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18 or cheap kamagra supplier <. 19 in school) 138% FPL*** Children <. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN* For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care.

See info here 1 2 1 2 3 1 2 Income $884 (up from $875 in 2020) $1300 (up from $1,284 in 2020) $1,482 $2,004 $2,526 $2,146 $2,903 Resources $15,900 (up from $15,750 in 2020) $23,400 (up from $23,100 in 2020) cheap kamagra supplier NO LIMIT** NO LIMIT 2020 levels are in GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates and attachments here * MAGI and ESSENTIAL plan levels are based on Federal Poverty Levels, which are not released until later in 2021. 2020 levels are used until then. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?.

WHAT IS THE HOUSEHOLD cheap kamagra supplier SIZE?. See rules here. HOW TO READ THE HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels.

Box 10 on page 3 are cheap kamagra supplier the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers. People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &.

Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to cheap kamagra supplier adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R. § 435.4.

Certain populations have an even higher income limit - 224% FPL for pregnant cheap kamagra supplier women and babies <. Age 1, 154% FPL for children age 1 - 19. CAUTION.

What is counted as income may not be cheap kamagra supplier what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI).

There are good changes and cheap kamagra supplier bad changes. GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income.

BAD cheap kamagra supplier. There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see.

ALSO SEE 2018 Manual on Lump cheap kamagra supplier Sums and Impact on Public Benefits - with resource rules HOW TO DETERMINE SIZE OF HOUSEHOLD TO IDENTIFY WHICH INCOME LIMIT APPLIES The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid.

Here are the 2 basic categories and the rules for calculating cheap kamagra supplier their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article.

Everyone cheap kamagra supplier else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp.

8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, cheap kamagra supplier including how to determine the Household Size. See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient.

Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, cheap kamagra supplier use the rule in the 1st "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p.

573, NYS GIS 2000 MA-007 cheap kamagra supplier CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.

The following programs were available prior to 2014, cheap kamagra supplier but are now discontinued because they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household.

It was sometimes known cheap kamagra supplier as "S/CC" category for Singles and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income.

This category has now been subsumed under the new MAGI adult group cheap kamagra supplier whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL.

For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize cheap kamagra supplier their purchase of Qualified Health Plans on the Exchange. PAST INCOME &. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order.

These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs cheap kamagra supplier in NYS. This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care.

The special income standard for housing expenses helps pay for housing cheap kamagra supplier expenses to help certain nursing home or adult home residents to safely transition back to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust.

KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income cheap kamagra supplier Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify.

"Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC cheap kamagra supplier plan. Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community.

Questions regarding the special income standard may be directed to DOH at 518-474-8887 cheap kamagra supplier. Who is eligible for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC.

How much is cheap kamagra supplier the allowance?. The rates vary by region and change yearly. Region Counties Deduction (2021) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St.

Lawrence, Tioga, Tompkins $450 Long Island Nassau, Suffolk $1,393 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,535 (up from 1,451 in 2020) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $524 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $1,075 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $469 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $413 Past rates published as follows, available on DOH website 2021 rates published in Attachment I to GIS 20 MA/13 -- 2021 Medicaid Levels and Other cheap kamagra supplier Updates 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS.

2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern cheap kamagra supplier $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo.

Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 cheap kamagra supplier DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!. HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard.

See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it. The procedures in NYC are explained in this Troubleshooting guide. In NYC, submit the application with the MAP-751W (check off "Budgeting Changes" and "Special Housing Standard").

(The MAP-751W is also posted in languages other than English in this link. (Updated 3-15-2021.)) NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest).

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

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

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Those in QMB receive additional liquid kamagra subsidies for Medicare costs. See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y.

§ 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging Note. Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP.

See this article for more info. TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A.

Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3.

The Three MSP Programs - What are they and how are they Different?. 4. FOUR Special Benefits of MSP Programs.

Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare WHO IS AUTOMATICALLY ENROLLED IN AN MSP Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP Enrolling in an MSP if you have Medicaid and Just Became Eligible for Medicare MIPPA - SSA Notifies Social Security recipients that they may be eligible for MSP based on their income.

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

NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A.

SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2021) Single Couple Single Couple Single Couple $1,094 $1,472 $1,308 $1,762 $1,469 $1,980 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &.

B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application.

18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA 027.

Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid.

Cannot have both, not even Medicaid with a spend-down. 2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits.

The income limits are tied to the Federal Poverty Level (FPL). 2021 FPL levels were released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented.

During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.

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.

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

No cheap kamagra supplier http://www.findlayillinois.net/ventolin-online-canada/ Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &. Rules and cheap kamagra supplier Household Size 3. The Three MSP Programs - What are they and how are they Different?.

4. FOUR cheap kamagra supplier Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare WHO IS AUTOMATICALLY ENROLLED IN AN MSP Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP Enrolling in an MSP if you have Medicaid and Just cheap kamagra supplier 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 cheap kamagra supplier MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP.

1.A cheap kamagra supplier. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2021) Single Couple Single Couple Single Couple $1,094 $1,472 $1,308 $1,762 $1,469 $1,980 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” cheap kamagra supplier 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 cheap kamagra supplier 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 cheap kamagra supplier 07 MA 027.

Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid cheap kamagra supplier. Cannot have both, not even Medicaid with a spend-down. 2.

INCOME LIMITS and RULES Each of the cheap kamagra supplier three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2021 FPL levels were released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II NOTE. There is usually a cheap kamagra supplier lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment).

Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply cheap kamagra supplier 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.

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Former Editor-in-Chief of the Postgraduate Medical Journal Dr Barry Ian Hoffbrand died suddenly on April 24, 2020 at the http://www.skywrite-translations.com/how-to-buy-renova-in-usa/ age of 86.A prominent member of a generation of very bright young doctors at University College Hospital (UCH) in London who went on buy cheap kamagra oral jelly to distinguished careers, he was much admired for his keen intellect, clinical perception and skills, gentle good humour and kindly nature, combined with a wonderfully sharp intelligence. Professor Dame Jane Dacre remembered him as ‘a kind, witty, clever man, and a great physician’.He was born in Bradford, West Yorkshire, to Philip Hoffbrand, a bespoke tailor, and Minnie (née Freedman), both from Jewish families from Eastern Europe. After Bradford Grammar School, he went up to buy cheap kamagra oral jelly read medicine from 1952 to 1956 at The Queen’s College, Oxford, where he was a keen member of the college cricket team—the Quondams. He was pleased to feature in the 1950s on the silver Quondams Cup.

Clinical training on a Goldsmid scholarship followed from 1956 to 1958 at UCH Medical School, London, where he was awarded prizes in clinical pathology and haematology. His postgraduate medical training was mainly at UCH, where he was house physician to Max (later Lord) Rosenheim, after an initial 6 months at St Luke’s buy cheap kamagra oral jelly Hospital, Bradford. He also spent a year as senior research fellow from 1967 to 1968 at the Cardiovascular Research Institute, at the University of California Medical Center in San Francisco. Barry’s research on cardiovascular physiology lead to a DM in 1971 from Oxford University.Barry was appointed in 1970 as a consultant physician at the Whittington Hospital and honorary senior clinical lecturer at UCH Medical School, with interests in general and …INTRODUCTIONAs cardiac arrest occurs in around 20% of the patients with severe erectile dysfunction treatment, a large number of them will require immediate resuscitative efforts.1 Cardiopulmonary resuscitation (CPR) in erectile dysfunction treatment kamagra has become a source of speculation and debate worldwide.

Healthcare professionals (HCPs) resuscitating this subset of patients are subject to fears and enormous mental stress pertaining to risk of transmission, breach in personal protective equipment (PPE), unsure effectiveness of PPE and nevertheless bleak positive outcomes in patients despite best resuscitative measures.2 CPR, which is conventionally deemed to be life-saving for patients, appears as an aerosol-generating buy cheap kamagra oral jelly procedure risking lives of HCPs caring for patients with erectile dysfunction treatment. Protected code blue algorithm has been formulated to address both performer and patient safety.3POCUS-INTEGRATED CPR. WHY THE buy cheap kamagra oral jelly NEED IN erectile dysfunction treatment?. Danilo Buonsenso and colleagues have described erectile dysfunction treatment era as demanding less stethoscope and more ultrasound usage in clinical practice.4 PPE is now an essential measure for HCP protection, and goggles used as a part of PPE are associated with fogging and poor visibility.

This coupled with the inability to confirm endotracheal tube position with stethoscope due to poor accessibility in PPE, increases the risk of oesophageal intubation, re-intubation attempts, aerosol generation and thus HCP exposure. Bedside ultrasound could act as visual buy cheap kamagra oral jelly stethoscope in the described scenario. Sono-CPR in erectile dysfunction treatment can help intervene quickly in treatable cases and reduce the time spent by HCP in futile resuscitative efforts. Reduced time spent equates to reduced duration of aerosol exposure and thus reduced risk of transmission.

Various algorithms are described for sono-cardiopulmonary resuscitation (sono-CPR) during cardiac arrest, but none are discussed to address patients with erectile dysfunction treatment.5 It buy cheap kamagra oral jelly would hence be wise to integrate bedside point-of-care ultrasound (POCUS) in the code blue algorithm.HOW THE BEDSIDE TOOL HELPS?. Hypoxemia and respiratory failure attribute over 80% aetiology of cardiac arrest in patients with erectile dysfunction treatment.1 Prioritising oxygenation and ventilation using definitive airway and use of high-efficiency particulate air filters reduces airborne transmission, thereby making early intubation the dictum of resuscitation.3 Considering poor visualisation due to fogging with the goggles and face shield, inability to use stethoscope and lack of availability of end-tidal CO2 (EtCO2) in resource constraint settings, ultrasound-guided real-time intubation by trained HCP or endotracheal tube (ETT) placement confirmation post intubation could prove beneficial. Confirming ETT placement and direct visualisation of oesophagal lumen can be done using a linear ultrasound probe.6 In cases of oesophageal intubation, tissue-air hyperechoic lines are visualised in both trachea and buy cheap kamagra oral jelly oesophagus, referred to as ‘double-track sign’.State of hypercoagulability and myocardial dysfunction exist in patients with erectile dysfunction treatment, hence increasing the likelihood of myocardial infarction or pulmonary thromboembolism as aetiologies of cardiac arrest.7 Regional wall motion abnormality, dilated right atrium or right ventricle, plethoric inferior vena cava are easily identified by goal-directed echocardiography. Pneumothorax has been reported in patients with erectile dysfunction treatment, and ultrasound can identify absence of lung sliding, helping in quick needle thoracocentesis in arrest and peri-arrest cases.

Few cases of cardiac tamponade owing to myopericarditis have also been reported and bedside ultrasound can help diagnose and perform pericardiocentesis in such patients.Literature suggests that the chances of Return Of Spontaneous Circulation (ROSC) and survival to hospital admission at 24 hours is better in patients with baseline cardiac activity rather than no baseline cardiac activity. In patients with no baseline cardiac activity on arrival, one can withhold CPR, thereby protecting the HCP in this resource-intensive, aerosol-generating futile resuscitative effort.8 Asystole could be the disguised entity of fine ventricular fibrillation, which can be confirmed by fibrillatory cardiac activity on transthoracic echocardiography and can be buy cheap kamagra oral jelly defibrillated, thereby increasing the chances of earlier ROSC.9POCUS-INTEGRATED CPR. THE PROPOSED ALGORITHMCPR is a chaotic scenario, and to prevent added chaos, there is a need for a well-trained ultrasound performer placed in an appropriate area (figure 1). Intubating room needs to consist of minimal necessary number of HCPs, and all of them should be equipped with full PPE.

Ultrasound device could be a potential fomite facilitating cross-transmission and requires adequate protection of buy cheap kamagra oral jelly machine and its components with a transparent cover, sheet or bag. When unavailable, low-level disinfectant solution should be used between each patient.Proposed algorithm for integration of POCUS during CPR in patients with erectile dysfunction treatment with team dynamics. The illustration is original work of the buy cheap kamagra oral jelly authors Dr Brunda RL and colleagues. CPR, cardiopulmonary resuscitation.

HCP, healthcare professional. POCUS, point-of-care ultrasound buy cheap kamagra oral jelly. PPE, personal protective equipment. RA, right atrium.

RV, right buy cheap kamagra oral jelly ventricle. VF, ventricular fibrillation. USG, ultrasonography." data-icon-position data-hide-link-title="0">Figure 1 Proposed algorithm for integration of POCUS during CPR in patients with erectile dysfunction treatment with team dynamics. The illustration is original work buy cheap kamagra oral jelly of the authors Dr Brunda RL and colleagues.

CPR, cardiopulmonary resuscitation. HCP, healthcare buy cheap kamagra oral jelly professional. POCUS, point-of-care ultrasound. PPE, personal protective equipment.

RA, right atrium buy cheap kamagra oral jelly. RV, right ventricle. VF, ventricular fibrillation. USG, ultrasonography.When a patient experiences cardiac arrest, there is a need for HCPs with full PPE to buy cheap kamagra oral jelly check pulse and begin CPR as per standard guidelines.

After 2 min of CPR, if there is no ROSC, during the 10 second pause for rhythm assessment, a trained HCP can perform POCUS in a stepwise manner. Each step needs to be buy cheap kamagra oral jelly performed individually during 10 second pause without prolonging delay between chest compressions and compromising the quality of CPR. Any treatable aetiology identified during the algorithm requires immediate intervention.Step 1. Assess cardiac activity—Sub-xiphoid view can be procured and cardiac activity assessed.

If absent, consider termination of efforts, and if present, resuscitative buy cheap kamagra oral jelly efforts can be continued.After repeating 2 min cycle of CPR, if there has been no ROSC, consider hypoxic aetiology as the cause of arrest in patients with erectile dysfunction treatment and intubate without delay. Withholding chest compressions during intubation is recommended.3Step 2. Assess ETT placement—At the level of thyroid gland, above the suprasternal notch, place ultrasound probe transversely and visualise the oesophagus.10 If the posterior wall of oesophagus is obscured by a dark acoustic shadow or if there is ‘double-track’ sign, consider failed endotracheal intubation and perform immediate re-intubation.Step 3. Assess lung for pneumothorax—Assess lung sliding, and if absent look for ‘stratosphere sign’ in M-mode of ultrasound.10 buy cheap kamagra oral jelly If detected, perform immediate needle thoracocentesis.Step 4.

Assess for Cardiac etiology of arrest—Obtain sub-xiphoid window preferably, and look for the presence of cardiac tamponade, chamber dilatation or collapse, regional wall motion abnormality and cardiac contractility.Availability of trained personnel and smaller portable ultrasound devices makes its use during cardiac arrest plausible.CPR with the help of POCUS could thus prove to improve chances of ROSC and also reduced transmission to HCP by early identification, treatment of reversible causes and avoidance of prolonged efforts. Sono-CPR appears to be more HCP-friendly than prolonged blind CPR and necessitates its utility in the era of erectile dysfunction treatment addressing performer safety as well as patient safety..

Former Editor-in-Chief of the Postgraduate Medical Journal Dr Barry Ian Hoffbrand died suddenly on April 24, 2020 at the age of 86.A prominent member of a generation of very bright young doctors at University College Hospital (UCH) in London who went on to distinguished careers, he was much admired for his keen intellect, http://www.skywrite-translations.com/how-to-buy-renova-in-usa/ clinical perception and skills, gentle cheap kamagra supplier good humour and kindly nature, combined with a wonderfully sharp intelligence. Professor Dame Jane Dacre remembered him as ‘a kind, witty, clever man, and a great physician’.He was born in Bradford, West Yorkshire, to Philip Hoffbrand, a bespoke tailor, and Minnie (née Freedman), both from Jewish families from Eastern Europe. After Bradford Grammar School, he went up to read medicine from 1952 to 1956 at cheap kamagra supplier The Queen’s College, Oxford, where he was a keen member of the college cricket team—the Quondams. He was pleased to feature in the 1950s on the silver Quondams Cup. Clinical training on a Goldsmid scholarship followed from 1956 to 1958 at UCH Medical School, London, where he was awarded prizes in clinical pathology and haematology.

His postgraduate medical training was mainly at cheap kamagra supplier UCH, where he was house physician to Max (later Lord) Rosenheim, after an initial 6 months at St Luke’s Hospital, Bradford. He also spent a year as senior research fellow from 1967 to 1968 at the Cardiovascular Research Institute, at the University of California Medical Center in San Francisco. Barry’s research on cardiovascular physiology lead to a DM in 1971 from Oxford University.Barry was appointed in 1970 as a consultant physician at the Whittington Hospital and honorary senior clinical lecturer at UCH Medical School, with interests in general and …INTRODUCTIONAs cardiac arrest occurs in around 20% of the patients with severe erectile dysfunction treatment, a large number of them will require immediate resuscitative efforts.1 Cardiopulmonary resuscitation (CPR) in erectile dysfunction treatment kamagra has become a source of speculation and debate worldwide. Healthcare professionals (HCPs) resuscitating this subset of patients are subject to fears and enormous mental stress pertaining to risk of transmission, breach in personal protective equipment (PPE), unsure effectiveness of PPE cheap kamagra supplier and nevertheless bleak positive outcomes in patients despite best resuscitative measures.2 CPR, which is conventionally deemed to be life-saving for patients, appears as an aerosol-generating procedure risking lives of HCPs caring for patients with erectile dysfunction treatment. Protected code blue algorithm has been formulated to address both performer and patient safety.3POCUS-INTEGRATED CPR.

WHY THE NEED cheap kamagra supplier IN erectile dysfunction treatment?. Danilo Buonsenso and colleagues have described erectile dysfunction treatment era as demanding less stethoscope and more ultrasound usage in clinical practice.4 PPE is now an essential measure for HCP protection, and goggles used as a part of PPE are associated with fogging and poor visibility. This coupled with the inability to confirm endotracheal tube position with stethoscope due to poor accessibility in PPE, increases the risk of oesophageal intubation, re-intubation attempts, aerosol generation and thus HCP exposure. Bedside ultrasound could act as visual stethoscope in the described cheap kamagra supplier scenario. Sono-CPR in erectile dysfunction treatment can help intervene quickly in treatable cases and reduce the time spent by HCP in futile resuscitative efforts.

Reduced time spent equates to reduced duration of aerosol exposure and thus reduced risk of transmission. Various algorithms are described for sono-cardiopulmonary resuscitation (sono-CPR) during cardiac arrest, but none are discussed to address patients with erectile dysfunction treatment.5 It would hence be wise to cheap kamagra supplier integrate bedside point-of-care ultrasound (POCUS) in the code blue algorithm.HOW THE BEDSIDE TOOL HELPS?. Hypoxemia and respiratory failure attribute over 80% aetiology of cardiac arrest in patients with erectile dysfunction treatment.1 Prioritising oxygenation and ventilation using definitive airway and use of high-efficiency particulate air filters reduces airborne transmission, thereby making early intubation the dictum of resuscitation.3 Considering poor visualisation due to fogging with the goggles and face shield, inability to use stethoscope and lack of availability of end-tidal CO2 (EtCO2) in resource constraint settings, ultrasound-guided real-time intubation by trained HCP or endotracheal tube (ETT) placement confirmation post intubation could prove beneficial. Confirming ETT placement cheap kamagra supplier and direct visualisation of oesophagal lumen can be done using a linear ultrasound probe.6 In cases of oesophageal intubation, tissue-air hyperechoic lines are visualised in both trachea and oesophagus, referred to as ‘double-track sign’.State of hypercoagulability and myocardial dysfunction exist in patients with erectile dysfunction treatment, hence increasing the likelihood of myocardial infarction or pulmonary thromboembolism as aetiologies of cardiac arrest.7 Regional wall motion abnormality, dilated right atrium or right ventricle, plethoric inferior vena cava are easily identified by goal-directed echocardiography. Pneumothorax has been reported in patients with erectile dysfunction treatment, and ultrasound can identify absence of lung sliding, helping in quick needle thoracocentesis in arrest and peri-arrest cases.

Few cases of cardiac tamponade owing to myopericarditis have also been reported and bedside ultrasound can help diagnose and perform pericardiocentesis in such patients.Literature suggests that the chances of Return Of Spontaneous Circulation (ROSC) and survival to hospital admission at 24 hours is better in patients with baseline cardiac activity rather than no baseline cardiac activity. In patients with no baseline cardiac activity on arrival, one can withhold CPR, thereby protecting the HCP in this resource-intensive, aerosol-generating futile resuscitative effort.8 Asystole could be the disguised entity of fine ventricular fibrillation, which can be cheap kamagra supplier confirmed by fibrillatory cardiac activity on transthoracic echocardiography and can be defibrillated, thereby increasing the chances of earlier ROSC.9POCUS-INTEGRATED CPR. THE PROPOSED ALGORITHMCPR is a chaotic scenario, and to prevent added chaos, there is a need for a well-trained ultrasound performer placed in an appropriate area (figure 1). Intubating room needs to consist of minimal necessary number of HCPs, and all of them should be equipped with full PPE. Ultrasound device could be a potential fomite facilitating cross-transmission and requires adequate protection of machine and cheap kamagra supplier its components with a transparent cover, sheet or bag.

When unavailable, low-level disinfectant solution should be used between each patient.Proposed algorithm for integration of POCUS during CPR in patients with erectile dysfunction treatment with team dynamics. The illustration is original work of the authors Dr cheap kamagra supplier Brunda RL and colleagues. CPR, cardiopulmonary resuscitation. HCP, healthcare professional. POCUS, point-of-care cheap kamagra supplier ultrasound.

PPE, personal protective equipment. RA, right atrium. RV, right cheap kamagra supplier ventricle. VF, ventricular fibrillation. USG, ultrasonography." data-icon-position data-hide-link-title="0">Figure 1 Proposed algorithm for integration of POCUS during CPR in patients with erectile dysfunction treatment with team dynamics.

The illustration is original work of cheap kamagra supplier the authors Dr Brunda RL and colleagues. CPR, cardiopulmonary resuscitation. HCP, healthcare cheap kamagra supplier professional. POCUS, point-of-care ultrasound. PPE, personal protective equipment.

RA, right cheap kamagra supplier atrium. RV, right ventricle. VF, ventricular fibrillation. USG, ultrasonography.When a patient experiences cardiac arrest, there is a need for HCPs with full PPE to check pulse cheap kamagra supplier and begin CPR as per standard guidelines. After 2 min of CPR, if there is no ROSC, during the 10 second pause for rhythm assessment, a trained HCP can perform POCUS in a stepwise manner.

Each step needs to be performed individually during 10 second cheap kamagra supplier pause without prolonging delay between chest compressions and compromising the quality of CPR. Any treatable aetiology identified during the algorithm requires immediate intervention.Step 1. Assess cardiac activity—Sub-xiphoid view can be procured and cardiac activity assessed. If absent, consider termination of efforts, and if present, resuscitative efforts can be continued.After repeating 2 min cycle of CPR, if there has been no ROSC, consider hypoxic aetiology as the cause of cheap kamagra supplier arrest in patients with erectile dysfunction treatment and intubate without delay. Withholding chest compressions during intubation is recommended.3Step 2.

Assess ETT placement—At the level of thyroid gland, above the suprasternal notch, place ultrasound probe transversely and visualise the oesophagus.10 If the posterior wall of oesophagus is obscured by a dark acoustic shadow or if there is ‘double-track’ sign, consider failed endotracheal intubation and perform immediate re-intubation.Step 3. Assess lung for pneumothorax—Assess lung sliding, and if absent look for ‘stratosphere sign’ in M-mode cheap kamagra supplier of ultrasound.10 If detected, perform immediate needle thoracocentesis.Step 4. Assess for Cardiac etiology of arrest—Obtain sub-xiphoid window preferably, and look for the presence of cardiac tamponade, chamber dilatation or collapse, regional wall motion abnormality and cardiac contractility.Availability of trained personnel and smaller portable ultrasound devices makes its use during cardiac arrest plausible.CPR with the help of POCUS could thus prove to improve chances of ROSC and also reduced transmission to HCP by early identification, treatment of reversible causes and avoidance of prolonged efforts. Sono-CPR appears to be more HCP-friendly than prolonged blind CPR and necessitates its utility in the era of erectile dysfunction treatment addressing performer safety as well as patient safety..

Kamagra jelly uk next day delivery

Exercising your core during pregnancy might sound odd, but certified pregnancy exercise specialist Dahlas Fletcher explains that safe exercise is the kamagra jelly uk next day delivery key to optimum bodily functioning and can aid your growing baby’s development.Safe and effective exercise during and after pregnancy are incredibly important to keep your body functioning optimally and also for your growing baby’s development.Having a strong and functional pregnant core is also important, as it can alleviate pressure on the lower back, help with better postural alignment, provide an increased sense of https://geolistening.com/buy-viagra-without-a-prescription/ control during birth as well as set you up for a better postpartum recovery.However, when it comes to core workouts during pregnancy there can be great confusion. Especially since when core exercise are mentioned, most people think of typical exercises for the six-pack (or rectus abdominis) such as sit ups, planks and crunches… which you may not have realised are not the best prenatal workout choices, regardless of kamagra jelly uk next day delivery what trimester you are in!. Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like kamagra jelly uk next day delivery this.What's the difference between abs and core?.

There is a difference between your outer and inner core.The rectus abdominis is the outer layer of the abdominal muscles. Its purpose is forward flexion of the spine, and during pregnancy this area has to separate to make way for kamagra jelly uk next day delivery your growing baby in utero. Because of this, 'traditional' moves such as sit ups, planks and crunches are not optimal as this separated area cannot activate effectively.Too much intra-abdominal pressure this area from non-optimal movement can then result in a common postnatal concern called diastasis recti which is damage to the midline or centre of the core called the linea alba.So what part of the pregnant core should we be training?. Your abs are actually four layers deep - and the deep core muscles do kamagra jelly uk next day delivery not even include the rectus abdominis or six-pack.

Imagine a whole apple. When you look at kamagra jelly uk next day delivery it, you cannot see the core.The deeper part of the core needs to be given priority during pregnancy, and in particular these four parts of the deep areas of the core. The pelvic floor The transverse abdominis (TVA) The multifidus The diaphragmThese four areas of the deep core are really strong as they are helping to support your growing baby in the womb, so safe and effective exercise during pregnancy that target them can set you up for a better birth and recovery.Easy ways to activate your deep core during pregnancy1. Breathe your way to a better coreOne of the easiest and most efficient way to train the deep core kamagra jelly uk next day delivery area during pregnancy is through breath combined with functional movement.

Breathing effectively is central to all the workouts I do with all my prenatal clients. Every exercise has kamagra jelly uk next day delivery an ideal time to breathe in order to allow the abdominals, diaphragm, pelvic floor to work in synergy.Breathing also plays a major part in preparing for birth and recovery. During pregnancy, it is important to avoid breath holding as this creates increased intra-abdominal pressure which can result in a hernia or a worse a prolapse. Instead, try to exhale on the effort of all movements, not only during a workout but also when you kamagra jelly uk next day delivery go about your day.2.

Pelvic floor activationThe pelvic floor is the foundation of your core. The pelvic floor muscles are located in your pelvis and stretch like a hammock from the pubic bone (at the front) to the coccyx or tailbone (at the back) and kamagra jelly uk next day delivery from side to side. Think of the foundation of a house or building – without a stable base it collapses. The pelvic floor is the foundation of your core so needs to function effectively to support the kamagra jelly uk next day delivery total core and your growing baby.I can’t stress enough how important it is to learn how to relax your pelvic floor first in order to contract it.

When performing Kegels try to avoid clenching and instead focus on a gentle lift and exhale, this will naturally allow the pelvic floor to activate, as kamagra jelly uk next day delivery seen below.Unfortunately, when many women perform Kegels overactivation of the pelvic floor occurs. This combined with other cues, such as “draw your belly to spine” and “tuck your tailbone under” can have a negative effect on this important deep core muscle.Difficulties such as incontinence then arise when trying to relax and release a muscle that is turned on all the time. This also happens when the deep core is compensating for other areas that are a bit too lax, or not functioning quite kamagra jelly uk next day delivery right. These parts can become hypotonic - meaning they aren't contracting with enough strength or at the right time.

The goal with all kamagra jelly uk next day delivery our muscles including our pelvic floor is balance. We want muscles that can contract fully and relax fully during all forms of movement including during a workout and as you go about your day.3. Functional total body movementA strong core means less risk of pain and injury, and it also means you can safely lift items (such as groceries, toddlers and car capsules) and function better kamagra jelly uk next day delivery during pregnancy plus the lifetime of motherhood.Core training does not mean spot training your midline or abs with a million crunches – it is about strengthening everything from your shoulders to your knees, as this will improve your stability and strength in every plane of motion. Exercises such as side lying leg raises, glute bridges and squats are all fabulous ways to exercise during pregnancy.

These movements when combined with correct alignment and breath will also train your kamagra jelly uk next day delivery core.When exercising during pregnancy, if your core is not safely and effectively engaged abdominal separation can be worsened and pelvic floor dysfunction risk increased. Therefore, during your precious journey it is so important to learn how to accommodate your changing pregnant body and connect to your deep core.After training pregnant women for over 13 years I have been fascinated by how much stronger they become with simple quality movements. Becoming stronger or fitter during pregnancy does not just happen by kamagra jelly uk next day delivery staying physically active – it really requires learning and understanding how to strengthen your deep core properly, and how to move your body effectively during a workout and also as you go about your day, this ensures you connect better on all levels.The physical changes of pregnancy can cause many women to lose the connection with their core. However, with proper training and specific exercises, this connection can actually improve during pregnancy and set you up for a lifetime of benefits that go way beyond washboard abs.Dahlas Fletcher is a certified pregnancy and postpartum exercise specialist, mother of three, and founder of BodyFabulous.

Follow her on Instagram or Facebook.Giving birth only days ago wasn't going to stop Katy perry from joining in kamagra jelly uk next day delivery on the VMAs 2020 fun. Katy Perry may have only given birth to her first child Daisy Dove, five days ago - but it didn’t stop her from joining in on the fun of the VMA’s wacky red carpet on Monday.Taking to her Instagram stories amid the awards ceremony, Perry shared a picture of her rocking grey high-waisted knickers and a nude nursing bra fitted with breast pumps.“Hair and makeup by. @exhuastion,” the singer joked to her kamagra jelly uk next day delivery 105 million followers.Like what you see?. Sign up to our bodyandsoul.com.au newsletter to read more stories like this.The 35-year old and her partner Orlando Bloom welcomed Daisy Dove Bloom on August 27, announcing the birth through UNICEF, of which they are both Goodwill Ambassadors.“We are floating with love and wonder from the safe and healthy arrival of our daughter,” UNICEF quoted the new parents as saying, alongside a cute close-up of Daisy’s tiny hand.The statement continued.

€œBut we know we’re kamagra jelly uk next day delivery the lucky ones and not everyone can have a birthing experience as peaceful as ours. Communities around the world are still experiencing a shortage of healthcare workers and every 11 seconds a pregnant woman or newborn dies."The couple have teamed up with UNICEF for a charity campaign asking wellwishers to donate to “help every mother and newborn get the care they need.”.

Exercising your core during pregnancy might sound odd, but certified pregnancy exercise specialist Dahlas Fletcher explains that safe exercise is the key to optimum bodily functioning and can aid your growing baby’s development.Safe and effective exercise during cheap kamagra supplier and after pregnancy are incredibly important to keep your body functioning optimally and also for your growing baby’s Buy viagra without a prescription development.Having a strong and functional pregnant core is also important, as it can alleviate pressure on the lower back, help with better postural alignment, provide an increased sense of control during birth as well as set you up for a better postpartum recovery.However, when it comes to core workouts during pregnancy there can be great confusion. Especially since when core exercise are cheap kamagra supplier mentioned, most people think of typical exercises for the six-pack (or rectus abdominis) such as sit ups, planks and crunches… which you may not have realised are not the best prenatal workout choices, regardless of what trimester you are in!. Like what you see?. Sign up to our cheap kamagra supplier bodyandsoul.com.au newsletter for more stories like this.What's the difference between abs and core?. There is a difference between your outer and inner core.The rectus abdominis is the outer layer of the abdominal muscles.

Its purpose is forward flexion of the spine, and during pregnancy this area has to cheap kamagra supplier separate to make way for your growing baby in utero. Because of this, 'traditional' moves such as sit ups, planks and crunches are not optimal as this separated area cannot activate effectively.Too much intra-abdominal pressure this area from non-optimal movement can then result in a common postnatal concern called diastasis recti which is damage to the midline or centre of the core called the linea alba.So what part of the pregnant core should we be training?. Your abs are actually four cheap kamagra supplier layers deep - and the deep core muscles do not even include the rectus abdominis or six-pack. Imagine a whole apple. When you look at it, you cannot see the core.The deeper part of the core needs to be cheap kamagra supplier given priority during pregnancy, and in particular these four parts of the deep areas of the core.

The pelvic floor The transverse abdominis (TVA) The multifidus The diaphragmThese four areas of the deep core are really strong as they are helping to support your growing baby in the womb, so safe and effective exercise during pregnancy that target them can set you up for a better birth and recovery.Easy ways to activate your deep core during pregnancy1. Breathe your way to a better coreOne of the easiest and most efficient way to train the deep core area during cheap kamagra supplier pregnancy is through breath combined with functional movement. Breathing effectively is central to all the workouts I do with all my prenatal clients. Every exercise has an ideal time to breathe in order to allow the abdominals, diaphragm, pelvic cheap kamagra supplier floor to work in synergy.Breathing also plays a major part in preparing for birth and recovery. During pregnancy, it is important to avoid breath holding as this creates increased intra-abdominal pressure which can result in a hernia or a worse a prolapse.

Instead, try to exhale on the effort cheap kamagra supplier of all movements, not only during a workout but also when you go about your day.2. Pelvic floor activationThe pelvic floor is the foundation of your core. The pelvic floor muscles are located in your pelvis and stretch like a hammock from the pubic bone (at the front) to the coccyx or tailbone (at cheap kamagra supplier the back) and from side to side. Think of the foundation of a house or building – without a stable base it collapses. The pelvic floor is the foundation of your core so needs to function effectively to support the total core and cheap kamagra supplier your growing baby.I can’t stress enough how important it is to learn how to relax your pelvic floor first in order to contract it.

When performing Kegels try to avoid clenching and instead focus on a gentle lift and exhale, this will naturally allow the pelvic floor to activate, as cheap kamagra supplier seen below.Unfortunately, when many women perform Kegels overactivation of the pelvic floor occurs. This combined with other cues, such as “draw your belly to spine” and “tuck your tailbone under” can have a negative effect on this important deep core muscle.Difficulties such as incontinence then arise when trying to relax and release a muscle that is turned on all the time. This also happens when the deep core is compensating for other areas that are a bit too cheap kamagra supplier lax, or not functioning quite right. These parts can become hypotonic - meaning they aren't contracting with enough strength or at the right time. The goal with all our cheap kamagra supplier muscles including our pelvic floor is balance.

We want muscles that can contract fully and relax fully during all forms of movement including during a workout and as you go about your day.3. Functional total body movementA strong core means less risk of pain and injury, and it also means you can safely lift items (such as groceries, toddlers and car capsules) and function better during pregnancy plus the lifetime of motherhood.Core training cheap kamagra supplier does not mean spot training your midline or abs with a million crunches – it is about strengthening everything from your shoulders to your knees, as this will improve your stability and strength in every plane of motion. Exercises such as side lying leg raises, glute bridges and squats are all fabulous ways to exercise during pregnancy. These movements when combined with correct alignment and breath will also train your core.When exercising during pregnancy, if your core is not safely and effectively engaged abdominal separation can be worsened and pelvic floor dysfunction risk increased cheap kamagra supplier. Therefore, during your precious journey it is so important to learn how to accommodate your changing pregnant body and connect to your deep core.After training pregnant women for over 13 years I have been fascinated by how much stronger they become with simple quality movements.

Becoming stronger or fitter during pregnancy does not just happen by staying physically active – it really requires learning and understanding how to strengthen your deep core properly, and how to move your body effectively during a workout and also as you go about your day, this ensures you connect better on all levels.The physical changes of pregnancy can cause many cheap kamagra supplier women to lose the connection with their core. However, with proper training and specific exercises, this connection can actually improve during pregnancy and set you up for a lifetime of benefits that go way beyond washboard abs.Dahlas Fletcher is a certified pregnancy and postpartum exercise specialist, mother of three, and founder of BodyFabulous. Follow her on Instagram or Facebook.Giving birth only days ago wasn't going to stop Katy perry from joining in on the cheap kamagra supplier VMAs 2020 fun. Katy Perry may have only given birth to her first child Daisy Dove, five days ago - but it didn’t stop her from joining in on the fun of the VMA’s wacky red carpet on Monday.Taking to her Instagram stories amid the awards ceremony, Perry shared a picture of her rocking grey high-waisted knickers and a nude nursing bra fitted with breast pumps.“Hair and makeup by. @exhuastion,” the singer joked to her cheap kamagra supplier 105 million followers.Like what you see?.

Sign up to our bodyandsoul.com.au newsletter to read more stories like this.The 35-year old and her partner Orlando Bloom welcomed Daisy Dove Bloom on August 27, announcing the birth through UNICEF, of which they are both Goodwill Ambassadors.“We are floating with love and wonder from the safe and healthy arrival of our daughter,” UNICEF quoted the new parents as saying, alongside a cute close-up of Daisy’s tiny hand.The statement continued. €œBut we cheap kamagra supplier know we’re the lucky ones and not everyone can have a birthing experience as peaceful as ours. Communities around the world are still experiencing a shortage of healthcare workers and every 11 seconds a pregnant woman or newborn dies."The couple have teamed up with UNICEF for a charity campaign asking wellwishers to donate to “help every mother and newborn get the care they need.”.

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The IO will allow the Minister Antabuse prices walmart to require any person who sells a drug to provide information about a shortage or kamagra 24 hour delivery potential shortage of that drug. The IO gives the Minister this authority if there are reasonable grounds to believe that. the drug is at risk of going into shortage or is in shortage the shortage is caused or made worse, directly or indirectly, by the erectile dysfunction treatment kamagra the shortage poses a risk of injury to human health the requested information is necessary to identify or assess the shortage. why it occurred its effects on human health what measures could be taken to prevent or alleviate the shortage the person would not provide the information without a legal obligation To prevent or alleviate a shortage, the Minister may also add or amend terms and conditions to an kamagra 24 hour delivery authorization to sell a drug. The Minister may do so if there are reasonable grounds to believe that.

the drug is at risk of going into shortage or is in shortage the shortage is caused or made worse, directly or indirectly, by the erectile dysfunction treatment kamagra the shortage poses a risk of injury to human health If you have any questions, please contact us by email at. Hc.prsd-questionsdspr.sc@canada.ca. Related links and guidanceOn this page Policy objectiveThis guidance is to provide Canadians with access to information on the safety and efficacy/effectiveness of products being used for the erectile dysfunction treatment kamagra. These products are being imported and sold in Canada under 2 interim orders. All personal and confidential business information (CBI) will be protected prior to release.

The disclosed information will be made publicly available for non-commercial purposes after Health Canada completes its regulatory review process, while adhering to Canada’s Privacy Act.Providing public access to this information supports Canada’s objective for transparent decision-making. Public access also provides valuable information that may help with the use or development of erectile dysfunction treatment19 drugs and medical devices.This guidance document outlines the process for publicly disclosing information in a market authorization application under the 2 interim orders. The process includes. procedures when releasing information types of information that fall under the guidelines for CBI and that may be eligible for redaction protection of personal informationScope and application This document applies to information relied upon to issue a market authorization under the. Interim order respecting the importation, sale and advertising of drugs for use in relation to erectile dysfunction treatment (September 16, 2020) and interim order respecting the importation and sale of medical devices for use in relation to erectile dysfunction treatment(March 18, 2020)The public release of safety and efficacy/effectiveness information reviewed under the 2 interim orders is governed by common law.

Information requested for release is assessed case by case to determine what is CBI. Personal information is removed before the safety and efficacy/effectiveness information is released to the public.Following Health Canada’s review of an application, safety and efficacy information will be released as follows. Automatically disclosed in applications submitted under the interim order for importing, selling and advertising drugs (proactive release) disclosed on request in applications submitted under the interim order for importing and selling medical devices (released upon request)Information in applications that have been authorized, including those authorized and then revoked, is in scope for public release. This includes. Original application documents documents filed after market authorization is issued (filed at Health Canada’s request or to meet a condition of approval)Information in applications that are refused and were never authorized is out of scope for public release.

This document does not apply to clinical information submitted to support the market authorization of a medical device under the Medical Device Regulations or of a new drug submission under the Food and Drug Regulations (FDR). The exception are new drug submissions for erectile dysfunction treatment indications submitted under the FDR. For more information on the public release of this information, see the Public Release of Clinical Information. Guidance document.Also not applicable under this document is the CBI disclosure authority under section 21.1(3)(c) of the Food and Drugs Act. This section permits the Minister of Health to disclose CBI to certain persons for the purpose of protection or promotion of human health or the safety of the public.

For information on this authority, see the guidance document Disclosure of Confidential Business Information under Paragraph 21.1(3)(c) of the Food and Drugs Act.Proactive release of drug application informationWe will proactively publish safety and efficacy information used to support interim order drug applications upon authorization. This includes clinical information in applications submitted under sections 3, 6 and 14 of the interim order.How to request clinical information in medical device applicationsWe will publish safety and effectiveness information used to support interim order medical device applications when we receive a request from the public and within the limits of our administrative capacity. Requests made for multiple applications will be processed in sequence and subject to prioritization. Further prioritization may be given to products that have a greater impact on the health system, such as. Products that are used a lot products that have a higher public interestRequests received for information in applications under the interim order will be prioritized over requests for clinical information in non-erectile dysfunction treatment19-related drugs submissions and device applications.To request clinical information on medical device applications, use our special portal to submit an electronic request form.

Be sure to identify the product name listed on the following sites. Publication process Publication of safety and efficacy information used to support drug interim order applications The publication of information follows the process described in section 4 and Appendix C of the Public Release of Clinical Information guidance document.In accordance with PRCI timelines, we aim to publish a final redacted and anonymized package on our clinical information portal within 120 calendar days from starting the process. The process starts automatically on the day an authorization is issued.Step 1. Notice to the company and request for proposed CBI redactions and anonymizationFollowing the authorization of a drug under the interim order, Health Canada will give the manufacturer an opportunity to take part in a process initiation meeting. The first 60 days of the 120-day publication process is allocated for the company to review the clinical information.

The company uses the Proposed Redaction Control Sheet (Appendix E, Public Release of Clinical Information (PRCI) guidance document) to propose any redaction of CBI. Proposed CBI redactions should pertain to information that meets the definition of confidential business information. This is defined in Section 2 of the Food and Drugs Act, which mirrors common law in the context of confidential business information that meets each of the following 3 elements of the definition. That is not publicly available in respect of which the person has taken measures that are reasonable in the circumstances to ensure that it remains not publicly available and that has actual or potential economic value to the person or their competitors because it is not publicly available and its disclosure would result in a material financial loss to the person or a material financial gain to their competitorsFollowing an assessment of the proposals, text within an in-scope document found to meet the above definition will be protected. Similar to Public Release of Clinical Information policies, any information that meets the definition of “clinical information” will not be considered confidential business information.

Exceptions to the PRCI regulations described in C.08.009.2(2)(a) and (b) of the Food and Drug Regulations or section 43.12(2)(a) and (b) of the Medical Device Regulations will be considered when applying redactions to confidential business information. Further information on the application of these exceptions can be found in the Health Canada PRCI guidance document.All personal information should be anonymized in accordance with section 6 of the Public Release of Clinical Information guidance document. The proposal package from the manufacturer should include. The proposed redaction control sheet the draft anonymization report annotated documentsManufacturers submit for Health Canada assessment using either CanadaPost ePost Connect or a suitable secure file transfer site of the manufacturer’s choosing.Step 2. Health Canada assessment of company representationsWithin 30 days of receiving the proposal package, Health Canada will complete and return our assessment of the proposed CBI redactions and anonymization methodology.

Proposed redactions that meet the definition of confidential business information will be protected. We will review the anonymization methodology to ensure all personal information is protected while maximizing the disclosure of useful clinical information. Step 3. Revision of proposed CBI redactions and anonymizationIf proposed CBI redactions are rejected or revision is required to the anonymization methodology, in accordance with the Public Release of Clinical Information. Guidance document, the manufacturer will be given 15 days to make the revisions and resubmit.

We will send our final assessment to the manufacturer within 5 days of receiving the revised package. Step 4. Finalization and publicationWithin 5 days of receiving our final assessment, the manufacturer must format and submit the final redacted and anonymization clinical documents within 5 days of receiving our final assessment. The final documents must comply with the Guidance Document. Preparation of Regulatory Activities using the Electronic Common Technical Document (eCTD) Format.

These documents are to be submitted using the Common Electronic Submission Gateway. We will publish the final redacted documents within 5 days of receiving the final sequence.Publication of safety and effectiveness information used to support medical device interim order applicationsThe publication of information within an interim order application will proceed through the abbreviated process described below. Our goal is to publish a final redacted and anonymized package on our clinical information portal within 120 calendar days from initiation of the process.Step 1. Health Canada screening of requestsAfter we receive a request for information, we will retrieve the interim order application from docubridge (or other location). Information related to safety and effectiveness will be considered in-scope of publication.

Other information will not be released publicly. Only information available at the time the request is made will be considered for disclosure. Information submitted after the original request for disclosure will be considered for public release upon receipt of a subsequent request.Examples of in scope information include. Clinical testing information validation testing that supports the effectiveness of the product, including testing performed in vitro or in silico summaries or overviews on safety or efficacy pre- or post-market, including literature reviewsExamples of out of scope information include. Manufacturing details not related to safety or efficacy engineering and design details general documents, such as user manuals, package inserts and instructions for use individual patient information, such as patient listings and case report forms, that require extensive anonymization interim clinical study data (see the PRCI guidance)Step 2a.

Health Canada assessment of confidential business information To reduce administrative burden on the manufacturer, we will review in-scope records for confidential business information, as defined in Section 2 of the Food and Drugs Act, which mirrors common law in the context of confidential business information that meets each of the following 3 elements of the definition will be protected. That is not publicly available in respect of which the person has taken measures that are reasonable in the circumstances to ensure that it remains not publicly available and that has actual or potential economic value to the person or their competitors because it is not publicly available and its disclosure would result in a material financial loss to the person or a material financial gain to their competitorsText in an in-scope document found to meet this definition will be redacted using a PDF redaction tool. Similar to Public Release of Clinical Information policies, any information that meets the definition of “clinical information” will not be considered confidential business information. Exceptions to the PRCI regulations are outlined section 43.12(2)(a) and (b) of the Medical Device Regulations. These exceptions will be considered when applying redactions to confidential business information.

Further information on the application of these exceptions can be found in the PRCI guidance document.Step 2b. Assessing personal informationIn general, in-scope records do not contain a large volume of personal identification information. Any personal information, as defined in the Privacy Act and in accordance with PRCI guidance, information that could help to identify an individual will be protected. For example, this can include the names of authors and investigators as well as subject identification numbers.A large volume of indirectly identifying information is not expected in the medical device records that are in-scope of publication. Consequently, limited protection of personal information is anticipated.Personal information will be redacted using a PDF redaction tool.

Step 3. Notice to the company and request for redaction proposalFollowing the review and redaction of in scope documents, we will send the manufacturer a written notice indicating our intent to publish the identified documents. A copy of the release package will be sent for the manufacturer’s review. Any further proposed redactions by the manufacturer must be received within 14 calendar days.Manufacturer are asked to use the Proposed Redaction Control Sheet (see Appendix E of the PRCI guidance document) to suggest further redactions.Step 4. Health Canada assessment of company representationsAny further redactions proposed by the manufacturer will be assessed in accordance with the process outlined in step 2, above.

Those that meet the definition of personal or confidential business information will be accepted.Step 5. PublicationIn-scope documents will be published within 120 days following receipt of the request. The redacted information will be uploaded to the Clinical Information Portal, indexed by application number. Published documents will carry a watermark and be subject to terms of use, as described in the PRCI guidance.Mailing addressInformation Science and Openness DivisionResource Management and Operations DirectorateHealth Products and Food BranchHealth Canada Graham Spry Building 250 Lanark Ave Ottawa ON K1A 0K9 Telephone. 613-960-4687Email.

Hc.clinicaldata-donneescliniques.sc@canada.ca Terminology and definitions Anonymization. Means the process through which personal information is modified by. removing direct identifiers and any related code that would enable linkage with identifying information and ensuring that the remaining indirect identifiers no longer present a serious possibility of re-identifying an individual CBI. Confidential business information, as meant in common law and as defined in Section 2 of the Food and Drugs Act. in respect of a person to whose business or affairs the information relates, means (subject to the regulations) business information that.

Is not publicly available in respect of which the person has taken measures that are reasonable in the circumstances to ensure that it remains not publicly available has actual or potential economic value to the person or their competitors because it is not publicly available and its disclosure would result in a material financial loss to the person or a material financial gain to their competitors Clinical information. Means information in respect of a clinical trial, clinical studies or investigational testing, such as. clinical overviews, clinical summaries and clinical study reports for drugs summaries and detailed information of all clinical studies and investigational testing that provided evidence of safety and effectiveness for medical devices Clinical study report. Means an "integrated" full report of an individual study of any therapeutic, prophylactic or diagnostic agent (drug or treatment) conducted in patients, in which.

These products discover here are being imported and sold in Canada under 2 cheap kamagra supplier interim orders. All personal and confidential business information (CBI) will be protected prior to release. The disclosed information will be made publicly available for non-commercial purposes after Health Canada completes its regulatory review process, while adhering to Canada’s Privacy Act.Providing public access to this information supports Canada’s objective for transparent decision-making.

Public access also provides valuable information that may help with the use or development of erectile dysfunction treatment19 drugs and cheap kamagra supplier medical devices.This guidance document outlines the process for publicly disclosing information in a market authorization application under the 2 interim orders. The process includes. procedures when releasing information types of information that fall under the guidelines for CBI and that may be eligible for redaction protection of personal informationScope and application This document applies to information relied upon to issue a market authorization under the.

Interim order respecting the importation, sale and advertising of drugs for use cheap kamagra supplier in relation to erectile dysfunction treatment (September 16, 2020) and interim order respecting the importation and sale of medical devices for use in relation to erectile dysfunction treatment(March 18, 2020)The public release of safety and efficacy/effectiveness information reviewed under the 2 interim orders is governed by common law. Information requested for release is assessed case by case to determine what is CBI. Personal information is removed before the safety and efficacy/effectiveness information is released to the public.Following Health Canada’s review of an application, safety and efficacy information will be released as follows.

Automatically disclosed in applications submitted under cheap kamagra supplier the interim order for importing, selling and advertising drugs (proactive release) disclosed on request in applications submitted under the interim order for importing and selling medical devices (released upon request)Information in applications that have been authorized, including those authorized and then revoked, is in scope for public release. This includes. Original application documents documents filed after market authorization is issued (filed at Health Canada’s request or to meet a condition of approval)Information in applications that are refused and were never authorized is out of scope for public release.

This document does not apply to clinical information submitted to support the market authorization of a medical device under the Medical Device Regulations or of a new drug submission under the cheap kamagra supplier Food and Drug Regulations (FDR). The exception are new drug submissions for erectile dysfunction treatment indications submitted under the FDR. For more information on the public release of this information, see the Public Release of Clinical Information.

Guidance document.Also not applicable under this document is the CBI disclosure authority under section 21.1(3)(c) of the Food and Drugs Act cheap kamagra supplier. This section permits the Minister of Health to disclose CBI to certain persons for the purpose of protection or promotion of human health or the safety of the public. For information on this authority, see the guidance document Disclosure of Confidential Business Information under Paragraph 21.1(3)(c) of the Food and Drugs Act.Proactive release of drug application informationWe will proactively publish safety and efficacy information used to support interim order drug applications upon authorization.

This includes clinical information in applications submitted under sections 3, cheap kamagra supplier 6 and 14 of the interim order.How to request clinical information in medical device applicationsWe will publish safety and effectiveness information used to support interim order medical device applications when we receive a request from the public and within the limits of our administrative capacity. Requests made for multiple applications will be processed in sequence and subject to prioritization. Further prioritization may be given to products that have a greater impact on the health system, such as.

Products that are used a lot products that have a higher public interestRequests received for information in applications under the interim order will be prioritized over requests for clinical information in non-erectile dysfunction treatment19-related drugs submissions and device applications.To request clinical information on medical device applications, use our special cheap kamagra supplier portal to submit an electronic request form. Be sure to identify the product name listed on the following sites. Publication process Publication of safety and efficacy information used to support drug interim order applications The publication of information follows the process described in section 4 and Appendix C of the Public Release of Clinical Information guidance document.In accordance with PRCI timelines, we aim to publish a final redacted and anonymized package on our clinical information portal within 120 calendar days from starting the process.

The process cheap kamagra supplier starts automatically on the day an authorization is issued.Step 1. Notice to the company and request for proposed CBI redactions and anonymizationFollowing the authorization of a drug under the interim order, Health Canada will give the manufacturer an opportunity to take part in a process initiation meeting. The first 60 days of the 120-day publication process is allocated for the company to review the clinical information.

The company uses the Proposed Redaction Control Sheet cheap kamagra supplier (Appendix E, Public Release of Clinical Information (PRCI) guidance document) to propose any redaction of CBI. Proposed CBI redactions should pertain to information that meets the definition of confidential business information. This is defined in Section 2 of the Food and Drugs Act, which mirrors common law in the context of confidential business information that meets each of the following 3 elements of the definition.

That is not publicly available in cheap kamagra supplier respect of which the person has taken measures that are reasonable in the circumstances to ensure that it remains not publicly available and that has actual or potential economic value to the person or their competitors because it is not publicly available and its disclosure would result in a material financial loss to the person or a material financial gain to their competitorsFollowing an assessment of the proposals, text within an in-scope document found to meet the above definition will be protected. Similar to Public Release of Clinical Information policies, any information that meets the definition of “clinical information” will not be considered confidential business information. Exceptions to the PRCI regulations described in C.08.009.2(2)(a) and (b) of the Food and Drug Regulations or section 43.12(2)(a) and (b) of the Medical Device Regulations will be considered when applying redactions to confidential business information.

Further information on the application of these exceptions can be found in the Health Canada PRCI guidance document.All personal information should be anonymized in accordance with cheap kamagra supplier section 6 of the Public Release of Clinical Information guidance document. The proposal package from the manufacturer should include. The proposed redaction control sheet the draft anonymization report annotated documentsManufacturers submit for Health Canada assessment using either CanadaPost ePost Connect or a suitable secure file transfer site of the manufacturer’s choosing.Step 2.

Health Canada assessment of company representationsWithin 30 days of receiving the proposal package, Health Canada will complete and return our assessment of the proposed CBI redactions and anonymization methodology cheap kamagra supplier. Proposed redactions that meet the definition of confidential business information will be protected. We will review the anonymization methodology to ensure all personal information is protected while maximizing the disclosure of useful clinical information.

Step 3 cheap kamagra supplier. Revision of proposed CBI redactions and anonymizationIf proposed CBI redactions are rejected or revision is required to the anonymization methodology, in accordance with the Public Release of Clinical Information. Guidance document, the manufacturer will be given 15 days to make the revisions and resubmit.

We will send our final assessment to the cheap kamagra supplier manufacturer within 5 days of receiving the revised package. Step 4. Finalization and publicationWithin 5 days of receiving our final assessment, the manufacturer must format and submit the final redacted and anonymization clinical documents within 5 days of receiving our final assessment.

The final documents must comply with the Guidance Document cheap kamagra supplier. Preparation of Regulatory Activities using the Electronic Common Technical Document (eCTD) Format. These documents are to be submitted using the Common Electronic Submission Gateway.

We will publish the final redacted documents within 5 days of receiving the final sequence.Publication of safety and effectiveness information used to support medical device interim order applicationsThe publication cheap kamagra supplier of information within an interim order application will proceed through the abbreviated process described below. Our goal is to publish a final redacted and anonymized package on our clinical information portal within 120 calendar days from initiation of the process.Step 1. Health Canada screening of requestsAfter we receive a request for information, we will retrieve the interim order application from docubridge (or other location).

Information related to safety cheap kamagra supplier and effectiveness will be considered in-scope of publication. Other information will not be released publicly. Only information available at the time the request is made will be considered for disclosure.

Information submitted after the original request for disclosure will be considered for public release upon receipt of a subsequent request.Examples of in cheap kamagra supplier scope information include. Clinical testing information validation testing that supports the effectiveness of the product, including testing performed in vitro or in silico summaries or overviews on safety or efficacy pre- or post-market, including literature reviewsExamples of out of scope information include. Manufacturing details not related to safety or efficacy engineering and design details general documents, such as user manuals, package inserts and instructions for use individual patient information, such as patient listings and case report forms, that require extensive anonymization interim clinical study data (see the PRCI guidance)Step 2a.

Health Canada assessment of confidential business information To reduce administrative burden on the manufacturer, we will review in-scope records for confidential business information, as defined in Section 2 of the Food and Drugs Act, which mirrors common law in the context of confidential cheap kamagra supplier business information that meets each of the following 3 elements of the definition will be protected. That is not publicly available in respect of which the person has taken measures that are reasonable in the circumstances to ensure that it remains not publicly available and that has actual or potential economic value to the person or their competitors because it is not publicly available and its disclosure would result in a material financial loss to the person or a material financial gain to their competitorsText in an in-scope document found to meet this definition will be redacted using a PDF redaction tool. Similar to Public Release of Clinical Information policies, any information that meets the definition of “clinical information” will not be considered confidential business information.

Exceptions to the PRCI regulations are outlined section 43.12(2)(a) and (b) of the cheap kamagra supplier Medical Device Regulations. These exceptions will be considered when applying redactions to confidential business information. Further information on the application of these exceptions can be found in the PRCI guidance document.Step 2b.

Assessing personal informationIn general, in-scope records do not contain a large volume cheap kamagra supplier of personal identification information. Any personal information, as defined in the Privacy Act and in accordance with PRCI guidance, information that could help to identify an individual will be protected. For example, this can include the names of authors and investigators as well as subject identification numbers.A large volume of indirectly identifying information is not expected in the medical device records that are in-scope of publication.

Consequently, limited protection of personal information is anticipated.Personal information will be redacted cheap kamagra supplier using a PDF redaction tool. Step 3. Notice to the company and request for redaction proposalFollowing the review and redaction of in scope documents, we will send the manufacturer a written notice indicating our intent to publish the identified documents.

A copy of the release package will be sent for the manufacturer’s review cheap kamagra supplier. Any further proposed redactions by the manufacturer must be received within 14 calendar days.Manufacturer are asked to use the Proposed Redaction Control Sheet (see Appendix E of the PRCI guidance document) to suggest further redactions.Step 4. Health Canada assessment of company representationsAny further redactions proposed by the manufacturer will be assessed in accordance with the process outlined in step 2, above.

Those that meet the definition of personal or confidential business information will be accepted.Step cheap kamagra supplier 5. PublicationIn-scope documents will be published within 120 days following receipt of the request. The redacted information will be uploaded to the Clinical Information Portal, indexed by application number.

Published documents will carry a watermark and be subject to terms of use, as described in the PRCI guidance.Mailing addressInformation Science and Openness DivisionResource Management and Operations DirectorateHealth Products and Food BranchHealth Canada Graham Spry Building 250 Lanark Ave Ottawa cheap kamagra supplier ON K1A 0K9 Telephone. 613-960-4687Email. Hc.clinicaldata-donneescliniques.sc@canada.ca Terminology and definitions Anonymization.

Means the cheap kamagra supplier process through which personal information is modified by. removing direct identifiers and any related code that would enable linkage with identifying information and ensuring that the remaining indirect identifiers no longer present a serious possibility of re-identifying an individual CBI. Confidential business information, as meant in common law and as defined in Section 2 of the Food and Drugs Act.

in respect of a person to whose business or affairs the information relates, means (subject to cheap kamagra supplier the regulations) business information that. Is not publicly available in respect of which the person has taken measures that are reasonable in the circumstances to ensure that it remains not publicly available has actual or potential economic value to the person or their competitors because it is not publicly available and its disclosure would result in a material financial loss to the person or a material financial gain to their competitors Clinical information. Means information in respect of a clinical trial, clinical studies or investigational testing, such as.

clinical overviews, clinical summaries and clinical study reports for drugs summaries and detailed information of all clinical studies and investigational testing that provided evidence of safety and effectiveness for cheap kamagra supplier medical devices Clinical study report. Means an "integrated" full report of an individual study of any therapeutic, prophylactic or diagnostic agent (drug or treatment) conducted in patients, in which. the clinical and statistical description, presentations and analyses are integrated into a single report incorporating tables and figures into the main text of the report or at the end of the text appendices contain the protocol, sample case report forms, investigator-related information, information related to the test drugs/investigational products, including active control/comparators, technical statistical documentation, related publications, patient data listings and technical statistical details such as derivations, computations, analyses and computer output FDA.

Food and cheap kamagra supplier Drugs Act FDR. Food and Drug Regulations IMDRF ToC. International Medical Device Regulators Forum Table of Contents Medical device.

Has the same meaning as insee the Medical cheap kamagra supplier Devices Regulations. For information on the classification of medical devices, please see the guidance documents on the. risk-based classification system for in vitro diagnostic devices (IVDDs) risk-based classification system for non-in vitro diagnostic devices (non-IVDDs) Non-commercial purpose.

Means the information will not be used to support a marketing authorization application anywhere in the world or sold or traded to another person Personal information.

Kamagra for her

Two letters in the journal focus on the volume of intravenous fluid to be used during resuscitation and early management of paediatric patients pop over to this web-site presenting with diabetic ketoacidosis (DKA).1 2 The correspondence encapsulates an important debate about kamagra for her intravenous fluids and risk of morbidities, such as cerebral oedema, and provides us with the range in contemporary opinions in the UK.Lillie et al1 use their insights from the South Thames Retrieval service (STRS) and its 20 referring district general hospitals to highlight a concern about the new British Society for Paediatric Endocrinology and Diabetes (BSPED) guideline3 and integrated care pathway4 for the management of DKA. The authors have a network of emergency practice, and they imply that the new emphasis by the BSPED on permissive rather than restrictive (ie, reduced volume rules) intravenous fluids will be disruptive to the measures that they have taken since dealing with three cerebral oedema deaths in their region. Wright and Thomas2 have responded on behalf of the BSPED DKA kamagra for her interest group. They emphasise the importance of adequate intravenous fluid resuscitation in limiting morbidity.

They also provide an instructive table2 showing fluid resuscitation and rehydration volumes used in a number of protocols, including that of STRS and kamagra for her the new BSPED approach. The main differences come down to the estimate of fluid deficit, the use of an intravenous fluid bolus at presentation and the calculation of maintenance fluid requirements.The STRS approach assumes a 10% fluid deficit in all patients with DKA at presentation, versus the new BSPED guideline’s use of three levels in estimated fluid deficit based on severity of acidosis (ie, pH >7.2, 5%. PH 7.1 to 7.2, kamagra for her 7%. And pH <7.1, 10%).

In the STRS approach, an intravenous fluid bolus of 10 mL/kg normal saline (NS) is kamagra for her reserved for patients in shock. In contrast, the new BSPED guideline recommends that all patients with DKA receive an intravenous bolus of 10 mL/kg NS, with an extra 10 mL/kg NS (20 mL/kg in total) for those in shock. Last, in the STRS protocol, the 10% fluid deficit is repaired over 48 hours by adding the volume to restrictive or so-called reduced volume rules for maintenance intravenous requirements kamagra for her and for body weight (ie, up to 10 kg, 2 mL/kg/hour. 10–14 kg, 1 mL/kg/hour and >40 kg, fixed volume 40 mL/hr).

The new BSPED guideline also recommends replacing the presumed fluid deficit over kamagra for her 48 hours, but this hourly volume is added to standard (and higher than reduced volume rules) maintenance intravenous fluids.4 5Now, add to this mixture of opinions, the UK National Institute for Health and Care Excellence (NICE) latest updated pathway for DKA in children and young people.6 Like the new BSPED guideline, NICE also estimates fluid deficit based on severity of acidosis. However, severity of fluid deficit is dichotomised to 5% or 10% based on whether pH is above or below 7.1, respectively. Like the STRS approach, there is no routine use of an intravenous NS fluid bolus in severe kamagra for her DKA. Last, like the STRS approach the estimated fluid deficit is repaired over 48 hours by adding the hourly volume to maintenance requirement calculated using reduced volume rules.How can there be such variance in opinion and recommendations and what should we do?.

To be fair, the new BSPED guideline3 was only ever ‘… an interim recommendation pending the publication of the future NICE review.’ But, more importantly, the BSPED website acknowledges that the onus kamagra for her for decision-making remains with the clinician. A similar stance on responsibility of guideline users is also taken by NICE.The new information that seems to have influenced the BSPED and the NICE updates on DKA is the Pediatric Emergency Care Applied Research Network (PECARN) clinical trial of fluid infusion rates for paediatric DKA (FLUID trial).7 It is worth re-reading the paper and its protocol and supplementary appendix, in particular have a look at Figure S1 on compliance to assigned fluid rate. The bottom line of the FLUID trial is kamagra for her that neither the rate of administration (fast vs slow repair) nor the sodium chloride content (NS vs 0.45% saline) of intravenous fluids significantly influenced neurological outcomes. Wright and Thomas2 show in their table that the difference between fast and slow repair in the trial was complex and not only included a difference in timing of fluid-deficit repair (ie, fast with 50% repair in first 12 hours followed by 50% repair in next 24 hours vs slow repair evenly distributed over 48 hours).

It also kamagra for her involved differences in presumed fluid deficit (10% vs 5%) and use of intravenous NS boluses (20 mL/kg vs 10 mL/kg). Close review of the compliance to assigned fluid rate in the FLUID trial (see Supplemental Figure S17) shows that actual fluid received by patients in the fast and slow repair groups are similar to those suggested by the BSPED and STRS/NICE, respectively. If there kamagra for her is no difference in neurological outcome, does the difference in fluid strategy really matter, as each of our correspondents argue?. To attempt to answer this question we have to look at two key details of the FLUID trial.

The first is that of the 1389 patients kamagra for her undergoing randomisation, 1263 (91%) had Glasgow Coma Scale (GCS) score 15, 99 (7%) had GCS score 14 and 28 (2%) had GCS score <14. In essence, the test of fast versus slow fluid strategy is strongly influenced by patients with DKA who are fully awake at presentation. Both of our correspondents1 2 acknowledge that patients with altered mental state raise concern, although their approaches kamagra for her differ—on this matter we have no answer from the FLUID trial. The other detail to consider is that the uniformly used standard insulin infusion rate (0.1 U/kg/hour) differs from the dosing range (0.05 to 0.1 U/kg/hour) used in UK practice.3 4 6 One theoretical aim of low-dose insulin (0.05 U/kg/hour)8 9 is to avoid too rapid decrease in serum glucose concentration (ie, >5.5 mmol/L/hour), with consequent too rapid change in serum osmolarity, which may increase the risk of cerebral oedema.10 11 Does this idea mean that the low-dose insulin strategy enables better tolerance of fast-fluid repair rate, with low risk of morbidity?.

Impossible to answer kamagra for her. As we see from the FLUID trial, such a proposition—with an outcome of brain injury in less than 1% of DKA episodes—is likely untestable in a future sufficiently powered clinical trial.Taking all the above together, there is clearly a need to realign the variance in DKA fluid management reflected in the STRS,1 BSPED2–4 and NICE6 approaches. Even though we have gold standard clinical information from the PECARN DKA FLUID trial,7 the relevance of that information to all paediatric patients presenting with DKA needs careful consideration. Which means that clinicians still need to exercise judgement in individual situations.

Finally, the letter by Lillie et al1 also reminds us of the value of systems of care. Their hub-and-spoke network for emergency DKA care is not just about adopting latest recommendations but is also tasked with bringing about any necessary knowledge-to-action change (see the table and figure 2 as responses to three cerebral oedema DKA deaths),1 a process called implementation science.12.

Two letters in the journal focus on the volume of intravenous fluid to be used during resuscitation and early management of paediatric patients presenting with diabetic ketoacidosis (DKA).1 2 The correspondence encapsulates an important debate about intravenous fluids and risk of morbidities, such as cerebral oedema, and provides us with Where can i buy viagra over the counter the range in contemporary opinions in the UK.Lillie et al1 use their insights from the South Thames Retrieval service (STRS) and its 20 referring district general hospitals to highlight a concern about the new British Society for Paediatric Endocrinology and Diabetes (BSPED) guideline3 and integrated care pathway4 for the management of DKA cheap kamagra supplier. The authors have a network of emergency practice, and they imply that the new emphasis by the BSPED on permissive rather than restrictive (ie, reduced volume rules) intravenous fluids will be disruptive to the measures that they have taken since dealing with three cerebral oedema deaths in their region. Wright and Thomas2 have responded on behalf of cheap kamagra supplier the BSPED DKA interest group. They emphasise the importance of adequate intravenous fluid resuscitation in limiting morbidity. They also provide an instructive table2 showing fluid resuscitation and cheap kamagra supplier rehydration volumes used in a number of protocols, including that of STRS and the new BSPED approach.

The main differences come down to the estimate of fluid deficit, the use of an intravenous fluid bolus at presentation and the calculation of maintenance fluid requirements.The STRS approach assumes a 10% fluid deficit in all patients with DKA at presentation, versus the new BSPED guideline’s use of three levels in estimated fluid deficit based on severity of acidosis (ie, pH >7.2, 5%. PH 7.1 to 7.2, cheap kamagra supplier 7%. And pH <7.1, 10%). In the STRS approach, an cheap kamagra supplier intravenous fluid bolus of 10 mL/kg normal saline (NS) is reserved for patients in shock. In contrast, the new BSPED guideline recommends that all patients with DKA receive an intravenous bolus of 10 mL/kg NS, with an extra 10 mL/kg NS (20 mL/kg in total) for those in shock.

Last, in the STRS protocol, the 10% fluid deficit is repaired over 48 hours by adding the volume to restrictive or so-called reduced volume rules for maintenance cheap kamagra supplier intravenous requirements and for body weight (ie, up to 10 kg, 2 mL/kg/hour. 10–14 kg, 1 mL/kg/hour and >40 kg, fixed volume 40 mL/hr). The new BSPED guideline also recommends replacing the presumed fluid deficit over 48 hours, but this hourly cheap kamagra supplier volume is added to standard (and higher than reduced volume rules) maintenance intravenous fluids.4 5Now, add to this mixture of opinions, the UK National Institute for Health and Care Excellence (NICE) latest updated pathway for DKA in children and young people.6 Like the new BSPED guideline, NICE also estimates fluid deficit based on severity of acidosis. However, severity of fluid deficit is dichotomised to 5% or 10% based on whether pH is above or below 7.1, respectively. Like the STRS approach, there is no routine cheap kamagra supplier use of an intravenous NS fluid bolus in severe DKA.

Last, like the STRS approach the estimated fluid deficit is repaired over 48 hours by adding the hourly volume to maintenance requirement calculated using reduced volume rules.How can there be such variance in opinion and recommendations and what should we do?. To be fair, the new BSPED guideline3 was only ever ‘… an interim recommendation pending the publication of the future NICE review.’ But, more importantly, the BSPED website acknowledges cheap kamagra supplier that the onus for decision-making remains with the clinician. A similar stance on responsibility of guideline users is also taken by NICE.The new information that seems to have influenced the BSPED and the NICE updates on DKA is the Pediatric Emergency Care Applied Research Network (PECARN) clinical trial of fluid infusion rates for paediatric DKA (FLUID trial).7 It is worth re-reading the paper and its protocol and supplementary appendix, in particular have a look at Figure S1 on compliance to assigned fluid rate. The bottom line of the FLUID trial cheap kamagra supplier is that neither the rate of administration (fast vs slow repair) nor the sodium chloride content (NS vs 0.45% saline) of intravenous fluids significantly influenced neurological outcomes. Wright and Thomas2 show in their table that the difference between fast and slow repair in the trial was complex and not only included a difference in timing of fluid-deficit repair (ie, fast with 50% repair in first 12 hours followed by 50% repair in next 24 hours vs slow repair evenly distributed over 48 hours).

It also involved differences in presumed fluid deficit (10% vs 5%) and use of intravenous NS boluses (20 mL/kg vs 10 mL/kg) cheap kamagra supplier. Close review of the compliance to assigned fluid rate in the FLUID trial (see Supplemental Figure S17) shows that actual fluid received by patients in the fast and slow repair groups are similar to those suggested by the BSPED and STRS/NICE, respectively. If there is no difference in neurological outcome, does the difference cheap kamagra supplier in fluid strategy really matter, as each of our correspondents argue?. To attempt to answer this question we have to look at two key details of the FLUID trial. The first cheap kamagra supplier is that of the 1389 patients undergoing randomisation, 1263 (91%) had Glasgow Coma Scale (GCS) score 15, 99 (7%) had GCS score 14 and 28 (2%) had GCS score <14.

In essence, the test of fast versus slow fluid strategy is strongly influenced by patients with DKA who are fully awake at presentation. Both of cheap kamagra supplier our correspondents1 2 acknowledge that patients with altered mental state raise concern, although their approaches differ—on this matter we have no answer from the FLUID trial. The other detail to consider is that the uniformly used standard insulin infusion rate (0.1 U/kg/hour) differs from the dosing range (0.05 to 0.1 U/kg/hour) used in UK practice.3 4 6 One theoretical aim of low-dose insulin (0.05 U/kg/hour)8 9 is to avoid too rapid decrease in serum glucose concentration (ie, >5.5 mmol/L/hour), with consequent too rapid change in serum osmolarity, which may increase the risk of cerebral oedema.10 11 Does this idea mean that the low-dose insulin strategy enables better tolerance of fast-fluid repair rate, with low risk of morbidity?. Impossible to cheap kamagra supplier answer. As we see from the FLUID trial, such a proposition—with an outcome of brain injury in less than 1% of DKA episodes—is likely untestable in a future sufficiently powered clinical trial.Taking all the above together, there is clearly a need to realign the variance in DKA fluid management reflected in the STRS,1 BSPED2–4 and NICE6 approaches.

Even though we have gold standard clinical information from the PECARN cheap kamagra supplier DKA FLUID trial,7 the relevance of that information to all paediatric patients presenting with DKA needs careful consideration. Which means that clinicians still need to exercise judgement in individual situations. Finally, the letter by Lillie et al1 also reminds us cheap kamagra supplier of the value of systems of care. Their hub-and-spoke network for emergency DKA care is not just about adopting latest recommendations but is also tasked with bringing about any necessary knowledge-to-action change (see the table and figure 2 as responses to three cerebral oedema DKA deaths),1 a process called implementation science.12.

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