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Yes. 71%No. 29%Would your vote change if this is the only pediatrics practice in the community?.

Yes. 25%No. 75%And now, bioethicist Jacob M.

Appel, MD, JD, weighs in:As a general principle, physicians outside the emergency and hospital settings are free to choose their patients with very few restrictions. They are also allowed to "fire" current patients as long as they afford them an adequate opportunity to establish care elsewhere. However, having the legal right to do so does not necessarily make all such decisions ethical.

In this scenario, it might prove helpful to understand why the pediatrician has adopted such a policy.One explanation might be concern that unvaccinated children will expose other pediatric patients to measles -- such as in a waiting room setting. Some of the pediatrician's patients may not yet be candidates for the measles treatment due to immature age or medical comorbidities. Others may have been vaccinated but the treatment did not "take" and they failed to generate the immunity necessary to ward off the ventolin.

If enough children are vaccinated, even those in whom the treatment does not work will be protected, because the odds of them coming into contact with infected people remain low.The pediatrician may believe he or she has a duty to protect his most vulnerable patients from those whose parents choose not to accept a safe and effective public health measure. If he or she were to continue treating unvaccinated patients, he or she might even have an ethical duty to place signs in his waiting room warning other patients of this exposure risk. While he or she could certainly configure his office and schedule to ensure the children of "anti-vax" parents did not come into contact with others, rather than refusing to see them, few ethicists would argue that he or she has an obligation to do so.

However, those that favor such accommodation of "anti-vaxxers" might argue that children should not be penalized for the poor choices of their parents.Another explanation might be that the pediatrician wishes to pressure parents into accepting vaccination. Before doing so, he or she would be wise to inquire why parents are rejecting these treatments. Overwhelming evidence supports pediatric vaccination.

Many of the scourges of past generations such as polio and diphtheria have nearly been eliminated, saving thousands of lives, and claims that the measles-mumps-rubella (MMR) treatment is connected to autism have been widely debunked as fraudulent. But well-meaning parents may be misinformed, especially when celebrities and even the current president question the medically recommended treatment schedule.A pediatrician -- especially the only one in a community -- might have an ethical duty to attempt to educate these parents before refusing care to their children. At the same time, treatments often do carry some rare risks to an individual child.

This creates a "collective action problem" or "dilemma of the commons" in which self-interested parents, not acting in good faith, may try to freeload off the herd immunity generated by other families who have accepted such minor risks for the common good. Such behavior is deeply problematic. However, individual physicians are not ideally situated to play a coercive role in the implementation of public health measures.What is most puzzling is why parents are allowed to refuse vaccination for their children at all when they are not allowed to reject other life-saving, health-preserving, or protective measures.

While courts generally override parents who reject essential blood transfusions or chemotherapy for their offspring, opponents of compulsory vaccination often note that the acute risk of not vaccinating is lower than these interventions. A more fitting comparison might be to require that young children ride in car seats, wear bicycle helmets, etc. The most likely explanation for different approaches to similar risks is that no political will exists to force vaccination upon the large and increasing number of resistant parents.

Unfortunately, while not using a car seat only puts one's own child at risk, refusing vaccination places the lives of other people's children in jeopardy.Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.

Appel is the author of the recent book, Who Says You're Dead?. Medical &. Ethical Dilemmas for the Curious &.

Concerned.And check out some of our past Ethics Consult cases:Should Christian Clinic Provide IVF to Lesbian Couple?. Is a asthma treatment Human Challenge Trial Ethical?.

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Key PointsOn January 23, 2017, President Donald Trump reinstated and expanded the Mexico City Policy via presidential memorandum, Where to buy ventolin renaming it “Protecting Life in Global Health Assistance.” This explainer provides an overview of the policy, including its history, changes over time, and current application.First announced in 1984 by the Reagan administration, the policy has ventolin how long does it take to work been rescinded and reinstated by subsequent administrations along party lines and has now been in effect for 19 of the past 34 years.The policy requires foreign non-governmental organizations (NGOs) to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. Funds) as a condition of receiving U.S. Government global family planning assistance and, as of Jan ventolin how long does it take to work. 23, 2017, most other U.S. Global health ventolin how long does it take to work assistance.The Trump administration’s application of the policy extends to the vast majority of U.S.

Bilateral global health assistance, including funding for HIV under PEPFAR, maternal and child health, malaria, nutrition, and other programs. This marks a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounts for approximately $600 million of that total).Additionally, as a result of a March 2019 policy announcement and subsequent information released in June 2019, the policy, for the first time, prohibits foreign NGOs who accept the policy from providing any financial support using any source of funds and for any purpose to other foreign NGOs ventolin how long does it take to work that perform or actively promote abortion as a method of family planning. This greatly extends its reach to other areas of U.S. Development assistance beyond global ventolin how long does it take to work health and to other non-U.S. Funding streams.More recently, in September 2020, a proposed rule to extend the policy to contracts was published.

If finalized, it would greatly extend the reach of the policy ventolin how long does it take to work beyond grants and cooperative agreements to also include contracts.KFF analyses have found that:more than half of the countries in which the U.S. Provides bilateral global health assistance allow for legal abortion in at least one case not permitted by the policy (analysis). Andhad the expanded policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject ventolin how long does it take to work to the policy (analysis).What is the Mexico City Policy?. The Mexico City Policy is a U.S. Government policy that – when in effect – has required foreign NGOs to certify that ventolin how long does it take to work they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S.

Funds) as a condition of receiving U.S. Global family planning assistance and, as of ventolin how long does it take to work Jan. 23, 2017, most other U.S. Global health assistance.The policy was first announced by the ventolin how long does it take to work Reagan administration at the 2nd International Conference on Population, which was held in Mexico City, Mexico, on August 6-14, 1984 (hence its name. See Box 1).

Under the Trump ventolin how long does it take to work administration, the policy has been renamed “Protecting Life in Global Health Assistance” (PLGHA). Among opponents, it is also known as the “Global Gag Rule,” because among other activities, it prohibits foreign NGOs from using any funds (including non-U.S. Funds) to provide information about abortion as a method of family planning and to lobby a foreign ventolin how long does it take to work government to legalize abortion. €œ[T]he United States does not consider abortion an acceptable element of family planning programs and will no longer contribute to those of which it is a part. €¦[T]he United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations.”When ventolin how long does it take to work first instituted in 1984, the Mexico City Policy marked an expansion of existing legislative restrictions that already prohibited U.S.

Funding for abortion internationally, with some exceptions (see below). Prior to the policy, ventolin how long does it take to work foreign NGOs could use non-U.S. Funds to engage in certain voluntary abortion-related activities as long as they maintained segregated accounts for any U.S. Money received, ventolin how long does it take to work but after the Mexico City Policy was in place, they were no longer permitted to do so if they wanted to receive U.S. Family planning assistance.The Trump administration’s application of the policy to the vast majority of U.S.

Bilateral global health assistance, including funding for HIV under the ventolin how long does it take to work U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), maternal and child health, malaria, nutrition, and other programs, marks a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total). The Administration’s more recent extension of the policy to include any financial support (health or otherwise) provided by foreign NGOs for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning is likely to encompass significant additional funding.When has ventolin how long does it take to work it been in effect?. The Mexico City Policy has been in effect for 19 of the past 34 years, primarily through executive action, and has been instated, rescinded, and reinstated by presidential administrations along party lines (see Table 1).The policy was first instituted in 1984 (taking effect in 1985) by President Ronald Reagan and continued to be in effect through President George H.W. Bush’s administration ventolin how long does it take to work.

It was rescinded by President Bill Clinton in 1993 (although it was reinstated legislatively for one year during his second term. See below) ventolin how long does it take to work. The policy was reinstated by President George W. Bush in 2001 and ventolin how long does it take to work then rescinded by President Barack Obama in 2009. It is currently in effect, having been reinstated by President Trump in 2017.

YearsIn Effect? ventolin how long does it take to work. Presidential Administration (Party Affiliation)Executive (E) or Congressional (C) Action?. 1985-1989YesReagan (R)E1989-1993YesBush (R)E1993-1999 Sept.NoClinton ventolin how long does it take to work (D)E1999 Oct.-2000 Sept.Yes*Clinton (D)C2000 Oct.-2001NoClinton (D)E2001-2009YesBush (R)E2009-2017NoObama (D)E2017-presentYesTrump (R)ENOTES. Shaded blue indicate periods when policy was in effect. * There was a temporary, one-year legislative imposition of the policy, which included a portion of the restrictions in effect in other years and an option for the president to waive these restrictions in part.

However, if the waiver option was exercised (for no more than $15 million in family planning assistance), then $12.5 million of this funding would be ventolin how long does it take to work transferred to maternal and child health assistance. The president did exercise the waiver option.SOURCES. €œPolicy Statement of the United States of ventolin how long does it take to work America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. Bill Clinton Administration, “Subject. AID Family Planning Grants/Mexico City Policy,” Memorandum ventolin how long does it take to work for the Acting Administrator of the Agency for International Development, January 22, 1993, Clinton White House Archives, https://clintonwhitehouse6.archives.gov/1993/01/1993-01-22-aid-family-planning-grants-mexico-city-policy.html.

FY 2000 Consolidated Appropriations Act, P.L. 106-113. George W. Bush Administration, “Subject. Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, January 22, 2001, Bush Administration White House Archives, https://georgewbush-whitehouse.archives.gov/news/releases/20010123-5.html.

€œSubject. Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, March 28, 2001, Federal Register, https://www.federalregister.gov/documents/2001/03/29/01-8011/restoration-of-the-mexico-city-policy. George W. Bush Administration, “Subject. Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html.

Barack Obama Administration, “Mexico City Policy and Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, the Administrator of the United States Agency for International Development, January 23, 2009, Obama White House Archives, https://obamawhitehouse.archives.gov/the-press-office/mexico-city-policy-and-assistance-voluntary-population-planning. White House, “The Mexico City Policy,” Memorandum for the Secretary of State, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 23, 2017, https://www.whitehouse.gov/the-press-office/2017/01/23/presidential-memorandum-regarding-mexico-city-policy.How is it instituted (and rescinded)?. The Mexico City Policy has, for the most part, been instituted or rescinded through executive branch action (typically via presidential memoranda). While Congress has the ability to institute the policy through legislation, this has happened only once in the past.

A modified version of the policy was briefly applied by Congress during President Clinton’s last year in office as part of a broader arrangement to pay the U.S. Debt to the United Nations. (At that time, President Clinton was able to partially waive the policy’s restrictions.) Other attempts to institute the policy through legislation have not been enacted into law, nor have legislative attempts to overturn the policy. See Table 1.Who does the policy apply to?. The policy, when in effect, applies to foreign NGOs as a condition for receiving U.S.

Family planning support and, now, other global health assistance, either directly (as the main – or prime – recipient of U.S. Funding) or indirectly (as a recipient of U.S. Funding through an agreement with the prime recipient. Referred to as a sub-recipient). Specifically, a foreign NGO “recipient agrees that it will not, during the term of this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to any other foreign non-governmental organization that conducts such activities.”Foreign NGOs include:international NGOs that are based outside the U.S.,regional NGOs that are based outside the U.S., andlocal NGOs in assisted countries.U.S.

NGOs, while not directly subject to the Mexico City Policy, must also agree to ensure that they do not provide funding to any foreign NGO sub-recipients unless those sub-recipients have first certified adherence to the policy. Specifically, a U.S. NGO “recipient (A) agrees that it will not furnish health assistance under this award to any foreign non-governmental organization that performs or actively promotes abortion as a method of family planning in foreign countries. And (B) further agrees to require that such sub-recipients do not provide financial support to any other foreign non-governmental organization that conducts such activities.”As in the past, the current policy does not apply to funding provided by the U.S. Government to foreign governments (national or sub-national), public international organizations, and other multilateral entities, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the treatment Alliance.

However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy. See “What is ‘financial support’?. € below.To what assistance does it apply?. In the past, foreign NGOs have been required to adhere to the Mexico City Policy – when it was in effect – as a condition of receiving support through certain U.S. International funding streams.

Family planning assistance through the U.S. Agency for International Development (USAID) and, beginning in 2003, family planning assistance through the U.S. Department of State. In the 2003 memorandum announcing the policy’s expansion to include the Department of State, President Bush stated that the policy did not apply to funding for global HIV/AIDS programs and that multilateral organizations that are associations of governments are not included among “foreign NGOs.”The current policy, reinstated in 2017, applies to the vast majority of U.S. Bilateral global health assistance furnished by all agencies and departments.

“Assistance” includes “the provision of funds, commodities, equipment, or other in-kind global health assistance.” Specifically, the expanded policy applies to nearly all bilateral global health assistance, including. family planning and reproductive healthfor the first time:maternal and child health (including household-level water, sanitation, and hygiene (WASH))nutritionHIV under PEPFARtuberculosismalaria under the President’s Malaria Initiative (PMI)neglected tropical diseasesglobal health securitycertain types of research activitiesThe policy applies to the assistance described above that is appropriated directly to three agencies and departments. USAID. The Department of State, including the Office of the Global AIDS Coordinator, which oversees and coordinates U.S. Global HIV funding under PEPFAR.

And for the first time, the Department of Defense (DoD). When such funding is transferred to another agency, including the Centers for Disease Control (CDC) and the National Institutes of Health (NIH), it remains subject to the policy, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly.The policy applies to three types of funding agreements for such assistance. Grants. Cooperative agreements. And, for the first time, contracts, pending necessary rule-making that would be needed to do so (a proposed rule to accomplish this was published in September 2020).The policy does not apply to U.S.

Assistance for. Water supply and sanitation activities, which is usually focused on infrastructure and systems. Humanitarian assistance, including activities related to migration and refugee assistance activities as well as disaster and humanitarian relief activities. The American Schools and Hospitals Abroad (ASHA) program. And Food for Peace (FFP).

However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy. See “What is ‘financial support’?. € below.What activities are prohibited?. The policy prohibits foreign NGOs that receive U.S. Family planning assistance and, now, most other U.S.

Bilateral global health assistance from using funds from any source (including non-U.S. Funds) to “perform or actively promote abortion as a method of family planning.” In addition to providing abortions with non-U.S. Funds, restricted activities also include the following:providing advice and information about and offering referral for abortion – where legal – as part of the full range of family planning options,promoting changes in a country’s laws or policies related to abortion as a method of family planning (i.e., engaging in lobbying), andconducting public information campaigns about abortion as a method of family planning.The prohibition of these activities are why the policy has been referred to by its critics as the “Global Gag Rule.”Additionally, for the first time, the policy prohibits foreign NGOs from providing any financial support with any source of funds (including non-U.S. Funding) and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning. See “What is “financial support?.

€ below.The policy, however, does not prohibit foreign NGOs from:providing advice and information about, performing, or offering referral for abortion in cases where the pregnancy has either posed a risk to the life of the mother or resulted from incest or rape. Andresponding to a question about where a safe, legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have a legal abortion (passively providing information, versus actively providing medically-appropriate information).In addition, the expanded policy does not apply to healthcare providers who have an affirmative duty required under local law to provide counseling about and referrals for abortion as a method of family planning.Does it restrict direct U.S. Funding for abortion overseas?. U.S. Funding for abortion is already restricted under several provisions of the law.

Specifically, before the Mexico City Policy was first announced in 1984, U.S. Law already prohibited the use of U.S. Aid:to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion (the Helms Amendment, 1973, to the Foreign Assistance Act);for biomedical research related to methods of or the performance of abortion as a means of family planning (the Biden Amendment, 1981, to the Foreign Assistance Act). Andto lobby for or against abortion (the Siljander Amendment, first included in annual appropriations in 1981 and included each year thereafter).Then, shortly after the policy was announced in 1984, the Kemp-Kasten Amendment was passed in 1985, prohibiting the use of U.S. Aid to fund any organization or program, as determined by the president, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it is now included in annual appropriations).Before the Mexico City Policy, U.S.

Aid recipients could use non-U.S. Funds to engage in certain abortion-related activities but were required to maintain segregated accounts for U.S. Assistance. The Mexico City Policy reversed this practice. No longer were foreign NGOs allowed to use non-U.S.

Funds, maintained in segregated accounts, for voluntary abortion-related activities if they wished to continue to receive or be able to receive U.S. Family planning funds.Does the policy prohibit post-abortion care?. The Mexico City Policy does not restrict the provision of post-abortion care, which is a supported activity of U.S. Family planning assistance. Whether or not the Mexico City Policy is in effect, recipients of U.S.

Family planning assistance are allowed to use U.S. And non-U.S. Funding to support post-abortion care, no matter the circumstances of the abortion (whether it was legal or illegal).What has been the impact of the policy?. Several studies have looked at the impact of the policy. A 2011 quantitative analysis by Bendavid, et.

Al, found a strong association between the Mexico City Policy and abortion rates in sub-Saharan Africa. This study was recently updated to include several more years of data, again identifying a strong association. Specifically, the updated study found that during periods when the policy was in place, abortion rates rose by 40% in countries with high exposure to the Mexico City Policy compared to those with low exposure, while the use of modern contraceptives declined by 14% and pregnancies increased by 12% in high exposure compared to low exposure countries. In other words, it found patterns that “strengthen the case for the role played by the policy” in “a substantial increase in abortions across sub-Saharan Africa among women affected by the U.S. Mexico City Policy … [and] a corresponding decline in the use of modern contraception and increase in pregnancies,” likely because foreign NGOs that declined U.S.

Funding as a result of the Mexico City Policy – often key providers of women’s health services in these areas – had fewer resources to support family planning services, particularly contraceptives. Increased access to and use of contraception have been shown to be key to preventing unintended pregnancies and thereby reducing abortion, including unsafe abortion. The study also found patterns that “suggest that the effects of the policy are reversible” when the policy is not in place.Additionally, there has been anecdotal evidence and qualitative data on the impact of the policy, when it has been in force in the past, on the work of organizations that have chosen not to agree to the policy and, therefore, forgo U.S. Funding that had previously supported their activities. For example, they have reported that they have fewer resources to support family planning and reproductive health services, including family planning counseling, contraceptive commodities, condoms, and reproductive cancer screenings.While it is likely too early to assess the full effects of the current policy on NGOs and the individuals they serve, as the policy is applied on a rolling basis as new funding agreements or modifications to existing agreements are made, some early data are available.

Several early qualitative and quantitative studies have been released, and at least one long-term, quantitative assessment is underway. Additionally, an official assessment by the U.S. Department of State on implementation during the first six months of the policy has been released (see below). This review acknowledged that it took “place early in the policy’s implementation, when affected U.S. Government departments and agencies have added a significant portion of the funding affected by the policy to grants and cooperative agreements only recently [i.e., after the period the review examined].

A follow-on analysis would allow an opportunity to address one of the primary concerns presented in feedback from third-party stakeholder organizations, namely that six months is insufficient time to gauge the impacts of” the policy.Nonetheless, it is already clear that the reinstated and expanded version of the policy applies to a much greater amount of U.S. Global health assistance, and greater number of foreign NGOs, across many program areas. KFF has found that more than half (37) of the 64 countries that received U.S. Bilateral global health assistance in FY 2016 allow for legal abortion in at least one case not permitted by the policy and that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy. In addition, at least 469 U.S.

NGOs that received U.S. Global health assistance during this period would have been required to ensure that their foreign NGO sub-recipients were in compliance. Additional foreign NGOs are likely to be impacted by the policy due to the revised interpretation of “financial support” announced in March 2019 and implemented beginning June 2019. See “What is ‘financial support’?. € below.A report released in March 2020 by the U.S.

Government Accountability Office (GAO) provided new information on the number of projects (awards) and NGOs affected. It found that from May 2017 through FY 2018:the policy had been applied to over 1,300 global health projects, with the vast majority of these through USAID and CDC, andNGOs declined to accept the policy in 54 instances, totaling $153 million in declined funding – specifically, seven prime awards amounting to $102 million and 47 sub-awards amounting to $51 million (more than two-thirds of sub-awards were intended for Africa) – across USAID and CDC. The Department of State and DoD did not identify any instances where NGOs declined to accept the policy conditions.What have the U.S. Government’s reviews of the policy found?. The U.S.

Government has published two reviews of the policy to date, with the first examining the initial six months of the policy released in February 2018 and the second examining the first 18 months of the policy released in August 2020.First ReviewIn February 2018, the Department of State announced the findings of an initial six-month review of implementation of the policy through the end of FY 2017 (September 2017). The report directed agencies to provide greater support for improving understanding of implementation among affected organizations and provided guidance to clarify terms included in standard provisions of grants and cooperative agreements. In the six-month review report, the Department of State report identified a number of “actions” for implementing agencies, such as a need for:more central and field-based training and implementation tools,a clearer explanation of termination of awards for NGOs found to be in violation of the policy, anda clarification of “financial support,” which was not defined in the standard provisions (see “What is financial support?. € below).The six month review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2017 (see Table 2). U.S.

Agency or DepartmentPolicy Implementation DateOverall # of Grants and Cooperative Agreements with Global Health Assistance FundingOf Overall #:(From the Policy Implementation Date through 9/30/2017)# That Received New Funding and Accepted Policy# That Received New Funding and Declined to Accept Policy^# That Had Not Received New Funding YetUSAIDMay 15, 20175804193158State*May 15, 2017142108034HHS+May 31, 20174991600339DoDMay 15, 20177742134TOTAL12987294565NOTES. * reflects PEPFAR funding implemented through the Department of State. Other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2017, USAID reported it was aware of three centrally funded prime partners, and 12 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards.

DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries. And HHS reported that no HHS partners declined to agree.SOURCES. KFF analysis of data from Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Second ReviewOn August 17, 2020, the Department of State released its second review of the policy, updating its initial six-month review (as an action item in the six-month review report, the department stated it would “conduct a further review of implementation of the policy by December 15, 2018, when more extensive experience will enable a more thorough examination of the benefits and challenges”).

The long-anticipated review, which examines the period from May 2017 through September 2018, found:the awards declined spanned a variety of program areas, including family planning and reproductive health (FP/RH), HIV and AIDS (HIV/AIDS), maternal and child health (MCH), tuberculosis (TB), and nutrition, in addition to cross-cutting awards;the awards declined spanned geographic areas but many were for activities in sub-Saharan Africa;agencies and departments made efforts to transition projects to another implementer in order to minimize disruption. Butnevertheless, among USAID awards involving health service delivery where prime and sub-award recipients declined to accept the policy, gaps or disruptions in service delivery were sometimes reported.The second review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2018 (see Table 3). U.S. Agency or DepartmentPolicy Implementation Date# of Grants and Cooperative Agreements with Global Health Assistance Funding# of Prime Awardees That Declined to Accept Policy^USAIDMay 15, 20174866State*May 15, 20173350HHS+May 31, 20174661DoDMay 15, 2017531TOTAL13408NOTES. * reflects PEPFAR funding implemented through the Department of State.

Other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2018, USAID reported it was aware of six centrally funded prime partners, and 47 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards. DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries.

And HHS reported that one HHS partner declined to agree.SOURCES. KFF analysis of data from Department of State, “Review of the Implementation of the Protecting Life in Global Health Assistance Policy ,” report, Aug. 17, 2020, https://www.state.gov/wp-content/uploads/2020/08/PLGHA-2019-Review-Final-8.17.2020-508.pdf, and Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Additionally, the review reports that 47 sub-awardees, all under USAID awards, declined to accept the policy. It is important to note that the review also states that information on sub-awards is not systematically collected by departments and agencies and that DoD was not able to collect information on sub-awards.What is “financial support”?.

In February 2018, in the initial six-month review issued when Secretary of State Tillerson led the department, the Department of State report included an “action” statement to clarify the definition of “financial support” as used in the standard provisions for grants and cooperative agreements. At issue was whether it applied more narrowly to certain funding provided by foreign NGOs (i.e., funding other than U.S. Global health funding) to other foreign NGOs specifically for the purpose of performing or actively promoting abortion as a method of family planning or if it applied more broadly to certain funding provided by foreign NGOs to other foreign NGOs for any purpose, if that foreign NGO happened to perform or actively promote abortion as a method of family planning. The State Department clarified that it was the more narrow interpretation.However, on March 26, 2019, Secretary of State Pompeo reversed this interpretation, announcing further “refinements” to the policy to clarify that it applied to the broader definition of financial support. Specifically, under the policy, U.S.-supported foreign NGOs agree to not provide any financial support (global health-related as well as other support), no matter the source of funds, to any other foreign NGO that performs or actively promotes abortion as a method of family planning.

In June 2019, USAID provided additional information to reflect this broader interpretation of the standard provisions.This marks the first time the policy has been applied this broadly, as it can now affect funding provided by other donors (such as other governments and foundations) and non-global health funding provided by the U.S. Government for a wide range of purposes if this funding is first provided to foreign NGOs who have accepted the policy (as recipients of U.S. Global health assistance) that then in turn provide that donor or U.S. Non global health funding for any purpose to foreign NGOs that perform or actively promote abortion as a method of family planning. For example, under the prior interpretation, a foreign NGO recipient of U.S.

Global health funding could not provide any non-U.S. Funding to another foreign NGO to perform or actively promote abortion as a method of family planning but could provide funding for other activities, such as education, even if the foreign NGO carried out prohibited activities. Under the broader interpretation, a foreign NGO could not provide any non-U.S. Funding for any activity to a foreign NGO that carried out prohibited activities. Similarly, while under the prior interpretation a foreign NGO recipient of U.S.

Global health funding could provide other U.S. Funding (such as humanitarian assistance) to another foreign NGO for non-prohibited activities, even if the foreign NGO carried out prohibited activities, now under the broader interpretation, it could not do so.What are the next steps in implementing the expanded policy?. The policy went into effect in May 2017 (see Table 2), although it is applied on a rolling basis, as new funding agreements and modifications to existing agreements occur. While it applies to all grants and cooperative agreements, the Trump administration has indicated that it intends the policy to apply to contracts, which would require a rule-making process (it began this process by publishing a proposed rule in September 2020)..

Key PointsOn January 23, 2017, President Where to buy ventolin Donald Trump reinstated and expanded the Mexico City Policy via presidential memorandum, renaming it “Protecting Life in Global Health Assistance.” This explainer provides an overview of the policy, including its history, changes over time, and current application.First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines and has now been in effect for 19 of cheap generic ventolin the past 34 years.The policy requires foreign non-governmental organizations (NGOs) to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. Funds) as a condition of receiving U.S. Government global family cheap generic ventolin planning assistance and, as of Jan. 23, 2017, most other U.S.

Global health assistance.The cheap generic ventolin Trump administration’s application of the policy extends to the vast majority of U.S. Bilateral global health assistance, including funding for HIV under PEPFAR, maternal and child health, malaria, nutrition, and other programs. This marks a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounts for approximately $600 million of that total).Additionally, as a result of a March 2019 policy announcement and subsequent information released in June 2019, the policy, for the first time, prohibits foreign NGOs who accept the policy from providing any financial support using any cheap generic ventolin source of funds and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning. This greatly extends its reach to other areas of U.S.

Development assistance beyond global health cheap generic ventolin and to other non-U.S. Funding streams.More recently, in September 2020, a proposed rule to extend the policy to contracts was published. If finalized, it would greatly extend the reach cheap generic ventolin of the policy beyond grants and cooperative agreements to also include contracts.KFF analyses have found that:more than half of the countries in which the U.S. Provides bilateral global health assistance allow for legal abortion in at least one case not permitted by the policy (analysis).

Andhad the expanded policy been in effect cheap generic ventolin during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy (analysis).What is the Mexico City Policy?. The Mexico City Policy is a U.S. Government policy that – when in effect – has required foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds cheap generic ventolin from any source (including non-U.S. Funds) as a condition of receiving U.S.

Global family planning assistance and, as of Jan cheap generic ventolin. 23, 2017, most other U.S. Global health assistance.The policy was first announced by the Reagan administration at the 2nd International Conference on Population, which was held in Mexico City, Mexico, on cheap generic ventolin August 6-14, 1984 (hence its name. See Box 1).

Under the Trump administration, the policy has been renamed “Protecting Life in cheap generic ventolin Global Health Assistance” (PLGHA). Among opponents, it is also known as the “Global Gag Rule,” because among other activities, it prohibits foreign NGOs from using any funds (including non-U.S. Funds) to provide information about abortion as a method of family planning and to cheap generic ventolin lobby a foreign government to legalize abortion. €œ[T]he United States does not consider abortion an acceptable element of family planning programs and will no longer contribute to those of which it is a part.

€¦[T]he United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family cheap generic ventolin planning in other nations.”When first instituted in 1984, the Mexico City Policy marked an expansion of existing legislative restrictions that already prohibited U.S. Funding for abortion internationally, with some exceptions (see below). Prior to cheap generic ventolin the policy, foreign NGOs could use non-U.S. Funds to engage in certain voluntary abortion-related activities as long as they maintained segregated accounts for any U.S.

Money received, but after the Mexico City Policy was in place, they were no longer permitted to do so if they cheap generic ventolin wanted to receive U.S. Family planning assistance.The Trump administration’s application of the policy to the vast majority of U.S. Bilateral global health assistance, cheap generic ventolin including funding for HIV under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), maternal and child health, malaria, nutrition, and other programs, marks a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total).

The Administration’s more recent extension of the policy to include any financial support (health or otherwise) provided by foreign NGOs for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning is likely to encompass significant additional funding.When has it been in cheap generic ventolin effect?. The Mexico City Policy has been in effect for 19 of the past 34 years, primarily through executive action, and has been instated, rescinded, and reinstated by presidential administrations along party lines (see Table 1).The policy was first instituted in 1984 (taking effect in 1985) by President Ronald Reagan and continued to be in effect through President George H.W. Bush’s administration cheap generic ventolin. It was rescinded by President Bill Clinton in 1993 (although it was reinstated legislatively for one year during his second term.

See below) cheap generic ventolin. The policy was reinstated by President George W. Bush in 2001 and then rescinded by President Barack Obama in cheap generic ventolin 2009. It is currently in effect, having been reinstated by President Trump in 2017.

YearsIn Effect? cheap generic ventolin. Presidential Administration (Party Affiliation)Executive (E) or Congressional (C) Action?. 1985-1989YesReagan (R)E1989-1993YesBush (R)E1993-1999 Sept.NoClinton (D)E1999 Oct.-2000 Sept.Yes*Clinton (D)C2000 Oct.-2001NoClinton (D)E2001-2009YesBush (R)E2009-2017NoObama (D)E2017-presentYesTrump cheap generic ventolin (R)ENOTES. Shaded blue indicate periods when policy was in effect.

* There was a temporary, one-year legislative imposition of the policy, which included a portion of the restrictions in effect in other years and an option for the president to waive these restrictions in part. However, if the waiver option was exercised (for no more than $15 million in family planning assistance), cheap generic ventolin then $12.5 million of this funding would be transferred to maternal and child health assistance. The president did exercise the waiver option.SOURCES. €œPolicy Statement of the United States of America at the United Nations International Conference on cheap generic ventolin Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated.

Bill Clinton Administration, “Subject. AID Family Planning Grants/Mexico City Policy,” Memorandum cheap generic ventolin for the Acting Administrator of the Agency for International Development, January 22, 1993, Clinton White House Archives, https://clintonwhitehouse6.archives.gov/1993/01/1993-01-22-aid-family-planning-grants-mexico-city-policy.html. FY 2000 Consolidated Appropriations Act, P.L. 106-113.

George W. Bush Administration, “Subject. Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, January 22, 2001, Bush Administration White House Archives, https://georgewbush-whitehouse.archives.gov/news/releases/20010123-5.html. €œSubject.

Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, March 28, 2001, Federal Register, https://www.federalregister.gov/documents/2001/03/29/01-8011/restoration-of-the-mexico-city-policy. George W. Bush Administration, “Subject. Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html.

Barack Obama Administration, “Mexico City Policy and Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, the Administrator of the United States Agency for International Development, January 23, 2009, Obama White House Archives, https://obamawhitehouse.archives.gov/the-press-office/mexico-city-policy-and-assistance-voluntary-population-planning. White House, “The Mexico City Policy,” Memorandum for the Secretary of State, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 23, 2017, https://www.whitehouse.gov/the-press-office/2017/01/23/presidential-memorandum-regarding-mexico-city-policy.How is it instituted (and rescinded)?. The Mexico City Policy has, for the most part, been instituted or rescinded through executive branch action (typically via presidential memoranda).

While Congress has the ability to institute the policy through legislation, this has happened only once in the past. A modified version of the policy was briefly applied by Congress during President Clinton’s last year in office as part of a broader arrangement to pay the U.S. Debt to the United Nations. (At that time, President Clinton was able to partially waive the policy’s restrictions.) Other attempts to institute the policy through legislation have not been enacted into law, nor have legislative attempts to overturn the policy.

See Table 1.Who does the policy apply to?. The policy, when in effect, applies to foreign NGOs as a condition for receiving U.S. Family planning support and, now, other global health assistance, either directly (as the main – or prime – recipient of U.S. Funding) or indirectly (as a recipient of U.S.

Funding through an agreement with the prime recipient. Referred to as a sub-recipient). Specifically, a foreign NGO “recipient agrees that it will not, during the term of this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to any other foreign non-governmental organization that conducts such activities.”Foreign NGOs include:international NGOs that are based outside the U.S.,regional NGOs that are based outside the U.S., andlocal NGOs in assisted countries.U.S. NGOs, while not directly subject to the Mexico City Policy, must also agree to ensure that they do not provide funding to any foreign NGO sub-recipients unless those sub-recipients have first certified adherence to the policy.

Specifically, a U.S. NGO “recipient (A) agrees that it will not furnish health assistance under this award to any foreign non-governmental organization that performs or actively promotes abortion as a method of family planning in foreign countries. And (B) further agrees to require that such sub-recipients do not provide financial support to any other foreign non-governmental organization that conducts such activities.”As in the past, the current policy does not apply to funding provided by the U.S. Government to foreign governments (national or sub-national), public international organizations, and other multilateral entities, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the treatment Alliance.

However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy. See “What is ‘financial support’?. € below.To what assistance does it apply?. In the past, foreign NGOs have been required to adhere to the Mexico City Policy – when it was in effect – as a condition of receiving support through certain U.S.

International funding streams. Family planning assistance through the U.S. Agency for International Development (USAID) and, beginning in 2003, family planning assistance through the U.S. Department of State.

In the 2003 memorandum announcing the policy’s expansion to include the Department of State, President Bush stated that the policy did not apply to funding for global HIV/AIDS programs and that multilateral organizations that are associations of governments are not included among “foreign NGOs.”The current policy, reinstated in 2017, applies to the vast majority of U.S. Bilateral global health assistance furnished by all agencies and departments. “Assistance” includes “the provision of funds, commodities, equipment, or other in-kind global health assistance.” Specifically, the expanded policy applies to nearly all bilateral global health assistance, including. family planning and reproductive healthfor the first time:maternal and child health (including household-level water, sanitation, and hygiene (WASH))nutritionHIV under PEPFARtuberculosismalaria under the President’s Malaria Initiative (PMI)neglected tropical diseasesglobal health securitycertain types of research activitiesThe policy applies to the assistance described above that is appropriated directly to three agencies and departments.

USAID. The Department of State, including the Office of the Global AIDS Coordinator, which oversees and coordinates U.S. Global HIV funding under PEPFAR. And for the first time, the Department of Defense (DoD).

When such funding is transferred to another agency, including the Centers for Disease Control (CDC) and the National Institutes of Health (NIH), it remains subject to the policy, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly.The policy applies to three types of funding agreements for such assistance. Grants. Cooperative agreements. And, for the first time, contracts, pending necessary rule-making that would be needed to do so (a proposed rule to accomplish this was published in September 2020).The policy does not apply to U.S.

Assistance for. Water supply and sanitation activities, which is usually focused on infrastructure and systems. Humanitarian assistance, including activities related to migration and refugee assistance activities as well as disaster and humanitarian relief activities. The American Schools and Hospitals Abroad (ASHA) program.

And Food for Peace (FFP). However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy. See “What is ‘financial support’?. € below.What activities are prohibited?.

The policy prohibits foreign NGOs that receive U.S. Family planning assistance and, now, most other U.S. Bilateral global health assistance from using funds from any source (including non-U.S. Funds) to “perform or actively promote abortion as a method of family planning.” In addition to providing abortions with non-U.S.

Funds, restricted activities also include the following:providing advice and information about and offering referral for abortion – where legal – as part of the full range of family planning options,promoting changes in a country’s laws or policies related to abortion as a method of family planning (i.e., engaging in lobbying), andconducting public information campaigns about abortion as a method of family planning.The prohibition of these activities are why the policy has been referred to by its critics as the “Global Gag Rule.”Additionally, for the first time, the policy prohibits foreign NGOs from providing any financial support with any source of funds (including non-U.S. Funding) and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning. See “What is “financial support?. € below.The policy, however, does not prohibit foreign NGOs from:providing advice and information about, performing, or offering referral for abortion in cases where the pregnancy has either posed a risk to the life of the mother or resulted from incest or rape.

Andresponding to a question about where a safe, legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have a legal abortion (passively providing information, versus actively providing medically-appropriate information).In addition, the expanded policy does not apply to healthcare providers who have an affirmative duty required under local law to provide counseling about and referrals for abortion as a method of family planning.Does it restrict direct U.S. Funding for abortion overseas?. U.S. Funding for abortion is already restricted under several provisions of the law.

Specifically, before the Mexico City Policy was first announced in 1984, U.S. Law already prohibited the use of U.S. Aid:to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion (the Helms Amendment, 1973, to the Foreign Assistance Act);for biomedical research related to methods of or the performance of abortion as a means of family planning (the Biden Amendment, 1981, to the Foreign Assistance Act). Andto lobby for or against abortion (the Siljander Amendment, first included in annual appropriations in 1981 and included each year thereafter).Then, shortly after the policy was announced in 1984, the Kemp-Kasten Amendment was passed in 1985, prohibiting the use of U.S.

Aid to fund any organization or program, as determined by the president, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it is now included in annual appropriations).Before the Mexico City Policy, U.S. Aid recipients could use non-U.S. Funds to engage in certain abortion-related activities but were required to maintain segregated accounts for U.S. Assistance.

The Mexico City Policy reversed this practice. No longer were foreign NGOs allowed to use non-U.S. Funds, maintained in segregated accounts, for voluntary abortion-related activities if they wished to continue to receive or be able to receive U.S. Family planning funds.Does the policy prohibit post-abortion care?.

The Mexico City Policy does not restrict the provision of post-abortion care, which is a supported activity of U.S. Family planning assistance. Whether or not the Mexico City Policy is in effect, recipients of U.S. Family planning assistance are allowed to use U.S.

And non-U.S. Funding to support post-abortion care, no matter the circumstances of the abortion (whether it was legal or illegal).What has been the impact of the policy?. Several studies have looked at the impact of the policy. A 2011 quantitative analysis by Bendavid, et.

Al, found a strong association between the Mexico City Policy and abortion rates in sub-Saharan Africa. This study was recently updated to include several more years of data, again identifying a strong association. Specifically, the updated study found that during periods when the policy was in place, abortion rates rose by 40% in countries with high exposure to the Mexico City Policy compared to those with low exposure, while the use of modern contraceptives declined by 14% and pregnancies increased by 12% in high exposure compared to low exposure countries. In other words, it found patterns that “strengthen the case for the role played by the policy” in “a substantial increase in abortions across sub-Saharan Africa among women affected by the U.S.

Mexico City Policy … [and] a corresponding decline in the use of modern contraception and increase in pregnancies,” likely because foreign NGOs that declined U.S. Funding as a result of the Mexico City Policy – often key providers of women’s health services in these areas – had fewer resources to support family planning services, particularly contraceptives. Increased access to and use of contraception have been shown to be key to preventing unintended pregnancies and thereby reducing abortion, including unsafe abortion. The study also found patterns that “suggest that the effects of the policy are reversible” when the policy is not in place.Additionally, there has been anecdotal evidence and qualitative data on the impact of the policy, when it has been in force in the past, on the work of organizations that have chosen not to agree to the policy and, therefore, forgo U.S.

Funding that had previously supported their activities. For example, they have reported that they have fewer resources to support family planning and reproductive health services, including family planning counseling, contraceptive commodities, condoms, and reproductive cancer screenings.While it is likely too early to assess the full effects of the current policy on NGOs and the individuals they serve, as the policy is applied on a rolling basis as new funding agreements or modifications to existing agreements are made, some early data are available. Several early qualitative and quantitative studies have been released, and at least one long-term, quantitative assessment is underway. Additionally, an official assessment by the U.S.

Department of State on implementation during the first six months of the policy has been released (see below). This review acknowledged that it took “place early in the policy’s implementation, when affected U.S. Government departments and agencies have added a significant portion of the funding affected by the policy to grants and cooperative agreements only recently [i.e., after the period the review examined]. A follow-on analysis would allow an opportunity to address one of the primary concerns presented in feedback from third-party stakeholder organizations, namely that six months is insufficient time to gauge the impacts of” the policy.Nonetheless, it is already clear that the reinstated and expanded version of the policy applies to a much greater amount of U.S.

Global health assistance, and greater number of foreign NGOs, across many program areas. KFF has found that more than half (37) of the 64 countries that received U.S. Bilateral global health assistance in FY 2016 allow for legal abortion in at least one case not permitted by the policy and that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy. In addition, at least 469 U.S.

NGOs that received U.S. Global health assistance during this period would have been required to ensure that their foreign NGO sub-recipients were in compliance. Additional foreign NGOs are likely to be impacted by the policy due to the revised interpretation of “financial support” announced in March 2019 and implemented beginning June 2019. See “What is ‘financial support’?.

€ below.A report released in March 2020 by the U.S. Government Accountability Office (GAO) provided new information on the number of projects (awards) and NGOs affected. It found that from May 2017 through FY 2018:the policy had been applied to over 1,300 global health projects, with the vast majority of these through USAID and CDC, andNGOs declined to accept the policy in 54 instances, totaling $153 million in declined funding – specifically, seven prime awards amounting to $102 million and 47 sub-awards amounting to $51 million (more than two-thirds of sub-awards were intended for Africa) – across USAID and CDC. The Department of State and DoD did not identify any instances where NGOs declined to accept the policy conditions.What have the U.S.

Government’s reviews of the policy found?. The U.S. Government has published two reviews of the policy to date, with the first examining the initial six months of the policy released in February 2018 and the second examining the first 18 months of the policy released in August 2020.First ReviewIn February 2018, the Department of State announced the findings of an initial six-month review of implementation of the policy through the end of FY 2017 (September 2017). The report directed agencies to provide greater support for improving understanding of implementation among affected organizations and provided guidance to clarify terms included in standard provisions of grants and cooperative agreements.

In the six-month review report, the Department of State report identified a number of “actions” for implementing agencies, such as a need for:more central and field-based training and implementation tools,a clearer explanation of termination of awards for NGOs found to be in violation of the policy, anda clarification of “financial support,” which was not defined in the standard provisions (see “What is financial support?. € below).The six month review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2017 (see Table 2). U.S. Agency or DepartmentPolicy Implementation DateOverall # of Grants and Cooperative Agreements with Global Health Assistance FundingOf Overall #:(From the Policy Implementation Date through 9/30/2017)# That Received New Funding and Accepted Policy# That Received New Funding and Declined to Accept Policy^# That Had Not Received New Funding YetUSAIDMay 15, 20175804193158State*May 15, 2017142108034HHS+May 31, 20174991600339DoDMay 15, 20177742134TOTAL12987294565NOTES.

* reflects PEPFAR funding implemented through the Department of State. Other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2017, USAID reported it was aware of three centrally funded prime partners, and 12 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards.

DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries. And HHS reported that no HHS partners declined to agree.SOURCES. KFF analysis of data from Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb.

6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Second ReviewOn August 17, 2020, the Department of State released its second review of the policy, updating its initial six-month review (as an action item in the six-month review report, the department stated it would “conduct a further review of implementation of the policy by December 15, 2018, when more extensive experience will enable a more thorough examination of the benefits and challenges”). The long-anticipated review, which examines the period from May 2017 through September 2018, found:the awards declined spanned a variety of program areas, including family planning and reproductive health (FP/RH), HIV and AIDS (HIV/AIDS), maternal and child health (MCH), tuberculosis (TB), and nutrition, in addition to cross-cutting awards;the awards declined spanned geographic areas but many were for activities in sub-Saharan Africa;agencies and departments made efforts to transition projects to another implementer in order to minimize disruption. Butnevertheless, among USAID awards involving health service delivery where prime and sub-award recipients declined to accept the policy, gaps or disruptions in service delivery were sometimes reported.The second review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2018 (see Table 3). U.S.

Agency or DepartmentPolicy Implementation Date# of Grants and Cooperative Agreements with Global Health Assistance Funding# of Prime Awardees That Declined to Accept Policy^USAIDMay 15, 20174866State*May 15, 20173350HHS+May 31, 20174661DoDMay 15, 2017531TOTAL13408NOTES. * reflects PEPFAR funding implemented through the Department of State. Other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy.

^ As of September 30, 2018, USAID reported it was aware of six centrally funded prime partners, and 47 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards. DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries. And HHS reported that one HHS partner declined to agree.SOURCES.

KFF analysis of data from Department of State, “Review of the Implementation of the Protecting Life in Global Health Assistance Policy ,” report, Aug. 17, 2020, https://www.state.gov/wp-content/uploads/2020/08/PLGHA-2019-Review-Final-8.17.2020-508.pdf, and Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Additionally, the review reports that 47 sub-awardees, all under USAID awards, declined to accept the policy. It is important to note that the review also states that information on sub-awards is not systematically collected by departments and agencies and that DoD was not able to collect information on sub-awards.What is “financial support”?.

In February 2018, in the initial six-month review issued when Secretary of State Tillerson led the department, the Department of State report included an “action” statement to clarify the definition of “financial support” as used in the standard provisions for grants and cooperative agreements. At issue was whether it applied more narrowly to certain funding provided by foreign NGOs (i.e., funding other than U.S. Global health funding) to other foreign NGOs specifically for the purpose of performing or actively promoting abortion as a method of family planning or if it applied more broadly to certain funding provided by foreign NGOs to other foreign NGOs for any purpose, if that foreign NGO happened to perform or actively promote abortion as a method of family planning. The State Department clarified that it was the more narrow interpretation.However, on March 26, 2019, Secretary of State Pompeo reversed this interpretation, announcing further “refinements” to the policy to clarify that it applied to the broader definition of financial support.

Specifically, under the policy, U.S.-supported foreign NGOs agree to not provide any financial support (global health-related as well as other support), no matter the source of funds, to any other foreign NGO that performs or actively promotes abortion as a method of family planning. In June 2019, USAID provided additional information to reflect this broader interpretation of the standard provisions.This marks the first time the policy has been applied this broadly, as it can now affect funding provided by other donors (such as other governments and foundations) and non-global health funding provided by the U.S. Government for a wide range of purposes if this funding is first provided to foreign NGOs who have accepted the policy (as recipients of U.S. Global health assistance) that then in turn provide that donor or U.S.

Non global health funding for any purpose to foreign NGOs that perform or actively promote abortion as a method of family planning. For example, under the prior interpretation, a foreign NGO recipient of U.S. Global health funding could not provide any non-U.S. Funding to another foreign NGO to perform or actively promote abortion as a method of family planning but could provide funding for other activities, such as education, even if the foreign NGO carried out prohibited activities.

Under the broader interpretation, a foreign NGO could not provide any non-U.S. Funding for any activity to a foreign NGO that carried out prohibited activities. Similarly, while under the prior interpretation a foreign NGO recipient of U.S. Global health funding could provide other U.S.

Funding (such as humanitarian assistance) to another foreign NGO for non-prohibited activities, even if the foreign NGO carried out prohibited activities, now under the broader interpretation, it could not do so.What are the next steps in implementing the expanded policy?. The policy went into effect in May 2017 (see Table 2), although it is applied on a rolling basis, as new funding agreements and modifications to existing agreements occur. While it applies to all grants and cooperative agreements, the Trump administration has indicated that it intends the policy to apply to contracts, which would require a rule-making process (it began this process by publishing a proposed rule in September 2020)..

What may interact with Ventolin?

• anti-infectives like chloroquine and pentamidine
• caffeine
• cisapride
• diuretics
• medicines for colds
• medicines for depression or for emotional or psychotic conditions
• medicines for weight loss including some herbal products
• methadone
• some antibiotics like clarithromycin, erythromycin, levofloxacin, and linezolid
• some heart medicines
• steroid hormones like dexamethasone, cortisone, hydrocortisone
• theophylline
• thyroid hormones

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

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Evidence for prevalence reductions, the rate of severe long-term complications caused by chlamydia and the potential harms of overdiagnoses and overtreatment. They find that all three points ventolin street price argue for the need to reassess and question current practices. €¦HIV and active TB may skew immune responses to asthmaThe HIATUS consortium in South Africa analysed asthma specific immunity in 95 patients hospitalised with asthma treatment and 38 controls without asthma treatment.

One aim was to ventolin street price assess immune responses in a small subset of people with HIV (n=44) and/or active TB (n=20). People with HIV (66% on antiretroviral therapy) displayed lower CD4 T-cell frequencies than HIV-negative patients, which was associated with lower magnitudes of CD4 T-cell and antibody responses to asthma. Among those ventolin street price with both HIV and active TB and those with severe lymphopenia, only a minority had asthma specific responses.

Results suggest that in people with HIV, untreated or poor CD4 reconstitution despite therapy may impede the generation of T cell and/or antibody responses against asthma, with a potential aggravating role of active TB. Results illustrate important ventolin street price reciprocal interactions between s, requiring confirmation in larger cohorts.Riou C, du Bruyn E, Stek C, et al. Relationship of asthma-specific CD4 response to asthma treatment severity and impact of HIV-1 and tuberculosis co.

J Clin Invest 2021;131:e149125.Systematic review underscores the disproportionately high burden of syphilis among MSMThe WHO Global Health Sector Strategy aims to reduce worldwide incidence of syphilis by 90% between 2018 and 2030.1 To help the global community set priorities, investigators compiled syphilis point prevalence estimates from studies done among men who have sex with men (MSM) in 2000–2020. Data from 275 studies in 77 countries, totalling 606 232 participants, yielded a global pooled prevalence of 7.5% (95% CI 7.0% to 8.0%), ranging regionally from 1.9% (Australia and New Zealand) to ventolin street price 10.6% (Latin America and the Caribbean). Prevalence was 8.7% versus 5.8% in countries with HIV prevalence among MSM above or below 5%, respectively.

Placing the findings into perspective, WHO previously estimated that the global syphilis prevalence among all men was 0.51% in 2016,2 which clearly ventolin street price illustrates how syphilis disproportionately affects MSM. Reducing incidence will require high rates of targeted screening and treatment.Tsuboi M, Evans J, Davies EP, et al. Prevalence of syphilis among men ventolin street price who have sex with men.

A global systematic review and meta-analysis from 2000 to 20. Lancet Glob Health ventolin street price 2021;9:e1110–e1118.Published in STI—The Editor’s Choice. A survey of MSM in Ireland reveals opportunities for improving knowledge of HIV and STIsPoor knowledge of HIV and STIs is one recognised determinant of risk among MSM.

Using data from a self-completed online national survey ventolin street price available to MSM living in Ireland in 2015, researchers analysed factors associated with having lower knowledge of HIV and STI transmission, testing and treatment. Among 2905 participants, 1055 (36%) were classed as having lower knowledge (ie, knowing ≤10/13 statements). HIV testing was ventolin street price less common among those with lower knowledge.

Multiple factors were associated with lower knowledge, notably being aged 18–24 years (vs >40 years), being born in Ireland and not being out to contacts. Knowledge was also lower among those who never visited a national MSM-specific sexual ventolin street price health promotion website. The findings highlight the need to promote knowledge of HIV and STIs among young MSM and suggest the potential utility of dedicated websites.Carey C, O'Donnell K, Davoren M et al.

Factors associated with lower knowledge of HIV and STI transmission, testing and treatment ventolin street price among MSM in Ireland. Findings from the MSM Internet Survey Ireland (MISI) 2015. Sex Trans ventolin street price Infect 2021.

97:351–356.HPV vaccination prevents penile HPV s in MSM and transgender women if administered at age ≤18 yearsTo assess treatment effectiveness against penile HPV s, a cross-sectional study recruited 687 participants aged 18–26 years. Most (97%) self-reported as non-straight male, with a small number (0.9%) identifying as female or transgender female. Using self-collected penile swabs, HPV prevalence was compared in 348 people who self-reported ever receiving ≥1 dose of the quadrivalent HPV ventolin street price treatment (4vHPV) versus 339 participants with no/unknown vaccination history.

HIV-positive status was reported by 3.7% and 0.6%, respectively. HPV vaccination administered at >18 years was ineffective, ventolin street price probably reflecting pre-vaccination HPV exposure. In contrast, the adjusted prevalence ratio was 0.15 (95% CI 0.04 to 0.62) among those vaccinated at age ≤18 years relative to those with no/unknown vaccination history, supporting the benefit of early vaccination in highly sexually active populations.Winer RL, Lin J, Querec TD, et al.

Effectiveness of human papillomaventolin (HPV) vaccination against penile HPV in men who have sex with men and transgender ventolin street price women. J Infect Dis 2021 Jul 28.HPV increases the risk of HIV acquisition in young African womenWhether HPV increases the risk of HIV acquisition remains unclear.3 4 In a substudy of a HIV prophylaxis trial (VOICE) conducted in South Africa, Uganda and Zimbabwe, HPV prevalence in cervicovaginal swabs was retrospectively compared in 138 women who acquired HIV versus 412 controls. While high in both groups, prevalence was higher in those ventolin street price who acquired HIV.

84% versus 65% for any HPV type, 66% versus 48% for low-risk types and 74% versus 55% for high-risk types (p<0.001). After adjusting for parameters that included sexual history and other STIs, HPV was associated with a 2.6 times higher risk of HIV ventolin street price seroconversion, and the risk increased with the number of HPV types detected. Expanding HPV vaccination coverage offers the potential added benefit of reducing HIV acquisition.Liu G, Mugo NR, Brown ER, et al.

Prevalent HPV increases the risk ventolin street price of HIV acquisition in African women. Advancing the argument for HPV immunisation. AIDS 2021 ventolin street price Jun 24.Growing concern of gonococcal strains with reduced susceptibility to extended-spectrum cephalosporinsNeisseria gonorrhoeae (NG) strains associated with treatment failure to ceftriaxone, the recommended treatment for uncomplicated gonorrhoea, have been reported worldwide.

Investigators conducted a whole genome analysis of 813 NG isolates collected between 2005 and 2017 and analysed results in the global context to characterise circulating lineages in the USA. Results showed distinct NG ventolin street price lineages with reduced extended-spectrum cephalosporin (ESC) susceptibility, which resulted from repeated importation, clonal expansion and extensive recombination events. Several were long established and persisting in circulation through the years within multiple sexual networks.

The results underline the need for ongoing surveillance of NG susceptibility to ESCs, improved availability of point-of-care antimicrobial susceptibility tests and development of ventolin street price antimicrobial drugs with novel mechanisms of action.Thomas JC, Joseph SJ, Cartee JC, et al. Phylogenomic analysis reveals persistence of gonococcal strains with reduced-susceptibility to extended-spectrum cephalosporins and mosaic penA-34. Nat Commun 2021;12:3801.Ethics statementsPatient consent for publicationNot required..

Successful baking requires careful measurement, the precise mixing of ingredients and an attentive eye while the mixture is in the cheap generic ventolin oven. However, the environment may have an impact on the final product. Humidity, quality of ingredients, type of oven used and cheap generic ventolin altitude can all mean the difference between a perfect cake and a goopy mess. Although chlamydia control may seem quite different from baking, there are some important parallels, notably the context in which control programmes are developed, implemented and evaluated.

The same inputs and approaches applied in different contexts may produce drastically different results.van Bergen et al1 describe the methods cheap generic ventolin of and conclusions from addressing the question ‘Where to go to in Chlamydia control?. €™ for the Netherlands in this issue of Sexually Transmitted s.The author and colleagues1 convened a panel that met in November 2019 and discussed expert perspectives on chlamydia control. This panel considered the interpretation of available evidence cheap generic ventolin on the impact and/or effectiveness of a variety of testing scenarios. Asymptomatic screening including opportunistic testing of asymptomatic patients in routine healthcare settings, syndromic testing, and at-home specimen collection and/or testing.

Their paper reports on a problem analysis and the consensus viewpoint that evolved from cheap generic ventolin this expert meeting, which suggested that future strategies should reduce rather than expand the role of widespread testing for asymptomatic chlamydial s, and therefore the authors conclude that they ‘do not recommend age-based screening and widespread testing for chlamydia in asymptomatic persons in the Netherlands’.1In this thought-provoking paper, van Bergen et al1 focus on the assessment of three points. Evidence for prevalence reductions, the rate of severe long-term complications caused by chlamydia and the potential harms of overdiagnoses and overtreatment. They find that all three points argue for the need to reassess cheap generic ventolin and question current practices. €¦HIV and active TB may skew immune responses to asthmaThe HIATUS consortium in South Africa analysed asthma specific immunity in 95 patients hospitalised with asthma treatment and 38 controls without asthma treatment.

One aim cheap generic ventolin was to assess immune responses in a small subset of people with HIV (n=44) and/or active TB (n=20). People with HIV (66% on antiretroviral therapy) displayed lower CD4 T-cell frequencies than HIV-negative patients, which was associated with lower magnitudes of CD4 T-cell and antibody responses to asthma. Among those with both HIV and active TB and those cheap generic ventolin with severe lymphopenia, only a minority had asthma specific responses. Results suggest that in people with HIV, untreated or poor CD4 reconstitution despite therapy may impede the generation of T cell and/or antibody responses against asthma, with a potential aggravating role of active TB.

Results illustrate important reciprocal interactions between s, requiring confirmation in larger cohorts.Riou C, du Bruyn E, Stek C, cheap generic ventolin et al. Relationship of asthma-specific CD4 response to asthma treatment severity and impact of HIV-1 and tuberculosis co. J Clin Invest 2021;131:e149125.Systematic review underscores the disproportionately high burden of syphilis among MSMThe WHO Global Health Sector Strategy aims to reduce worldwide incidence of syphilis by 90% between 2018 and 2030.1 To help the global community set priorities, investigators compiled syphilis point prevalence estimates from studies done among men who have sex with men (MSM) in 2000–2020. Data from 275 studies in 77 countries, totalling 606 232 participants, yielded a global pooled prevalence of 7.5% (95% cheap generic ventolin CI 7.0% to 8.0%), ranging regionally from 1.9% (Australia and New Zealand) to 10.6% (Latin America and the Caribbean).

Prevalence was 8.7% versus 5.8% in countries with HIV prevalence among MSM above or below 5%, respectively. Placing the cheap generic ventolin findings into perspective, WHO previously estimated that the global syphilis prevalence among all men was 0.51% in 2016,2 which clearly illustrates how syphilis disproportionately affects MSM. Reducing incidence will require high rates of targeted screening and treatment.Tsuboi M, Evans J, Davies EP, et al. Prevalence of syphilis among cheap generic ventolin men who have sex with men.

A global systematic review and meta-analysis from 2000 to 20. Lancet Glob cheap generic ventolin Health 2021;9:e1110–e1118.Published in STI—The Editor’s Choice. A survey of MSM in Ireland reveals opportunities for improving knowledge of HIV and STIsPoor knowledge of HIV and STIs is one recognised determinant of risk among MSM. Using data cheap generic ventolin from a self-completed online national survey available to MSM living in Ireland in 2015, researchers analysed factors associated with having lower knowledge of HIV and STI transmission, testing and treatment.

Among 2905 participants, 1055 (36%) were classed as having lower knowledge (ie, knowing ≤10/13 statements). HIV testing was less common among those with lower knowledge cheap generic ventolin. Multiple factors were associated with lower knowledge, notably being aged 18–24 years (vs >40 years), being born in Ireland and not being out to contacts. Knowledge was also lower among those who never visited cheap generic ventolin a national MSM-specific sexual health promotion website.

The findings highlight the need to promote knowledge of HIV and STIs among young MSM and suggest the potential utility of dedicated websites.Carey C, O'Donnell K, Davoren M et al. Factors associated with lower knowledge of cheap generic ventolin HIV and STI transmission, testing and treatment among MSM in Ireland. Findings from the MSM Internet Survey Ireland (MISI) 2015. Sex Trans Infect cheap generic ventolin 2021.

97:351–356.HPV vaccination prevents penile HPV s in MSM and transgender women if administered at age ≤18 yearsTo assess treatment effectiveness against penile HPV s, a cross-sectional study recruited 687 participants aged 18–26 years. Most (97%) self-reported as non-straight male, with a small number (0.9%) identifying as female or transgender female. Using self-collected penile swabs, HPV prevalence was compared in 348 people who self-reported ever receiving ≥1 dose of the quadrivalent HPV treatment (4vHPV) versus 339 cheap generic ventolin participants with no/unknown vaccination history. HIV-positive status was reported by 3.7% and 0.6%, respectively.

HPV vaccination cheap generic ventolin administered at >18 years was ineffective, probably reflecting pre-vaccination HPV exposure. In contrast, the adjusted prevalence ratio was 0.15 (95% CI 0.04 to 0.62) among those vaccinated at age ≤18 years relative to those with no/unknown vaccination history, supporting the benefit of early vaccination in highly sexually active populations.Winer RL, Lin J, Querec TD, et al. Effectiveness of human papillomaventolin (HPV) vaccination against penile HPV in cheap generic ventolin men who have sex with men and transgender women. J Infect Dis 2021 Jul 28.HPV increases the risk of HIV acquisition in young African womenWhether HPV increases the risk of HIV acquisition remains unclear.3 4 In a substudy of a HIV prophylaxis trial (VOICE) conducted in South Africa, Uganda and Zimbabwe, HPV prevalence in cervicovaginal swabs was retrospectively compared in 138 women who acquired HIV versus 412 controls.

While high in both groups, cheap generic ventolin prevalence was higher in those who acquired HIV. 84% versus 65% for any HPV type, 66% versus 48% for low-risk types and 74% versus 55% for high-risk types (p<0.001). After adjusting for parameters that included sexual history and other STIs, HPV was associated with a 2.6 cheap generic ventolin times higher risk of HIV seroconversion, and the risk increased with the number of HPV types detected. Expanding HPV vaccination coverage offers the potential added benefit of reducing HIV acquisition.Liu G, Mugo NR, Brown ER, et al.

Prevalent HPV increases the risk cheap generic ventolin of HIV acquisition in African women. Advancing the argument for HPV immunisation. AIDS 2021 Jun 24.Growing concern of gonococcal strains with reduced susceptibility to extended-spectrum cephalosporinsNeisseria gonorrhoeae (NG) strains associated with treatment failure to cheap generic ventolin ceftriaxone, the recommended treatment for uncomplicated gonorrhoea, have been reported worldwide. Investigators conducted a whole genome analysis of 813 NG isolates collected between 2005 and 2017 and analysed results in the global context to characterise circulating lineages in the USA.

Results showed distinct NG lineages with reduced extended-spectrum cephalosporin (ESC) susceptibility, which resulted from repeated importation, cheap generic ventolin clonal expansion and extensive recombination events. Several were long established and persisting in circulation through the years within multiple sexual networks. The results underline the need for ongoing surveillance of NG susceptibility to ESCs, improved availability of point-of-care antimicrobial susceptibility tests and development of antimicrobial drugs with novel mechanisms of action.Thomas JC, Joseph cheap generic ventolin SJ, Cartee JC, et al. Phylogenomic analysis reveals persistence of gonococcal strains with reduced-susceptibility to extended-spectrum cephalosporins and mosaic penA-34.

Nat Commun 2021;12:3801.Ethics statementsPatient consent for publicationNot required..

Can i buy ventolin over the counter in canada

L read this post here can i buy ventolin over the counter in canada. § 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1.

No can i buy ventolin over the counter in canada Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &.

Rules and Household Size 3 can i buy ventolin over the counter in canada. The Three MSP Programs - What are they and how are they Different?. 4.

FOUR Special Benefits of MSP can i buy ventolin over the counter in canada 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 can i buy ventolin over the counter in canada What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7.

What Happens After MSP Approved - How Part B Premium is can i buy ventolin over the counter in canada 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 can i buy ventolin over the counter in canada. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement.

See “Part A Buy-In” YES YES Pays Part A & can i buy ventolin over the counter in canada. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

Yes - Benefits begin the month after the can i buy ventolin over the counter in canada 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 i buy ventolin over the counter in canada. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!.

Must can i buy ventolin over the counter in canada choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2.

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

NOTE can i buy ventolin over the counter in canada. 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 can i buy ventolin over the counter in canada FPLs and go ahead and factor in any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y.

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

(a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS.

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

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

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

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

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

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

This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?.

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

3. The Three Medicare Savings Programs - what are they and how are they different?. 1.

Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations.

Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

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

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

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

However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid.

They cannot be in both. It is their choice. DOH MRG p.

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

Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable.

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

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

Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients.

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

18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center.

If you fail to enroll within those short periods, you might have to pay higher i thought about this Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties...

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

See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55.

Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010.

The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4.

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

Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?.

The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods.

Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit.

It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website.

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

See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below.

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

Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &.

Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason.

SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note.

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

Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare.

If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid.

See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address.

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

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

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

The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02.

Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals.

Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP.

08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE.

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

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

He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP.

(Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown.

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

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

See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as.

SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums.

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

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

!. ) 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?.

Applications for People who Have Medicare cheap generic ventolin What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How cheap generic ventolin 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 generic ventolin. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?.

YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays cheap generic ventolin Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

Yes - Benefits begin the month after cheap generic ventolin 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 cheap generic ventolin MA 027.

Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose cheap generic ventolin 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 cheap generic ventolin benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below.

NOTE cheap generic ventolin. 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 cheap generic ventolin released, districts will use the new FPLs and go ahead and factor in any COLA.

See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv.

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

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

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

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

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

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

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

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

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

Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

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

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

QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid.

They cannot be in both. It is their choice. DOH MRG p. 19.

In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1.

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

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

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

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

If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life..

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

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

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

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

And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods.

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

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

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

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

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

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

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

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

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

See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1.

Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare.

To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

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

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

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

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

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

Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown.

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

See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment.

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

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

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

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

​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year.

No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance.

However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider.