based on the 2022 FPL.

See 2022 Fact Sheet on MSP what is generic viagra in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv. L.

367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max).

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

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

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

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

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

In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021.)) 3. The Three Medicare Savings Programs - what are they and how are they different?. 1.

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

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

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

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

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

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

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

Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2.

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

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

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

See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down.

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

New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar.

A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment.

See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare.

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

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

The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. APPLYING FOR MSP DIRECTLY WITH LOCAL MEDICAID OFFICE Client already has Medicaid with Local District/HRA but not MSP. They should NOT have to submit an MSP application because the local district is required to review all Medicaid recipients for MSP eligibility and enroll them. (NYS DOH 2000-ADM-7 and GIS 05 MA 033).

But if a Medicaid recipient does not have MSP, contact the Local Medicaid office and request that they be enrolled. In NYC - Use Form 751W and check the box on page 2 requesting evaluation for Medicare Savings Program. Fax it to the Undercare Division at 1-917-639-0837 or email it to undercareproviderrelations@hra.nyc.gov. Use by secure email. If enrolling in the MSP will cause a Spenddown (because income will increase by the amount of the Part B premium, include a completed and signed "Choice Notice" (MAP-3054a)(3/19/2019)(You must adapt this notice - generally check box 3B on page 2 to select enrollment in MSP while keeping Medicaid.) If do not have Medicaid -- must apply for an MSP through their local social services district.

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

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

One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare" The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability.

Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19).

Obtaining MSP may increase their spenddown. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare - See article about the Medicare Insurance Payment Program (MIPP). IF CLIENT HAD MEDICAID THROUGH LOCAL DISTRICT - see here, same procedure for any Medicaid recipient who needs MSP. MIPPA - Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are.

· Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013.

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

In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check.

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

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

QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance.

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

Click here for an article that explains all of these rules.

Soc http://carlstephens.us/portfolio/stationery-branding/ can i get viagra over the counter. Serv. L. § 367-a(3)(a), (b), can i get viagra over the counter and (d). Note.

Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP. See this article for can i get viagra over the counter more info. TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A. Summary Chart of MSP Programs with current can i get viagra over the counter income limits 2.

Income Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and can i get viagra over the counter how are they Different?. 4. FOUR Special Benefits of MSP Programs.

Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment can i get viagra over the counter Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare WHO IS AUTOMATICALLY ENROLLED IN AN MSP Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP Enrolling in an MSP if you have Medicaid and Just Became Eligible for Medicare MIPPA - SSA Notifies Social Security recipients that they may be eligible for MSP based on their income. 6 can i get viagra over the counter. 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 can i get viagra over the counter LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2022) Single Couple Single Couple Single Couple $1,133 $1,526 $1,359 $1,831 $1,529 $2,060 Federal Poverty Level 100% FPL 100 – can i get viagra over the counter 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 & can i get viagra over the counter. 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 can i get viagra over the counter – 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 can i get viagra over the counter at Same Time?. YES YES NO!.

Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid can i get viagra over the counter 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 can i get viagra over the counter the Federal Poverty Level (FPL).

The figures in the chart are based on a document issued by HRA in March 2022 (Box 7) based on the 2022 FPL. See 2022 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y can i get viagra over the counter. Soc. Serv.

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

Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind.

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

18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month.

He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. APPLYING FOR MSP DIRECTLY WITH LOCAL MEDICAID OFFICE Client already has Medicaid with Local District/HRA but not MSP. They should NOT have to submit an MSP application because the local district is required to review all Medicaid recipients for MSP eligibility and enroll them.

(NYS DOH 2000-ADM-7 and GIS 05 MA 033). But if a Medicaid recipient does not have MSP, contact the Local Medicaid office and request that they be enrolled. In NYC - Use Form 751W and check the box on page 2 requesting evaluation for Medicare Savings Program. Fax it to the Undercare Division at 1-917-639-0837 or email it to undercareproviderrelations@hra.nyc.gov. Use by secure email.

If enrolling in the MSP will cause a Spenddown (because income will increase by the amount of the Part B premium, include a completed and signed "Choice Notice" (MAP-3054a)(3/19/2019)(You must adapt this notice - generally check box 3B on page 2 to select enrollment in MSP while keeping Medicaid.) If do not have Medicaid -- must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available).

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

One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare" The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district.

The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p.

19). Obtaining MSP may increase their spenddown. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare - See article about the Medicare Insurance Payment Program (MIPP). IF CLIENT HAD MEDICAID THROUGH LOCAL DISTRICT - see here, same procedure for any Medicaid recipient who needs MSP. MIPPA - Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply.

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

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

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

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

!. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​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.