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I love a great adventure. The anticipation, the rush of getting ready, the exhilaration of pushing your comfort zone and experiencing all that is foreign adds to the thrill. There’s nothing that compares to stepping into the great unknown and pushing your boundaries to the limit. That excites me. So at any given moment I’m always ready for the chaos that comes with being spontaneous. It’s my nature.

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Last Friday, I got the call. Steve in Little Orleans, MD had heard about me four years ago when I rode through his town, in the western part of Maryland, during my cross-country trek on horseback. Steve tracked me down on Friday. Did I know of anyone with a horse trailer who would trailer a horse to West Virginia?

It seems a long rider had left his lead horse with Steve for six weeks while the horse healed. In due time, the rope burn on the horse’s hock had finally healed and the horse was ready to be reunited with its owner.

The long rider, whom Steve described as a short Atilla the Hun and whom I’ll call Jack, started his cross-country trek in Harpers Ferry with a lead horse, a pack horse, and two other men and their horses.

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It probably took Jack five days, give or take a day or two, to journey the 100 miles to Little Orleans. A trip that would normally take an hour and 38 minutes by car takes five days for a long rider on horseback. The long rider’s horse is imperative to the success of the journey. Trying to make 4000 miles over the long-haul, means the long rider needs his horse to pace at 20 miles a day. For me, that averaged out to be three miles an hour—with breaks, fan fare, interviews and the like, I was in the saddle for eight or nine hours a day. Long hard days, but there’s nothing like seeing America at three miles an hour.

The first three weeks of any long rider’s journey are the hardest. Those weeks make or break the long rider, the horse and the journey. It’s not an adventure for the faint of heart. Jack’s companions bailed on him when they arrived in Little Orleans. After three weeks of staying with Steve while his horse was healing, Jack made the decision to push on with his pack horse, alone. Would it be possible for Steve to make arrangements for the horse to meet up with Jack when the horse healed?

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That’s where I came in. Did I know of anyone who would trailer the horse to Jack? You betcha. Me. It was a fellow “wanna-be” long rider in need. So I texted my partner, who was in the Doctor’s office on a late Friday afternoon. Did he want to join me? The Plan—to head out with the truck and trailer with an overnight stop at the Little Orleans Lodge, au gratis, from the owner Steve. In the morning we would load Jack’s horse and head out to Davis, WV where Jack and his pack horse were staying overnight. The trip would take a total of ten hours. Five there. Five back. I had no choice. I had to “pay it forward” for everyone who had been so kind-hearted in my time of need on my journey. This I had to do for them. Plus, I love a good adventure.

My partner, being the great sport that he is, was game. He’d be ready to leave in two hours. With a spring in my step, I packed up, made a picnic dinner to eat in the car and grabbed a great bottle of red, two wine glasses and a corkscrew. After all we were going to be staying in a rustic bed and breakfast for the night.—why not take full advantage of the evening?

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We arrived well into the evening, greeted by Steve, an affable retired post master, who had worked on the lodge since buying it for his wife and children back in the early 70s. When he retired, Steve turned it into a B&B on the C&O canal, a 184.5 mile long trail that winds around the Potomac River following the towpath of the Chesapeake and Ohio Canal. Steve was happy to host the eclectic group of trail-goers who by chance stumbled into his lodge on foot, bicycle or even horseback. Over a glass of wine, he shared the stories of those in his register: hippies, loners and couples, all who had set out on a journey to find themselves.

After a morning breakfast of two eggs over easy, sausage, potatoes and the most mouth-watering, sweetest biscuits I ever had, we loaded up Jack’s horse and headed on down the road to Davis, WV to meet up with the long rider, Jack.

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Steve was wrong. Jack looked more like Johnny Depp in the Pirates of the Caribbean. He acted like him too. In spite of himself, you couldn’t help but like him. Jack was a 31 year-old man with a black bandanna and tongue piercing, trying to figure life out from a horse’s point of view. He was ecstatic to have his lead horse back. I knew the feeling. Rocky, my lead horse, had injured himself when another horse kicked him in Illinois. I had to leave him behind to heal. Parting with him ripped my heart out. When we were reunited three weeks later, the joy in having him back defied description. I was lost without him. I knew the elation that Jack experienced in being reunited with his horse on their great adventure.

Before leaving, Jack asked me to write in his journal, to offer him advice or wisdom that I had garnered on my solo trek. I simply wrote, “Discover the joy, discover the journey, discover yourself.” Because that’s what it’s all about—on any adventure.

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Tomorrow I head out on another adventure. Australia. For two weeks. Part of the journey will be a 4WD trip to the Outback where I’ll be backpacking, tenting and dining with the Aborigines. Wish me luck and hope that I discover the joy, the journey and perhaps even myself. When I return from this Aussie Adventure, I’ll certainly share with you. Till then, G’day mate.

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When someone loses a pet and says to me in grief, “I know it’s not the same as losing a child, but it hurts so much,” my heart aches. Not because I know the pain of losing not one, but two children, but because I also know the pain of losing a dearly loved animal.

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Nothing, and I mean, nothing compares to the pain of losing a child, but that doesn’t diminish the heartache of any loss. Human or animal. The void in life after loss is incredible. Where there was once life, a huge black hole looms when death takes over. Where there was once love, heartache. Smiles. Sadness. Happiness. Loneliness. The loss of life fills your heart with an overwhelming emptiness and pain. The moment of loss—that incredible moment of pain—in the passing of life is unavoidably deep. It rips your heart out. Loss causes heartache and there’s just no getting around that. It’s a part of life.

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This past February I had to put down Eric’s beloved Shadow. It was so painfully hard, perhaps extra so, because it was Eric’s dog, my living link to my dead son. Shadow was the kindest, gentlest black lab I’d ever known. He had a huge heart with big soulful brown eyes. When the decision came to put him down, I left that to my surviving son, Peter. He had taken over Shadow’s care in Eric’s passing.

Shadow had developed brain cancer with severe epileptic seizures and it was Pete’s responsibility to ensure Shadow’s comfort in his final debilitating days. Pete rose to the occasion and gently helped Shadow every time he experienced a seizure. Pete was also there in the middle of the night to clean up the blood and excrement from Shadow’s thrashing. And Pete found the courage to tell me it was time to euthanize him. As Shadow’s big black head with the soulful eyes lay quietly in Peter’s lap as the vet administered the needle, my heart screamed in pain at yet another loss in our lives. Shadow. Eric’s big black lab with the soft soul. My heart ached and I cried.

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I was so thankful he didn’t die alone; Shadow deserved more than that. Nothing should die alone. Any—no all–life deserves more than that.

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This past spring, I was headed down York Road and had to come to a creeping crawl to avoid the growing crowd on the shoulder of the road. Some members of the crowd were crying, others didn’t know what to do, but all eyes looked toward the middle of the road. My eyes followed their gazes. In the middle of the road was a beautiful brindle pit bull, smashed and dying on York Road. No one was near him; he was dying alone. God no. I pulled over and ran to him. “Has anyone comforted the poor thing?” I screamed. “No,” came their replies in unison. “We didn’t know if he’d bite.” I was spitting mad with grief, pain and tears as I watched the poor dog hold on to dear life. Where was their compassion? I didn’t understand. As I knelt down and stroked the dog’s big beautiful head, his blood spilling over onto my knees, his tail gave a tiny wag as he tried to look at me. I held him, comforted him, and loved him in his final moments.

I was so thankful he didn’t die alone. I didn’t know him, but he deserved more than that.

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Monday morning I headed to the farm to tend to my two horses and the other ten horses I’ve cared for over the past five years. My routine always starts out the same. I whistle for my horses and say hi to the others gathered at the gate. Where was Blaze, the leader of the herd? I headed into the stall barn to dish up the grain. Still no Blaze. That’s odd. Where was she? I called for her. No Blaze.

After putting the other 11 horses in their respective feeding stations. I shlepped through the field, over the bridge, over the stream, and into the 50 acre field to find Blaze. There, just beyond the stream, she lay—struggling to get up, bloated, and covered with flies. She had colicked sometime during the night and the others had left her for dead. My God. My God. No. No. No. The poor thing. Tears streamed down my face as I knelt beside her. She moved her head and laid it on my foot, looking at me through bleeding eyes as she let out a soft whinny.

I fumbled for my cell phone and called my girlfriend, leaving a terrifying message, “Call the vet. Call the vet now!” I screamed through my sobs. Then I crumpled beside Blaze in the field and stroked her big beautiful brown head with the white blaze. She labored to breathe. “Hang on. Hang on.” I whispered in her ear. “He’s coming. He’s coming.”

The vet arrived but couldn’t get his SUV across the stream. Could we get her up? Blaze tried, oh she tried so hard, but she didn’t have enough left in her. With a heavy heart the vet returned to his car to get the needle to euthanize her.

“Blaze, get up. Get up. You can do it. Everyone’s waiting on the other side. Don’t die her alone. Come on honey….get up.” I sobbed in her ear. With one valiant effort the gentle leader rose off her barrel belly onto her buckled knees and stood. With painful, labored steps this beautiful beast made her way to the stream where her herd was waiting. It took her fifteen minutes but she finally crossed to the other side where she was greeted with whinies and neighs from her delighted followers. She grew stronger with every painful step through the support and love of her herd, owners and caretakers, and finally made it to the paddock where she was enveloped and loved as she was laid to rest.

An imperial leader, of the gentlest nature, Blaze. I loved Blaze and was thankful she didn’t have to die alone. She deserved more than that, as do all creatures, great and small.

Rest in Peace Blaze, our gentle leader

Rest in Peace Blaze, our gentle leader

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When something turns out way better than expected it brings such joy to life. I love pleasant surprises and this 4th of July weekend has been full of them.

Friday night kicked the weekend off with one. I was driving home from work and saw crabs for $20/doz. at what I thought was a local down and dirty pub with a bad reputation. Or at least that’s what I had been told. Twenty dollars for a dozen crabs was worth the risk of a bad reputation.

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Arriving home, I asked my partner if he wanted to go out for the deal. The catch? He had to at least look the part of a red neck. He couldn’t walk into the down and dirty bar as a prep. Could he do it? He tried. He came bounding down the stairs in an old worn out t-shirt. Perfect. Till my eyes rolled to his bottom half. The crease in the jeans still gave him away. No matter how hard he tries he just can’t look down and dirty. I guess that’s not really a flaw though. I smiled; he tried. He then looked me up and down and said, “Well you’re not really down and dirty either. “Ah, but no,” was my reply, “I just need to look good to a red neck guy.”

When we got out of the car in the parking lot and headed for the bar door, a Harley roared by. My partner said “Man, he couldn’t keep his eyes off you.”  I laughed, “Actually he couldn’t take his eyes off the crease in your jeans.”

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We pulled the door open, expecting the worse. To our pleasant surprise the restaurant was cute, the bar great, and the prices were fabulous. The owner came out, engaged us in conversation, and threw four extra crabs into our to-go bag. We’re definitely going to hit that down and dirty pub up for our weekly cheap date night. Pushing one’s comfort zone is grand.

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Saturday, the 4th of July, started out with a 5:45 am wake up call for me to get ready for my first parade in the Cavalry. My partner, coming along for pure support, rolled out of bed at the ungodly weekend hour to help me get Rocky, my horse, ready for the 4th of July parade in Takoma Park in Washington, DC.

Our first pleasant surprise came as we arrived in Takoma Park. Expecting an urban area with lots of noise, cars and pollution, we were greeted with a charming bedroom community with tree-lined sidewalks stretching in front of historic homes. Lawns were filled with a thousand or more  children, parents and grandparents decked out in red, white and blue, waving flags of all sizes. The weather was perfect and the air was filled with a patriotic hum, no matter which side of the political fence the flag was flying on.

In fact one long-haired silver woman in a purple tye-dyed flowing skirt came up to me in my military dress blues as I was mounting up on Rocky. She leaned in and thanked me for protecting her right to her far different views. She smiled as she pointed to the flower in her hair. I smiled back, knowing what she meant, and thanked her. Two different sides of the fence coming together as Americans to enjoy a parade in a small home-town.

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As we assembled for the parade, the Sergeant who was supposed to be carrying the flag for the hour-long parade was suffering from the flu. He grew weezy and weak and, unfortunately, had to withdraw. My commander turned to me and Rocky and said, “Step up, it’s your honor.” My second pleasant surprise. As we started off with the large flag flapping over Rocky’s ears, the crowd stood and erupted into cheers and applause. My heart surged, filling with pride and patriotism. I whispered to my commander, “I’m going to cry sir. I’m going to lose it.” “Hold on PFC Losey. Hang in there.” And I did, for the hour long ceremony as we paraded through the streets to thousands of red-blooded Americans celebrating our independence. Truth be told, tears streamed down my face, as we celebrated as one.

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After arriving home, we had no plans. So we took an afternoon of leisure hanging out in the pool, swimming side-by-side and then tying two floats together as we held hands and napped. Totally unlike us, and it felt so good, another pleasant surprise. I told my partner it would be a perfect day if I could once again hear the squeal of children playing in a pool. The phone rang.

My sister-in-law from my first marriage, whom I’ve been friends with for 27 years, was at Wegman’s. “Hey,” I said, “Why don’t you grab a 5 lb. bag of Sahlen hot dogs and bring the kids on over for a picnic and swim?” “I already have the hot dogs in the cart, along with cole slaw, strawberries and stuff to make shortcake. Game?” she asked.”You bet I am.” I replied. I ran upstairs and uncovered the goggles, the flippers, the frisbee and ball that Eric and Sam used to play on the beach with Cara and Peter far too many years ago.

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When my in-laws arrived, we baked the shortcake and headed out to the deck to grill the dogs, drink, and listen to the squeal of children once again playing in the pool. I sighed perfectly contented with my weekend full of patriotism and pleasant surprises. God I love the small joys of life.

Takoma Park Parade, July 4th 2009

Takoma Park Parade, July 4th 2009

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Driving the 350 miles up to my hometown of Buffalo for my nephew’s high school graduation, revealed to me an “aha” moment: people handle driving the way they handle life. Lead, follow or get out of the way! Please.

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As I was driving on an open stretch of route 15 in Pennsylvania, a silver Kia sedan sped up as it approached my rearview mirror. As it passed me, I noticed the twenty-something girl behind the wheel, who immediately slowed down once she pulled back into my lane in front of me. As I then pulled out to pass her, she immediately sped up, only to slow down again when I resumed my position behind her. She slowed down. I went to pass. She sped up. I’d pull back in. She’d slow down. This went on for a number of miles, when the “aha” moment hit me. She wanted to lead, but didn’t have the courage to be the leader.

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Along the way, the highway was strewn with state troopers pulling people over as they sped by. The twenty-something girl flying by me wanted to be in the lead but didn’t have the courage to be the lead driver. She wouldn’t commit. She wasn’t willing to take the risk of being pulled over for speeding. But she wanted to BE the leader, forcing the other drivers to either drive her speed or pass her. It was an unsafe practice for those following. Speed up. Slow down. Speed up. Slow down. It was an accident waiting to happen. She was not lead driver material. She needed to be following at a safe speed. I’m confident her approach to driving was the same as her approach to life. A young girl be-bopping along, accelerating, de-accelerating, pulling in and passing, trying to find the rhythm of her life.

When it comes to driving and life, I’m a leader but have no problem following—IF I’m behind a confident leader who makes good decisions. If not, get out of the way, ’cause I’ll take over and pass. I don’t have a lot of patience for hesitant leaders or drivers. Commit. Make a decision or move over and let someone else lead.

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En route to Buffalo, I encountered fierce thunderstorms with pelting rain and winds. Hail storm like conditions, just shy of hailstones coming down. As a pretty fearless driver, severe winter storms don’t stop me, let alone a little rain. Yet people were driving 25 mph hour on an interstate with their flashers on. People, please. It’s a little rain. Well a lot of rain. Eventually most of the drivers pulled over. Ah, relief. An open road where I could go. I led the drivers, confidently, to salvation, er, sunshine. It just took someone willing to commit and lead. I have no problem stepping up if need be. That’s who I am as I driver and who I am in life.

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My partner has an interesting approach to driving and to life. He meanders in both. If there’s a straight line to get from point A to E, he’ll drive from A to D to K to N back to C over to J and eventually he’ll make it to E, his end destination. This is his approach to most things in life. In the meantime, he’s made a lot of stops, said hi to many people and eventually accomplished what he sets out to do. If I’m on a mission and need to get from A to E in record time, and I’m with him, I have to restrain myself from pushing down on his knee to accelerate to 65 mph. It drives me bonkers. But if I’m not on a mission, and willing to meander, it makes for a very pleasant journey. That’s why I think we make good partners—one forces the other to stay on task, the other forces the other to stop and smell the roses.

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Although I stay on task, I am an adventurer. I love the journey, the drive, the discovery, the ability to make choices. My brother has a GPS named Lucille. I hate her. No, I will not turn because you told me to. I’ll turn because I choose to. No wait, I WANTED to go to the Ben and Jerry’s. It’s an unscheduled stop, don’t recalculate. Shut up. Stop it. Let me drive. Let me choose. Let me discover their new Mission to Marzipan flavor. Stop it. Stop it. Stop it. I don’t want to stay on task I want to stop and smell the roses. But she won’t let me, without giving me a huge headache. Big mouth Lucile shows no restraint. Recently, someone stole her. God Bless them.

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Did you know a study recently stated that people with lots of bumper stickers on their cars are aggressive drivers? I find that hilarious, because the cars that I usually see plastered with bumper stickers are Subarus touting world peace.

You’ll be happy to know that I don’t place bumper stickers on my vehicles. But if I were to sport a bumper sticker on my 4×4 F-150 it would simply be, “Visualize whirled peas.”

visualize-whirled-peas-bumper-sticker-5781

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“When the going gets tough, the tough eat donuts”–Ziggy

I love Ziggy. Do you remember him—the fat little bald guy in the 70’s comic strip by Tom Wilson? Ziggy had a “woe is me” perspective on life but offered simple words of wisdom.

The cartoon quote from above was lovingly cut out of the paper by my dad and taped to my mirror when I was 18. I’m sure it’s now tucked away in an attic box piled on top of other boxes from far too many moves. Every time I think of Ziggy, I think of my dad who passed away at an early age of 59, fifteen years ago.

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My dad didn’t cut that cartoon out to suggest I was getting fat. He simply cut it out because the humor struck a chord with him. When I was 18 I worked in the deli of a local grocery store. Oftentimes, at the end of the shift, I had to box up the fresh donuts from the bakery to be put out for the “day old” dollar sale the next day. So each night I’d box them up–and then buy ‘em. My particular favorites were the peanut donuts. Oh my, they were good. But, alas, they are not made anymore because of all the peanut allergen sufferers out there. Sigh. I loved a good peanut donut. The memory of biting into a fresh donut with falling nuts and crumbs waiting to be scooped up, filling my nose with the warm, nutty sensation, still makes my mouth water.

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The humor that my dad found in the comic strip was that I was a love-sick teen who had just broken up with my first forever boyfriend, who brought home a box of donuts at the end of the night to eat away the pain. When the going got tough, I ate donuts. My dad was trying to get me to move through the “woe is me” attitude from the teen-age breakup with humor. I loved that about my dad—he moved through life with humor and I couldn’t help but be sucked into it.

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That particular Ziggy cartoon was based on the quote from Joseph P. Kennedy, father of our 35th president John F. Kennedy, “When the going gets tough, the tough get going.” I’m sure the fiercely ambitious businessman and political figure, who thrived on competition and winning, gave that fatherly advice to his 9 children with a stern striking of his fist with emphasis on every word.

Not my dad. He cut out cartoons from the paper and taped them to my mirror. He peeled off Chiquita banana labels and pasted them somewhere in my school lunch box for me to discover with love. He’d sneak away early from work and show up unexpectedly for the last 15 minutes of my soccer game. He didn’t rule with an iron fist, rather with respect, love and humor.

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The humor that he used to get me through my first forever boyfriend break-up still makes me smile to this day. He was letting me know that life goes on, it’s what you make of it, it’s how you choose to move through it that makes all the difference.

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I had to stop eating donuts, not because they landed on my hips, but because I got sick of them. To this day I have a hard time eating donuts because I ate too much of a good thing way back when. As Marie Lloyd so simply states, ” A little of what you fancy does you good.” The lesson from Ziggy and my dad: taking it to the extreme is not necessarily a good thing. Although I have to admit when I see a “Hot Donuts Now” sign flashing at a Krispy Kreme, my car automatically pulls into the drive-thru. I’m just taking them home to the kids. Honest.

“A LITTLE of what you fancy does you good.” For sure.

Ziggy

Ziggy

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Sock. Shoe. Sock. Shoe. No. Sock. Sock. Shoe. Shoe. I do sock, sock, shoe, shoe. How do you approach your morning routine?In the end does it really matter? In Ted Menton’s After Goodbye, he tells the story of two children in the throes of cancer arguing in the cancer ward about which is better. Sock. Shoe. Sock. Shoe. or Sock. Sock. Shoe. Shoe.

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In spite of the cancer scenario, I find it amusing that two children facing the fight of their lives still find their individual routine’s worth fighting about. Sock. Shoe. vs. Sock. Sock. I have never been a routine person. Not me. In fact, if you ever placed me into a box, I’d scrape and claw my way out of it.

All my life, I’ve been known for my spontaneous nature. Until my children died. Then, I took great comfort in my routine. It was what got me up in the morning. Linda, first put on your sock, then your shoe. Nope. Put on your sock. Now put on your other sock. Okay, put on your shoe. Now your other shoe. Now put one foot in front of the other. Now take a step. Okay. Move the other foot. Move forward. Step by step. Move through the pain. You can do it. Sock. Sock. Shoe. Shoe. Move. Move. And that’s how I’ve moved through the passing pain of losing two children.

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Most of you know Monday marked the five year anniversary of Sam’s passing. My 10 year old son. I have been in a routine for the past five years in learning how to live again through the loss. Sock. Sock. Shoe. Shoe. Move. Move. Don’t you take that routine away from me. Like the children on the cancer ward, I took great comfort in owning my routine. It was the only thing I had control over. God forbid I put on Sock. Shoe. Sock. Shoe. It didn’t feel right. Just like my life without my children. Come to think of it, before the passing of my children I think I did Sock. Shoe. Sock. Shoe. But I couldn’t go back to the same routine. It wasn’t right. I needed a new routine. It was new, but a routine, just the same. Just like living and breathing without half my family. I had to learn to do it all over again. The basics of living.

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Know how I celebrated Sam’s anniversary? The “non-celebration,” as it were, ended up in my mowing the lawn. Now my partner prides himself on the perfectly parallel lines in the lawn. I never got that. I don’t. To me a lawn is a lawn. And this just isn’t a lawn; it’s a field, a three acre field next to a stream. It deserves to be a field. But nope. He wants it to be a lawn. Not me. I want it to be a field with dancing grass blowing in the breeze, next to the stream. I want it mowed three times a season. He wants it mowed once a week. Now I love to mow, so I took on the chore. On Sunday, I started running the perfectly parallel lines of the routine. Sock. Sock. Shoe. Shoe. Up. Down. Up. Down. Forty-five inches over from whence I started. Now another 45 inch wide mowing deck over. Then a dragon fly landed on the dancing grass next to the stream in the field I was cutting into a routine.

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Sam followed me across the country on my horse trip. Thousands of dragon flies followed me. They had my back. As Sam did. I wear a dragon fly bracelet as a remembrance of Sam. So I couldn’t do it. I couldn’t cut the field in parallel lines. I couldn’t cut the field so the dragon fly had no where to land. I couldn’t cut the field by way of routine. So in honor of Sam, I cut whoopsi-doodles. No rhyme or reason. Just by happen-chance, I have a field full of perfectly un-parallel lines. Perfect whoopsi-doodles where dragon flies can land on the missed grass of the 45 inch mowing deck. In the outskirts of the circles where 45 inches didn’t meet the other 45 inches. Where shoes come before socks. Where dragon flies land before parallel lines are cut. Where routines are lost and spirits soar. Where perhaps even socks are worn without shoes. For in the end, it just doesn’t matter.

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“Wow, Linda, you look fabulous and fit!” was the statement I heard Tuesday night at my Toastmaster’s meeting. Little did that person know I have, over the past 4 months, unintentionally dropped 1/5 of my weight.  Now, I’ve never had a problem with weight. I had four children and managed to stay relatively thin chasing after them through the years. But I found it truly ironic that I’m the thinnest I’ve ever been—even before my high school years—and was being rewarded with a “Wow, you look fit and fabulous.”  I didn’t feel it.

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Yesterday I nearly collapsed at work, drove to a 24/7 healthcare center, to be told I’m severely anemic. This coupled with the five other symptoms that have crept up on me over the past four months and the doctor scared me with the big C.

My dad died of cancer and it wasn’t something I was prepared to hear. Now lots more tests need to be done, so don’t get all melodramatic on me. I have lots of years left to live, I know that, and feel that, with every fiber of my being. The point to all of this is that you just don’t know what the day may bring. Are you living the life you were born to lead?

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“Always be a first-rate version of yourself, instead of a second-rate version of somebody else.”
–Judy Garland

This from a woman who played somebody else for 45 of her 47 years. This from a woman who attempted suicide numerous times throughout her tragic life. This from a woman who struggled with insecurities and addictions. This from a woman who was told by her producers that she was unattractive and overweight. This from a woman who died at 47, the same age I’m about to turn in three weeks. Was Judy Garland ever a first-rate version of herself?

Judy Garland will always be remembered as Dorothy in the Wizard of Oz, with her ruby red slippers, clicked three times, as she closed her eyes and chanted,  “There’s no place like home. There’s no place like home. There’s no place like home.” Ironically, Judy Garland never felt at home anywhere. I can only imagine why she never revealed her true self, always hiding it away—for fear that her adoring fans would cast aside the real Judy. They always wanted Dorothy. The cute little, pig-tailed girl from Kansas.

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I also imagine that Judy Garland did live the life she was born to lead. She was a wonderful actress and a beautiful singer with her deep contralto voice. No one does honor to Somewhere Over the Rainbow the way Judy performed it half a century ago. But she never believed she deserved to be Judy Garland and all that she achieved. She was just Frances Ethel Gumm from Grand Rapids, MN. When she was pushed into acting, Frances’ confidence was sucked out of her and for years she was only able to portray a second-rate version of somebody else.

When the big C is thrown at you, your life hits replay over and over again in your mind. “Have you lived the life you wanted? Have you achieved what you set out to achieve? What more do you have left to do?”  It begs the question, “What is your legacy?”

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So what is your legacy? If you were to die tomorrow, did you live the life you were born to lead? Will you leave behind something to remember? Did you live a first-rate version of yourself?

I hope I have.

I know my youngest son Sammy did. On Monday, he’ll be gone 5 years. On June 22. But I still remember his great grin. His aqua blue eyes. His mischevious sense of humor. And his terrific hugs. In his short 10 years, Sammy was a first-rate version of himself. There will never be another.  In the end, all you have are memories, and the ones spent with family and friends are the ones you treasure most.

So as I remember Sammy and Frances Ethel Gumm, who co-incidentally also died on June 22, as I head into the doctors for a follow-up visit to the big C scare, I hope to see a rainbow smiling down on me.

Somewhere Over the Rainbow (click, for a beautiful version by 6 year-old Connie Talbot on YouTube)

Somewhere over the rainbow
Way up high,
There’s a land that I heard of
Once in a lullaby.

Somewhere over the rainbow
Skies are blue,
And the dreams that you dare to dream
Really do come true.

Someday I’ll wish upon a star
And wake up where the clouds are far
Behind me.
Where troubles melt like lemon drops
Away above the chimney tops
That’s where you’ll find me.

Somewhere over the rainbow
Bluebirds fly.
Birds fly over the rainbow.
Why then, oh why can’t I?

If happy little bluebirds fly
Beyond the rainbow
Why, oh why can’t I? 1

I hope we all live the life we were born to lead—the way Sammy did, so beautifully and innocently with a verve for life and love. Love and miss you tons, my little Sammer Dam.

Sam Losey, 3/29/94 - 6/22/2004

Sam Losey, 3/29/94 - 6/22/2004

1 Somewhere Over the Rainbow, music by Harold Arlen and lyrics by E.Y. Harburg

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Many moons ago, when my mother was the age I am now, and I was but a girl of 16, my father came home one memorable day and announced to us that we were moving. To a farm. Although I was a tomboy with three older brothers, I was a city girl through and through. It’s all I had known.

As a family, we would be moving to a 10 acre farm, next to 3000 acres of state land, to a public school with a graduating class of 32.  Yep, I was downsizing as president of my class of 400, to 32 classmates, and upsizing from an 1/8 of an acre lot in the city, to thousands of acres in my backyard.

In order to get me to go without kicking and screaming, my father bribed me with a horse. He was a smart man.

Most of you know that horses are a huge part of my life and I have no problem getting down and dirty with ‘em. And others know me as a gussied up artist, author, and speaker. As Kippling writes, “Never the twain shall meet.” My wardrobe is determined by the activity of the day, yet whatever I’m wearing on the outside, doesn’t change the me I am on the inside. The old idiom, “Don’t judge a book by its cover,” is, well, cliché-like, but, it’s still relevant today.

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A month after we moved to the farm, on a blazingly hot summer day, my father ordered manure from our neighbor’s farm to fertilize the small garden he was tilling. I remember the moment the manure arrived. The fresh droppings reeked and steamed. But that’s not what I remember the most. Our neighbor’s ten year old daughter was sitting plop on top of the manure pile, with a wide grin, happy as a pig in….well you know.

My mother, father and I grabbed our shovels to start pushing the manure off the wagon into the garden. The little girl with the huge smile sitting in the stewing cow chips, looked at my mother incredulously. “What are you afraid to get them rings dirty?” she asked as she pushed the shit off with her bare feet. My mother stared back in horror.

Now my mother is not an outdoor person per se, but she did a great job of humoring her five children and outdoor-loving husband through countless camping trips, homeless animals, moves to the country, etc. But I don’t think I could ever picture her shoveling dung with her feet. On the other-hand I don’t think that grinning girl on top of that manure mountain would ever sit still in a theater either. But I don’t know, I lost track of her. Who am I to judge that she couldn’t or wouldn’t?

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On my solo cross-country journey by horseback, I did a lot of wilderness camping and would go days without eating or showering. Yep, I reeked, I’m sure, like the compost on that hot summer day, but there was something about the solace of the wilderness that helped to heal me on that long journey.

One stop in particular reminded me of that long-ago judgment day with my neighbor’s little girl. Camping for two days in a park outside of a penitentiary in rural Indiana, I was sitting under a tree journaling when a truck hauling a two-horse trailer arrived. I paid them no mind and continued writing. After tacking and mounting up, the owners made their way to me. They were retirees out for a late-summer ride and had never before encountered in their horse park a wild-haired, dirty, lone woman parked under a tree writing with two horses grazing beside her. Was she an escapee from the penitentiary—or worse yet, waiting to help a convict escape on her other horse? Still I paid them no attention as they inched in closer with their mounts—until the wife leaned over and whispered, “Is that a boy or a girl?” I looked up with a smile and said, “I’m a girl with a Master’s and perfectly good hearing.” But I sure didn’t look it.

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Last night, as I was mounting up for a high profile event with my horse, I had to pee. With no facilities around, I sheepishly entered my horse trailer, closed the door, and had to make do sitting plop on top of a manure bucket with freshly steaming dung, just like that little girl from my childhood. Who knew that would be me someday?

This morning after getting all-gussied up for work, I had to stop by my partner’s office to drop something off. He introduced me to the office cleaning lady, a nice enough woman, who totally misread me. She leaned over and said to him, “She’s very pretty, but it looks like she’s afraid to get those nails dirty.” He laughed, “Of anybody I know Linda has no problem getting down and dirty, but she cleans up real ‘purdy!’”

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Although the idiom, “Don’t judge a book by its cover” came about in the journal, American Speech in 1944, the idea has been around for centuries. Heed these wise words written by François Rabelais in La vie de Gargantua et de Pantagruel, “But it’s wrong to be so superficial when you’re weighing men’s work in the balance. Wouldn’t you yourself say that the monk’s robes hardly determine who the monk is? Or that there are some wearing monks’ robes who, on the inside, couldn’t be less monkish? Or that there are people wearing Spanish capes who, when it comes to courage, couldn’t have less of the fearless Spanish in them? And that’s why you have to actually open a book and carefully weigh what’s written there.”1

You have to actually open a book and carefully weigh what’s written there… Relevant words an incredible five centuries later. God, I love words! Down and dirty, but real “purdy!”

1 Wikipedia

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The Centers for Disease Control and Prevention eased its buy kamagra with prescription public health guidance for summer camps Friday, saying fully vaccinated teens don't need to wear face masks or stay 6 feet away from others.Fully vaccinated teens should still wear masks where required, including at local businesses and workplaces, http://buzzbucket.com/buy-cheap-kamagra-oral-jelly/ according to the CDC. Camps can be supportive of staff or campers who choose to continue to wear a mask even if vaccinated, the agency added.While unvaccinated teens should continue to wear masks, the CDC said they generally do not need to wear masks when buy kamagra with prescription outdoors unless they are in an area with "substantial to high transmission," in a crowded setting or attending activities that involve sustained close contact with others.The new guidance from the CDC comes ahead of the Memorial Day holiday weekend, the start of summer vacations and camping season for many Americans.On Wednesday, CDC Director Dr. Rochelle Walensky told House lawmakers that the agency was revising its public health guidance for summer camps to account for vaccinated teens.

Walensky cleared the expanded use of the Pfizer-BioNTech erectile dysfunction treatment in 12- to 15-year-olds two weeks ago.As of Thursday, more than 165 million Americans ages 12 and buy kamagra with prescription older have had at least one dose of a erectile dysfunction treatment, according to data compiled by the CDC. More than buy kamagra with prescription 132 million Americans age 12 and up are fully vaccinated, according to the CDC.The previous guidance from the CDC recommended that all kids, regardless of vaccinations, wear masks, with some exceptions for certain activities such as eating, drinking or swimming. It had been criticized by some public health experts and parents who say the risk of spreading erectile dysfunction treatment is low in outdoor settings and kids have a lower risk of severe illness."My whole goal is to make sure camps can remain open and that outbreaks don't occur," Walensky said during the hearing.

She added that her own children did buy kamagra with prescription not go to camps last summer. "I want camps to be open this summer."The guidance also comes two weeks after the buy kamagra with prescription CDC said fully vaccinated people no longer need to wear a face mask or stay 6 feet away from others in most settings, whether outdoors or indoors. Unvaccinated people should continue to wear masks, the agency said, as they remain at risk of mild or severe illness, death and risk of spreading the disease to others..

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Who should review their eligibility for 2022 health kamagra site insurance subsidies? Resources. The uninsured, many of who will be eligible for free or very low-cost health coverage Consumers who purchased coverage that’s not ACA-compliant Consumers who bought ‘off-exchange’ health plans Consumers enrolled in on-exchange plans, but who haven’t provide income details to the exchange or haven’t reconsidered their options recently For millions of Americans, the open enrollment period (OEP) to shop for 2022 ACA-compliant coverage will be unlike any of the previous eight OEPs. The reason? kamagra site. These consumers will – for the first time – be able to tap into the Affordable Care Act’s premium tax credits (more commonly referred to as health insurance subsidies).

Thanks to the American Rescue Plan, consumers who in previous years might have found themselves outside the eligible level for subsidies – or who may have found that subsidy amounts were so low as to not be enticing – are now among those eligible for premium tax credits. So if you haven’t shopped for health insurance lately, you might be surprised to see how affordable your health coverage options are this fall (starting November 1), and how many plan options are available in your area kamagra site. Millions have already tapped into the subsidies Most people who currently have coverage through the health insurance exchanges have seen improved affordability this year thanks to the American Rescue Plan (ARP). That includes millions of people who were already enrolled in plans when the ARP was enacted last March, as well as millions of others who signed up during the special enrollment period that continued through mid-August in most states (and is still ongoing in some states).

Use our updated kamagra site subsidy calculator to estimate how much you can save on your 2021 health insurance premiums. But there are still millions of others who are either uninsured or have obtained coverage elsewhere. And there are also people who already had coverage in the exchange in 2021 but didn’t take the option to switch to a more robust plan after the ARP was implemented. If you’re in either of these categories, you don’t want to miss the open enrollment kamagra site period in the fall of 2021.

The Build Back Better Act, which is still under consideration in Congress, would extend the ARP’s subsidies and ensure that health insurance stays affordable in 2023 and beyond. But even without any new legislative action, most of the ARP’s subsidy enhancements will remain in place for 2022. That means there will continue to be no upper income limit for premium tax credit (subsidy) eligibility, and the percentage of income that kamagra site people have to pay for the benchmark plan will continue to be lower than it was in prior years. The overall result is that subsidies are larger than they were in the past, and available to more people.

Who should make a point to review their subsidy eligibility?. So who needs to pay close attention this kamagra site fall, during open enrollment?. In reality, anyone who doesn’t have access to Medicare, Medicaid, or an employer-sponsored health plan – because even if you’re already enrolled and happy with the plan you have, auto-renewal is not in your best interest. But there are several groups of people who really need to shop for coverage this fall.

Let’s take a look at what each of these kamagra site groups can expect, and why you shouldn’t let open enrollment pass you by if you’re in one of these categories. 1. The uninsured – eligible for low-cost or NO-cost coverage The majority of uninsured Americans cite the cost of coverage as the reason they don’t have health insurance. Yet millions of those individuals kamagra site are eligible for free or very low-cost health coverage but haven’t yet enrolled.

This has been the case in prior years as well, but premium-free or very low-cost health plans are even more widely available as a result of the ARP. If you’re uninsured because you don’t think health insurance is affordable, know that more than a third of the people who enrolled via HealthCare.gov during the erectile dysfunction treatment/ARP special enrollment period this year purchased plans for less than $10/month. Even if you’ve checked in previous years and couldn’t afford the plans kamagra site that were available, you’ll want to check again this fall, since the subsidy rules have changed since last year. 2.

Consumers enrolled in non-ACA-compliant plans There are millions of Americans who have purchased health coverage that isn’t compliant with the ACA. Most of these plans are kamagra site either less robust than ACA-compliant plans, or use medical underwriting, or both. They include. Health care sharing ministry plans Farm Bureau non-insurance plans Short-term health insurance plans Fixed indemnity plans Grandmothered plans (no longer for sale, but some plans remain in effect) Grandfathered plans (no longer for sale, but some plans remain in effect) Direct primary care (DPC) memberships Discount plans People purchase or keep these plans for a variety of reasons.

But chief among them has long been the fact kamagra site that ACA-compliant coverage was unaffordable – or was assumed to be unaffordable. There are also people who prefer some of the benefits that some of these plans offer (the fellowship of being part of a health care sharing ministry, for instance, or the abundantly available primary care with a DPC membership). But by and large, the reason people choose coverage that isn’t ACA-compliant, or that isn’t even insurance at all, is because ACA-compliant coverage doesn’t fit in their budgets. This has long kamagra site included a few main groups of people.

Those who earned too much to qualify for subsidies, those affected by the “family glitch,” and those who qualified for only minimal subsidy assistance and still felt that the coverage available in the exchange wasn’t affordable. (Another group of people unable to afford coverage are those who earn less than the poverty level in 11 states that have refused to expand Medicaid and thus have a coverage gap. Some people kamagra site in the coverage gap purchase non-ACA-compliant coverage, but this population is also likely to not have any coverage at all. If you or a loved one are in the coverage gap, we encourage you to read this article.) The ARP has not fixed the family glitch or the coverage gap, although there are legislative and administrative solutions under consideration for each of these.

But the ARP has addressed the other two issues, and those provisions remain in place for 2022. The income cap for subsidy eligibility has been eliminated, which means that some kamagra site applicants can qualify for subsidies with income far above 400% of the poverty level. And for those who were already eligible for subsidies, the subsidy amounts are larger than they used to be, making coverage more affordable. So if you are enrolled in any sort of self-purchased health plan that isn’t compliant with the ACA, you owe it to yourself to check your on-exchange options this fall, during the open enrollment period.

Keep in mind that you can do that through the exchange, through an enhanced direct enrollment entity, or with the assistance of a health kamagra site insurance broker. 3. Buyers enrolled in off-exchange health plans There are also people who have “off-exchange” ACA-compliant plans that they’ve purchased directly from an insurance company, without using the exchange. (Note that this is not the same thing as enrolling in an on-exchange plans kamagra site through an enhanced direct enrollment entity, many of which are insurance companies).

There are a variety of reasons people have chosen to enroll in off-exchange health plans over the last several years. And for some kamagra site of those enrollees, 2022 might be the year to switch to an on-exchange plan. Since 2018, some people have opted for off-exchange plans if they weren’t eligible for premium subsidies and wanted to enroll in a Silver-level plan. This was a very rational choice, encouraged by state insurance commissioners and marketplaces alike.

But if you’ve been buying off-exchange coverage in order to get a Silver plan with a lower price tag, the primary point to keep in mind for 2022 is that kamagra site you might find that you’re now eligible for premium subsidies. Just like the people described above, who have enrolled in various non-ACA-compliant plans in an effort to obtain affordable coverage, the elimination of the income limit for subsidy eligibility is a game changer for people who were buying off-exchange coverage to get a lower price on a Silver plan. Some people have opted for off-exchange coverage because their preferred health insurer wasn’t participating in the exchange in their area. This might have been a deciding factor for an applicant who was only eligible for a very small subsidy — or no subsidy at all — and was willing kamagra site to pay full price for an off-exchange plan from the insurer of their choice.

But 2022 is the fourth year in a row with increasing insurer participation in the exchanges, and some big-name insurers are joining or rejoining the exchanges in quite a few states. So if you haven’t checked your on-exchange options in a while, this fall is definitely the time to do so. You might be surprised to see how many options you have, and kamagra site again, how affordable they are. 4.

Consumers enrolled in on-exchange plans, but no income details on file and no recent coverage reconsiderations If you’re already enrolled in an on-exchange plan and you had given the exchange a projection of your income for 2021, you probably saw your subsidy amount increase at some point this year. But if the exchange didn’t have an income on file for you, they wouldn’t have been able to activate a subsidy on your behalf (on the HealthCare.gov platform, subsidy amounts were automatically updated in September for people who hadn’t updated their accounts by that point, but only if you had provided a projected income to kamagra site the exchange when you enrolled in coverage for 2021). And even if your subsidy amount did get updated, you might have remained on the plan you had picked last fall, despite the option to pick a different one after the ARP was enacted. The good news is that you’ll be able to claim your full premium tax credit, for the entirety of 2021, when you file your 2021 tax return (assuming you had on-exchange health coverage throughout the year).

And during the open enrollment period for 2022 coverage, you can provide income information to the kamagra site exchange so that a subsidy is paid on your behalf each month next year. Reconsidering your plan choice during open enrollment might end up being beneficial as well. If you didn’t qualify for a subsidy in the past, or if you only qualified for a modest subsidy, you might have picked a Bronze plan or even a catastrophic plan, in an effort to keep your monthly premiums affordable. But with the ARP in place, you might find that you can kamagra site afford a more robust health plan.

And if your income doesn’t exceed 250% of the poverty level (and especially if it doesn’t exceed 200% of the poverty level), pay close attention to the available Silver plans. The larger subsidies may make it possible for you to afford a Silver plan with built-in cost-sharing reductions that significantly reduce out-of-pocket costs. One other point to keep in mind kamagra site. If you are receiving a premium subsidy this year, be aware that it might change next year due to a new insurer entering the market in your area and offering lower-priced plans.

Here’s more about how this works, and what to consider as you’re shopping for coverage this fall. The takeaway point here? kamagra site. Even if you’ve been happy with your plan, you should check your options during open enrollment. This is not the year to let your plan auto-renew.

Be sure you’ve provided the exchange with an updated income projection for 2022, and actively compare the plans that kamagra site are available to you. It’s possible that a plan with better coverage or a broader provider network might be affordable to you for 2022, even if it was financially out of reach when you checked last fall. Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable kamagra site Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.The American Rescue Plan, signed into law by President Biden on March 11 of this year, included major boosts to the affordability of health plans sold in the ACA marketplace for people of all incomes. Effective through 2022 and likely to be made permanent by pending legislation, the ARP improvements to affordability were as follows. A benchmark Silver plan (the second least expensive Silver plan) with strong cost sharing reduction kamagra site (CSR) subsidies became free to enrollees with household income up to 150% of the Federal Poverty Level (FPL) and costs no more than 2% of income for enrollees with income up to 200% FPL. That’s a maximum of $43 per month for a single person with an income of $25,520.

The previous income cap on subsidy eligibility was removed, so that no one who lacks access to affordable coverage elsewhere (i.e., from an employer) has to pay more than 8.5% of income for a benchmark Silver plan (less at lower incomes). The eliminated cap was 400% FPL ($51,040 for an individual, $104,880 for a family of four), and some households kamagra site with income well above that level now qualify for subsidies. The percentage of income required to buy a benchmark Silver plan was reduced at all income levels. Anyone who received any unemployment insurance income during 2021 was eligible for free high-CSR Silver coverage.

(Note that kamagra site the pending legislation calls for this subsidy enhancement to be extended by several years, but not necessarily made permanent.) Our 2022 Open Enrollment Guide. Everything you need to know to enroll in an affordable individual-market health plan. Preceding and then coinciding with these major subsidy boosts, the Biden administration had opened an emergency Special Enrollment Period (SEP) running from February 15 through August 15 in the 36 states that use the federal ACA exchange, HealthCare.gov. The SEP, implemented to help Americans get covered during the kamagra, functioned like a second open enrollment period kamagra site.

Anyone who lacked access to affordable coverage from other sources (e.g., employers) could enroll in a marketplace plan. The 15 state-based exchanges also opened emergency SEPs, with somewhat different durations and conditions, summarized here. ARP prompted an enrollment surge during the 2021 SEP The enhanced subsidies were posted on HealthCare.gov on April 1, and in the state-run exchanges within kamagra site a few weeks of that date. Existing enrollees were encouraged to update their information and get the new subsidies credited, and were allowed to switch plans if they chose.

Americans responded with a major surge in new enrollment and enrollment upgrades. From February 15 kamagra site through August 15. More than 2.8 million people enrolled in new health coverage. Of new kamagra site enrollees, 91% qualified for premium subsidies.

Of new enrollees, 44% obtained coverage for less than $10 per month. Most of these enrollees (41% in HealthCare.gov states) received free coverage with the highest level of CSR. As a kamagra site result, the median deductible fell from $750 in 2020 to $50 this year – meaning that half of enrollees obtained a plan with a deductible at or below that level (most of them in high-CSR Silver plans). The average premium paid by new consumers during the SEP (Feb.

15 – Aug. 15) fell 30%, from $117 kamagra site in 2020 to $81 in 2021. Marketplace enrollment in August 2021, at 12.2 million, was 15% higher than in August 2020, the previous August high, and 22% above the pre-kamagra August high (see p. 14 here) recorded in 2016.

More than 200,000 new and existing enrollees kamagra site qualified for free high-CSR Silver plans because they had received unemployment insurance income in 2021. Savings were also dramatic for existing marketplace enrollees. 8 million existing enrollees reduced the premiums on their existing plans or obtained new plans after ARP implementation. Existing enrollees reduced their premiums by kamagra site 50%, or by $67 per month, on average.

My premium went down how much?. To get a sense of the extent to which the ARP reduced enrollee costs (or encouraged people who might previously have considered coverage too expensive to enroll), consider these examples. In November 2020, a 40-year-old in Miami with an income of $24,000 per year would have paid $115 per month kamagra site for the least expensive available Silver plan, with a $1,500 deductible, and $119 per month for the second-cheapest Silver plan, with a $0 deductible. Thanks to the ARP, those plans would now cost this person $26 and $30 per month, respectively.

In November 2020, a pair of 60-year-olds in Dallas, Texas with an income of $70,000 – slightly over the income cap for premium subsidies, which the ARP eliminated – would have had to pay $1,669 per month for the lowest cost Gold plan, with a $2,300 deductible (Gold plans are cheaper than Silver Plans in Dallas), or $1,228 for the lowest cost Bronze plan, with an $8,550 deductible. Now, this couple can choose to pay $393 per month for the Gold plan (which includes free doctor visits kamagra site and generic drug prescriptions, neither subject to the deductible), or consider two free Bronze plans with deductibles over $8,000, a $2/month Bronze plan with a $6,100 deductible, and other options. A BlueCross Silver plan available for $420 per month might also be in the mix, if, say, the provider network is preferable. Which states saw the biggest gains in new enrollees?.

The new enrollment surge – and the savings – was particularly strong in twelve states that had not kamagra site enacted the ACA Medicaid expansion as of June 2021. Due to their failure to expand Medicaid, these states have a “coverage gap” for people who earn too little to qualify for marketplace coverage (less than 100% FPL, or $12,760 for an individual in 2021) but mostly also don’t qualify for Medicaid because of their states’ restrictive Medicaid eligibility. (That excludes Wisconsin, which has not enacted the ACA expansion but grants Medicaid eligibility to adults with income up to 100% FPL. Oklahoma, which expanded Medicaid beginning in July 2021, and Missouri, which will begin covering new Medicaid expansion enrollees in October, are included.) These twelve states – Alabama, Florida, Georgia, Kansas, Missouri, Mississippi, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas and Wyoming – accounted for 1.55 million new enrollees during the SEP, kamagra site or 55% of all new enrollees nationally.

In the non-expansion states, eligibility for marketplace subsidies begins at 100% FPL, as opposed to 138% FPL in Medicaid expansion states, where adults below that threshold qualify for Medicaid. Accordingly, in these states, about half of enrollees qualified for free high-CSR coverage, reporting incomes between 100% and 150% FPL. In these states, enrollment as of August 2021 (6.0 million) was 44% above enrollment in kamagra site August 2019, the last pre-kamagra year (4.2 million). More than 2 million people in non-expansion states are estimated to be stuck in the coverage gap – ineligible both for Medicaid and for ACA premium subsidies.

For people in these states, reporting an income just below or just above 100% FPL ($12,760 for an individual, $26,200 for a family of four) is the difference between receiving no help at all and having access to free Silver coverage with high CSR and low out-of-pocket costs. It’s important to keep in mind that the application for marketplace coverage requires an income estimate – and many people, unaware of the kamagra site minimum income requirement, underestimate their potential income. For tips on how to make sure you leave no stone unturned in seeking help paying for coverage, see this post. What do these numbers mean for 2022 open enrollment?.

As open enrollment for 2022 approaches (it kamagra site begins on November 1), the subsidies enhanced by the ARP remain in place for 2022. As Congress hashes out new investments for coming years in a pending budget bill, the pressure is intense to keep this good thing going in future years. As of now, with the sad exception of those stuck in the coverage gap in states that still refuse to enact the ACA Medicaid expansion, any citizen or legally present noncitizen who lacks access to other forms of affordable coverage should be able to find it in the marketplace. If you need coverage, make sure to check out your kamagra site options on HealthCare.gov or your state exchange.

The word that ACA marketplace plans are more affordable than ever has not yet reached many of the people who need coverage and qualify for premium subsidies. The Kaiser Family Foundation estimated in May that nearly 11 million uninsured people were subsidy-eligible. ACA enrollment assisters consistently report that kamagra site many people who are eligible for coverage have no idea what’s on offer. The Biden administration is trying to change that.

After years of radical cuts in federal funds for enrollment assistance, the administration this year has allocated a record $80 million to fund nonprofit enrollment “navigator” groups charged with outreach as well as enrollment assistance. The Urban Institute forecast that if the ARP subsidies are made permanent – solidifying the perception that truly affordable kamagra site coverage is here to stay — enrollment would increase by more than 5 million in 2022. The emergency SEP provided a jump start, boosting coverage as of August more than 1.5 million above the August 2020 level. In a fraught and complex legislative session, Congress will most likely – though not certainly – do its part and extend the subsidies beyond 2022.

There is certainly room for enrollment kamagra site to run higher in the open enrollment season that begins on November 1. Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Digital Media Award kamagra site.

He holds a Ph.D. In English literature from the University of Rochester..

Who should review their eligibility for 2022 health insurance buy kamagra with prescription subsidies?. The uninsured, many of who will be eligible for free or very low-cost health coverage Consumers who purchased coverage that’s not ACA-compliant Consumers who bought ‘off-exchange’ health plans Consumers enrolled in on-exchange plans, but who haven’t provide income details to the exchange or haven’t reconsidered their options recently For millions of Americans, the open enrollment period (OEP) to shop for 2022 ACA-compliant coverage will be unlike any of the previous eight OEPs. The reason? buy kamagra with prescription.

These consumers will – for the first time – be able to tap into the Affordable Care Act’s premium tax credits (more commonly referred to as health insurance subsidies). Thanks to the American Rescue Plan, consumers who in previous years might have found themselves outside the eligible level for subsidies – or who may have found that subsidy amounts were so low as to not be enticing – are now among those eligible for premium tax credits. So if you haven’t shopped for health insurance lately, you might be surprised to see how affordable your health coverage options are this fall (starting November 1), and how many plan options are available in buy kamagra with prescription your area.

Millions have already tapped into the subsidies Most people who currently have coverage through the health insurance exchanges have seen improved affordability this year thanks to the American Rescue Plan (ARP). That includes millions of people who were already enrolled in plans when the ARP was enacted last March, as well as millions of others who signed up during the special enrollment period that continued through mid-August in most states (and is still ongoing in some states). Use our buy kamagra with prescription updated subsidy calculator to estimate how much you can save on your 2021 health insurance premiums.

But there are still millions of others who are either uninsured or have obtained coverage elsewhere. And there are also people who already had coverage in the exchange in 2021 but didn’t take the option to switch to a more robust plan after the ARP was implemented. If you’re in either of these categories, you don’t want to miss the open enrollment period in the fall of buy kamagra with prescription 2021.

The Build Back Better Act, which is still under consideration in Congress, would extend the ARP’s subsidies and ensure that health insurance stays affordable in 2023 and beyond. But even without any new legislative action, most of the ARP’s subsidy enhancements will remain in place for 2022. That means there will continue to be no buy kamagra with prescription upper income limit for premium tax credit (subsidy) eligibility, and the percentage of income that people have to pay for the benchmark plan will continue to be lower than it was in prior years.

The overall result is that subsidies are larger than they were in the past, and available to more people. Who should make a point to review their subsidy eligibility?. So who needs to pay close attention this fall, during open buy kamagra with prescription enrollment?.

In reality, anyone who doesn’t have access to Medicare, Medicaid, or an employer-sponsored health plan – because even if you’re already enrolled and happy with the plan you have, auto-renewal is not in your best interest. But there are several groups of people who really need to shop for coverage this fall. Let’s take a look at what each of these groups can expect, and why you shouldn’t let open enrollment pass you buy kamagra with prescription by if you’re in one of these categories.

1. The uninsured – eligible for low-cost or NO-cost coverage The majority of uninsured Americans cite the cost of coverage as the reason they don’t have health insurance. Yet millions of those individuals are eligible buy kamagra with prescription for free or very low-cost health coverage but haven’t yet enrolled.

This has been the case in prior years as well, but premium-free or very low-cost health plans are even more widely available as a result of the ARP. If you’re uninsured because you don’t think health insurance is affordable, know that more than a third of the people who enrolled via HealthCare.gov during the erectile dysfunction treatment/ARP special enrollment period this year purchased plans for less than $10/month. Even if you’ve checked in previous years and couldn’t afford the plans buy kamagra with prescription that were available, you’ll want to check again this fall, since the subsidy rules have changed since last year.

2. Consumers enrolled in non-ACA-compliant plans There are millions of Americans who have purchased health coverage that isn’t compliant with the ACA. Most of these plans are either less buy kamagra with prescription robust than ACA-compliant plans, or use medical underwriting, or both.

They include. Health care sharing ministry plans Farm Bureau non-insurance plans Short-term health insurance plans Fixed indemnity plans Grandmothered plans (no longer for sale, but some plans remain in effect) Grandfathered plans (no longer for sale, but some plans remain in effect) Direct primary care (DPC) memberships Discount plans People purchase or keep these plans for a variety of reasons. But chief among buy kamagra with prescription them has long been the fact that ACA-compliant coverage was unaffordable – or was assumed to be unaffordable.

There are also people who prefer some of the benefits that some of these plans offer (the fellowship of being part of a health care sharing ministry, for instance, or the abundantly available primary care with a DPC membership). But by and large, the reason people choose coverage that isn’t ACA-compliant, or that isn’t even insurance at all, is because ACA-compliant coverage doesn’t fit in their budgets. This has long included a few main groups buy kamagra with prescription of people.

Those who earned too much to qualify for subsidies, those affected by the “family glitch,” and those who qualified for only minimal subsidy assistance and still felt that the coverage available in the exchange wasn’t affordable. (Another group of people unable to afford coverage are those who earn less than the poverty level in 11 states that have refused to expand Medicaid and thus have a coverage gap. Some people in the coverage gap purchase non-ACA-compliant coverage, but this population buy kamagra with prescription is also likely to not have any coverage at all.

If you or a loved one are in the coverage gap, we encourage you to read this article.) The ARP has not fixed the family glitch or the coverage gap, although there are legislative and administrative solutions under consideration for each of these. But the ARP has addressed the other two issues, and those provisions remain in place for 2022. The income cap for subsidy buy kamagra with prescription eligibility has been eliminated, which means that some applicants can qualify for subsidies with income far above 400% of the poverty level.

And for those who were already eligible for subsidies, the subsidy amounts are larger than they used to be, making coverage more affordable. So if you are enrolled in any sort of self-purchased health plan that isn’t compliant with the ACA, you owe it to yourself to check your on-exchange options this fall, during the open enrollment period. Keep in mind that you can do that through the exchange, through an enhanced direct enrollment entity, or with the assistance buy kamagra with prescription of a health insurance broker.

3. Buyers enrolled in off-exchange health plans There are also people who have “off-exchange” ACA-compliant plans that they’ve purchased directly from an insurance company, without using the exchange. (Note that this is not the same thing as enrolling in buy kamagra with prescription an on-exchange plans through an enhanced direct enrollment entity, many of which are insurance companies).

There are a variety of reasons people have chosen to enroll in off-exchange health plans over the last several years. And for some of those enrollees, 2022 might be the buy kamagra with prescription year to switch to an on-exchange plan. Since 2018, some people have opted for off-exchange plans if they weren’t eligible for premium subsidies and wanted to enroll in a Silver-level plan.

This was a very rational choice, encouraged by state insurance commissioners and marketplaces alike. But if you’ve been buying off-exchange coverage in order to get a Silver plan with buy kamagra with prescription a lower price tag, the primary point to keep in mind for 2022 is that you might find that you’re now eligible for premium subsidies. Just like the people described above, who have enrolled in various non-ACA-compliant plans in an effort to obtain affordable coverage, the elimination of the income limit for subsidy eligibility is a game changer for people who were buying off-exchange coverage to get a lower price on a Silver plan.

Some people have opted for off-exchange coverage because their preferred health insurer wasn’t participating in the exchange in their area. This might have been a deciding factor for an applicant who was only eligible for a very small subsidy — or no subsidy at buy kamagra with prescription all — and was willing to pay full price for an off-exchange plan from the insurer of their choice. But 2022 is the fourth year in a row with increasing insurer participation in the exchanges, and some big-name insurers are joining or rejoining the exchanges in quite a few states.

So if you haven’t checked your on-exchange options in a while, this fall is definitely the time to do so. You might be surprised to see how many options buy kamagra with prescription you have, and again, how affordable they are. 4.

Consumers enrolled in on-exchange plans, but no income details on file and no recent coverage reconsiderations If you’re already enrolled in an on-exchange plan and you had given the exchange a projection of your income for 2021, you probably saw your subsidy amount increase at some point this year. But if the exchange didn’t have an income on file for you, they wouldn’t have been buy kamagra with prescription able to activate a subsidy on your behalf (on the HealthCare.gov platform, subsidy amounts were automatically updated in September for people who hadn’t updated their accounts by that point, but only if you had provided a projected income to the exchange when you enrolled in coverage for 2021). And even if your subsidy amount did get updated, you might have remained on the plan you had picked last fall, despite the option to pick a different one after the ARP was enacted.

The good news is that you’ll be able to claim your full premium tax credit, for the entirety of 2021, when you file your 2021 tax return (assuming you had on-exchange health coverage throughout the year). And during the open enrollment period for 2022 coverage, you can provide income information to the exchange so that a buy kamagra with prescription subsidy is paid on your behalf each month next year. Reconsidering your plan choice during open enrollment might end up being beneficial as well.

If you didn’t qualify for a subsidy in the past, or if you only qualified for a modest subsidy, you might have picked a Bronze plan or even a catastrophic plan, in an effort to keep your monthly premiums affordable. But with the ARP in place, you might find that you buy kamagra with prescription can afford a more robust health plan. And if your income doesn’t exceed 250% of the poverty level (and especially if it doesn’t exceed 200% of the poverty level), pay close attention to the available Silver plans.

The larger subsidies may make it possible for you to afford a Silver plan with built-in cost-sharing reductions that significantly reduce out-of-pocket costs. One other buy kamagra with prescription point to keep in mind. If you are receiving a premium subsidy this year, be aware that it might change next year due to a new insurer entering the market in your area and offering lower-priced plans.

Here’s more about how this works, and what to consider as you’re shopping for coverage this fall. The takeaway buy kamagra with prescription point here?. Even if you’ve been happy with your plan, you should check your options during open enrollment.

This is not the year to let your plan auto-renew. Be sure you’ve provided the exchange with an updated income projection for 2022, buy kamagra with prescription and actively compare the plans that are available to you. It’s possible that a plan with better coverage or a broader provider network might be affordable to you for 2022, even if it was financially out of reach when you checked last fall.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational buy kamagra with prescription pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.The American Rescue Plan, signed into law by President Biden on March 11 of this year, included major boosts to the affordability of health plans sold in the ACA marketplace for people of all incomes.

Effective through 2022 and likely to be made permanent by pending legislation, the ARP improvements to affordability were as follows. A benchmark Silver plan (the second least expensive Silver plan) with strong cost sharing reduction (CSR) subsidies became free to enrollees with household income up to 150% of the Federal Poverty Level (FPL) and costs no more than 2% of income for enrollees with income up buy kamagra with prescription to 200% FPL. That’s a maximum of $43 per month for a single person with an income of $25,520.

The previous income cap on subsidy eligibility was removed, so that no one who lacks access to affordable coverage elsewhere (i.e., from an employer) has to pay more than 8.5% of income for a benchmark Silver plan (less at lower incomes). The eliminated buy kamagra with prescription cap was 400% FPL ($51,040 for an individual, $104,880 for a family of four), and some households with income well above that level now qualify for subsidies. The percentage of income required to buy a benchmark Silver plan was reduced at all income levels.

Anyone who received any unemployment insurance income during 2021 was eligible for free high-CSR Silver coverage. (Note that the pending legislation calls for this subsidy enhancement to be buy kamagra with prescription extended by several years, but not necessarily made permanent.) Our 2022 Open Enrollment Guide. Everything you need to know to enroll in an affordable individual-market health plan.

Preceding and then coinciding with these major subsidy boosts, the Biden administration had opened an emergency Special Enrollment Period (SEP) running from February 15 through August 15 in the 36 states that use the federal ACA exchange, HealthCare.gov. The SEP, implemented to buy kamagra with prescription help Americans get covered during the kamagra, functioned like a second open enrollment period. Anyone who lacked access to affordable coverage from other sources (e.g., employers) could enroll in a marketplace plan.

The 15 state-based exchanges also opened emergency SEPs, with somewhat different durations and conditions, summarized here. ARP prompted an enrollment surge during the 2021 SEP The enhanced subsidies were posted on HealthCare.gov on April 1, and in the state-run exchanges within a few buy kamagra with prescription weeks of that date. Existing enrollees were encouraged to update their information and get the new subsidies credited, and were allowed to switch plans if they chose.

Americans responded with a major surge in new enrollment and enrollment upgrades. From February buy kamagra with prescription 15 through August 15. More than 2.8 million people enrolled in new health coverage.

Of new enrollees, 91% qualified for premium subsidies buy kamagra with prescription. Of new enrollees, 44% obtained coverage for less than $10 per month. Most of these enrollees (41% in HealthCare.gov states) received free coverage with the highest level of CSR.

As a result, the median deductible fell from $750 in 2020 to $50 this year – meaning that half of enrollees obtained a plan with buy kamagra with prescription a deductible at or below that level (most of them in high-CSR Silver plans). The average premium paid by new consumers during the SEP (Feb. 15 – Aug.

15) fell 30%, from $117 in 2020 buy kamagra with prescription to $81 in 2021. Marketplace enrollment in August 2021, at 12.2 million, was 15% higher than in August 2020, the previous August high, and 22% above the pre-kamagra August high (see p. 14 here) recorded in 2016.

More than 200,000 new and existing buy kamagra with prescription enrollees qualified for free high-CSR Silver plans because they had received unemployment insurance income in 2021. Savings were also dramatic for existing marketplace enrollees. 8 million existing enrollees reduced the premiums on their existing plans or obtained new plans after ARP implementation.

Existing enrollees reduced their premiums by 50%, or buy kamagra with prescription by $67 per month, on average. My premium went down how much?. To get a sense of the extent to which the ARP reduced enrollee costs (or encouraged people who might previously have considered coverage too expensive to enroll), consider these examples.

In November 2020, a 40-year-old in Miami with an income of $24,000 per year would have paid $115 per month for the buy kamagra with prescription least expensive available Silver plan, with a $1,500 deductible, and $119 per month for the second-cheapest Silver plan, with a $0 deductible. Thanks to the ARP, those plans would now cost this person $26 and $30 per month, respectively. In November 2020, a pair of 60-year-olds in Dallas, Texas with an income of $70,000 – slightly over the income cap for premium subsidies, which the ARP eliminated – would have had to pay $1,669 per month for the lowest cost Gold plan, with a $2,300 deductible (Gold plans are cheaper than Silver Plans in Dallas), or $1,228 for the lowest cost Bronze plan, with an $8,550 deductible.

Now, this couple can choose to pay $393 per month for the Gold plan (which includes free doctor visits and generic drug prescriptions, neither subject to the deductible), or consider two free buy kamagra with prescription Bronze plans with deductibles over $8,000, a $2/month Bronze plan with a $6,100 deductible, and other options. A BlueCross Silver plan available for $420 per month might also be in the mix, if, say, the provider network is preferable. Which states saw the biggest gains in new enrollees?.

The new enrollment surge – and the savings – was particularly strong in twelve states that had not enacted the ACA Medicaid expansion as buy kamagra with prescription of June 2021. Due to their failure to expand Medicaid, these states have a “coverage gap” for people who earn too little to qualify for marketplace coverage (less than 100% FPL, or $12,760 for an individual in 2021) but mostly also don’t qualify for Medicaid because of their states’ restrictive Medicaid eligibility. (That excludes Wisconsin, which has not enacted the ACA expansion but grants Medicaid eligibility to adults with income up to 100% FPL.

Oklahoma, which expanded Medicaid beginning in July 2021, and Missouri, which will begin covering new Medicaid expansion enrollees in October, are included.) These twelve states – Alabama, Florida, Georgia, Kansas, Missouri, Mississippi, North Carolina, Oklahoma, South Carolina, buy kamagra with prescription South Dakota, Tennessee, Texas and Wyoming – accounted for 1.55 million new enrollees during the SEP, or 55% of all new enrollees nationally. In the non-expansion states, eligibility for marketplace subsidies begins at 100% FPL, as opposed to 138% FPL in Medicaid expansion states, where adults below that threshold qualify for Medicaid. Accordingly, in these states, about half of enrollees qualified for free high-CSR coverage, reporting incomes between 100% and 150% FPL.

In these states, enrollment as of August 2021 (6.0 buy kamagra with prescription million) was 44% above enrollment in August 2019, the last pre-kamagra year (4.2 million). More than 2 million people in non-expansion states are estimated to be stuck in the coverage gap – ineligible both for Medicaid and for ACA premium subsidies. For people in these states, reporting an income just below or just above 100% FPL ($12,760 for an individual, $26,200 for a family of four) is the difference between receiving no help at all and having access to free Silver coverage with high CSR and low out-of-pocket costs.

It’s important to keep in mind that the application for marketplace coverage buy kamagra with prescription requires an income estimate – and many people, unaware of the minimum income requirement, underestimate their potential income. For tips on how to make sure you leave no stone unturned in seeking help paying for coverage, see this post. What do these numbers mean for 2022 open enrollment?.

As open enrollment for 2022 approaches (it begins on November 1), the subsidies enhanced by the ARP remain buy kamagra with prescription in place for 2022. As Congress hashes out new investments for coming years in a pending budget bill, the pressure is intense to keep this good thing going in future years. As of now, with the sad exception of those stuck in the coverage gap in states that still refuse to enact the ACA Medicaid expansion, any citizen or legally present noncitizen who lacks access to other forms of affordable coverage should be able to find it in the marketplace.

If you need buy kamagra with prescription coverage, make sure to check out your options on HealthCare.gov or your state exchange. The word that ACA marketplace plans are more affordable than ever has not yet reached many of the people who need coverage and qualify for premium subsidies. The Kaiser Family Foundation estimated in May that nearly 11 million uninsured people were subsidy-eligible.

ACA enrollment assisters consistently report that many people who are eligible for coverage have no buy kamagra with prescription idea what’s on offer. The Biden administration is trying to change that. After years of radical cuts in federal funds for enrollment assistance, the administration this year has allocated a record $80 million to fund nonprofit enrollment “navigator” groups charged with outreach as well as enrollment assistance.

The Urban Institute forecast that if the ARP subsidies are made permanent – solidifying buy kamagra with prescription the perception that truly affordable coverage is here to stay — enrollment would increase by more than 5 million in 2022. The emergency SEP provided a jump start, boosting coverage as of August more than 1.5 million above the August 2020 level. In a fraught and complex legislative session, Congress will most likely – though not certainly – do its part and extend the subsidies beyond 2022.

There is certainly room for enrollment to run higher in buy kamagra with prescription the open enrollment season that begins on November 1. Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic.

He is the winner of the National Institute of Health Care Management’s 2016 Digital Media Award. He holds a Ph.D. In English literature from the University of Rochester..

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Instead, practice kamagra oral jelly usa separating yourself from your phone for periods of time. Some ways to do this. Don’t check any screen until you’ve been up for a half hour. Take a walk or go to lunch without your phone kamagra oral jelly usa. At dinner, try a “first-to-look” game.

Put all phones at the center of the table. The first one to look does the dishes or pays the tab! kamagra oral jelly usa. Why Am I Doing This?. Incoming texts, alerts, emails and vibrations are a near-constant presence in our lives, and these interruptions can take a toll on our minds, our sleep and our ability to engage with others. In one study, just the presence kamagra oral jelly usa of a cellphone in the room made people feel less connected to conversation partners.Screens don’t need to be banned entirely, but putting away our tech from time to time can help us focus on real life.To ease your dependency on screens, try creating some no-phone and no-screen zones in your home, work and play spaces.

To get the whole family involved, make a game out of not looking at your phones. 1. In the bed. Get a real alarm clock and charge your phone or tablet in another room overnight. It’s a lot easier to resist your tech when it’s not within an arm’s reach.

Getting tech out of the bedroom is a proven way to help you sleep better. The blue light from your screen has the same effect on your brain as sunlight, which means it wakes you up just when you want to be drifting off. For children, the allure of technology is strong. In one study, even having an unused device in the bedroom increased a child’s risk for sleep problems.2. At lunch.

When you’re at work, practice taking phone-free lunches. Leave your phone in your desk drawer, and suggest that your dining partners do the same. It will feel strange at first, but you’ll likely grow to like the daily break from emails and texts. One study found that just holding a phone or having it at the table, even if you don’t look at it, has an effect on those you’re with. In that study, people felt less empathy and social connection when their dining partner had their phone on the table or in their hand.3.

In the outdoors. Leave the phone at home when you walk the dog, take the kids for a stroll or go for a bike ride, hike or jog. If you’re in a new place and want to take photos, it’s OK to bring the phone — just put it in airplane mode, so you can only use it as a camera and you won’t be tempted by the pings of texts, tweets or emails.4. At the table. It’s better to keep phones away from the table during meals, and zero tolerance needs to apply to everyone , not just the children.

If you liked the “first-to-look” game, there are other games to try for meal-time screen use. Consider a “one glance policy,” which allows everyone at the table to glance, just once, at their phone during the meal. Or, make a rule that the phone can be used only once at dinner, and only for the benefit of the whole group, to Google a fact, resolve debates or enlighten the table with meaningless trivia. Anyone who uses the Google excuse to check email or texts loses all phone privileges at the next meal!. AdvertisementContinue reading the main storyAdvertisementContinue reading the main storyFresh Start ChallengeDay 4.

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What superpower would you want?. For today’s challenge, find a friend or partner and ask a connection question. Science tells us that when you skip the small talk and instead reveal something about yourself, you form deeper ties to the person you’re talking to, whether it’s a friend, family member or romantic partner. Pick a question (more options are below) and get talking!. Why Am I Doing This?.

The kamagra has strengthened some relationships and fractured others. Many people say they’ve forgotten how to talk to people and find the idea of socializing again to be daunting. Fortunately, relationship researchers have studied the best way for humans to forge deeper connections.A number of studies show that when we reveal our opinions and feelings rather than just basic facts about our lives, we’re more likely to build close relationships. Self-disclosure is the concept behind a study called “The Experimental Generation of Interpersonal Closeness,” led by Arthur Aron, a scientist at State University of New York at Stony Brook. Dr.

Aron’s goal was to create closeness between two strangers in a laboratory setting for research purposes.Knowing that self-disclosure fosters closeness, Dr. Aron and his colleagues theorized that they could accelerate the process of getting closer by getting strangers to talk for 45 minutes about a series of personal questions, each more revealing than the last. They called it, “sustained, escalating, reciprocal, personal self-disclosure.” (They soon learned that their questionnaire had a lasting effect after reports of ongoing closeness between the pairs in the study — including one couple who got married.)“The questions were designed to get increasingly revealing,” said Dr. Aron. €œWe also throw in items where you let the other person know you like them.

That turns out to be a very important thing in establishing closeness.”Although the questions became known as the 36 questions that lead to love, Dr. Aron points out that the goal of the questions is not to spur romance. Most of the time, the questions will help strangers to become friends, friends to become closer and romantic partners to feel more connected.“One of the main reasons self-disclosure is a good thing for friendships or romantic relationships is that it gives the other person the opportunity to be responsive,” said Dr. Aron. Asking and answering the questions lets you know “they understand, and they hear, and they value what you’re feeling.”The questions are broken up into three sets.

The early questions help people get comfortable with each other, and the later questions are more probing. You can pick one question or choose a few from each set. Here are some of the questions from the study. You can find the complete list here.Set I1. Given the choice of anyone in the world, whom would you want as a dinner guest?.

2. What would constitute a “perfect” day for you?. 3. What are three things you and the person you’re talking to appear to have in common.4. If you could wake up tomorrow having gained any one quality or ability, what would it be?.

Set II5. Is there something that you’ve dreamed of doing for a long time?. Why haven’t you done it?. 6. What is the greatest accomplishment of your life?.

7. What is your most treasured memory?. 8. Alternate sharing something you consider a positive characteristic of your conversation partner. Share a total of five items.Set III9.

Make three true “we” statements about yourself and the person you’re talking to. For instance, you could finish this sentence. €œWe are both in this room feeling … ”10. Share with your friend or partner an embarrassing moment in your life.11. Your house, containing everything you own, catches fire.

After saving your loved ones and pets, you have time to safely make a final dash to save any one item. What would it be?. Why?. 12. Share a personal problem and ask your friend or partner’s advice on how he or she might handle it.

Ask them to reflect back to you how you seem to be feeling about the problem you have chosen.AdvertisementContinue reading the main story.

AdvertisementContinue reading the main storyFresh Start ChallengeDay buy kamagra with prescription 5. Resist Your TechMay 21, 2021, 6:32 a.m. ETMay 21, buy kamagra with prescription 2021, 6:32 a.m. ETCredit...Nathalie LeesLeer en españolThe Challenge Many of us relied on screens to stay connected and entertained during the restrictions of kamagra life. To break your family or friends’ screen habits, you don’t have to go cold turkey.

Instead, practice separating yourself from your phone for buy kamagra with prescription periods of time. Some ways to do this. Don’t check any screen until you’ve been up for a half hour. Take a walk or go to lunch buy kamagra with prescription without your phone. At dinner, try a “first-to-look” game.

Put all phones at the center of the table. The first one to look buy kamagra with prescription does the dishes or pays the tab!. Why Am I Doing This?. Incoming texts, alerts, emails and vibrations are a near-constant presence in our lives, and these interruptions can take a toll on our minds, our sleep and our ability to engage with others. In one study, just the presence of a cellphone in the room made people feel less connected to conversation partners.Screens don’t need to be banned entirely, but putting away our tech from time to time can help us focus on buy kamagra with prescription real life.To ease your dependency on screens, try creating some no-phone and no-screen zones in your home, work and play spaces.

To get the whole family involved, make a game out of not looking at your phones. 1. In the bed. Get a real alarm clock and charge your phone or tablet in another room overnight. It’s a lot easier to resist your tech when it’s not within an arm’s reach.

Getting tech out of the bedroom is a proven way to help you sleep better. The blue light from your screen has the same effect on your brain as sunlight, which means it wakes you up just when you want to be drifting off. For children, the allure of technology is strong. In one study, even having an unused device in the bedroom increased a child’s risk for sleep problems.2. At lunch.

When you’re at work, practice taking phone-free lunches. Leave your phone in your desk drawer, and suggest that your dining partners do the same. It will feel strange at first, but you’ll likely grow to like the daily break from emails and texts. One study found that just holding a phone or having it at the table, even if you don’t look at it, has an effect on those you’re with. In that study, people felt less empathy and social connection when their dining partner had their phone on the table or in their hand.3.

In the outdoors. Leave the phone at home when you walk the dog, take the kids for a stroll or go for a bike ride, hike or jog. If you’re in a new place and want to take photos, it’s OK to bring the phone — just put it in airplane mode, so you can only use it as a camera and you won’t be tempted by the pings of texts, tweets or emails.4. At the table. It’s better to keep phones away from the table during meals, and zero tolerance needs to apply to everyone , not just the children.

If you liked the “first-to-look” game, there are other games to try for meal-time screen use. Consider a “one glance policy,” which allows everyone at the table to glance, just once, at their phone during the meal. Or, make a rule that the phone can be used only once at dinner, and only for the benefit of the whole group, to Google a fact, resolve debates or enlighten the table with meaningless trivia. Anyone who uses the Google excuse to check email or texts loses all phone privileges at the next meal!. AdvertisementContinue reading the main storyAdvertisementContinue reading the main storyFresh Start ChallengeDay 4.

Ask a Connection Question!. May 20, 2021, 5:00 a.m. ETMay 20, 2021, 5:00 a.m. ETCredit...Nathalie LeesLeer en españolThe ChallengeWhat was your role in the school play?. Your most embarrassing moment?.

What superpower would you want?. For today’s challenge, find a friend or partner and ask a connection question. Science tells us that when you skip the small talk and instead reveal something about yourself, you form deeper ties to the person you’re talking to, whether it’s a friend, family member or romantic partner. Pick a question (more options are below) and get talking!. Why Am I Doing This?.

The kamagra has strengthened some relationships and fractured others. Many people say they’ve forgotten how to talk to people and find the idea of socializing again to be daunting. Fortunately, relationship researchers have studied the best way for humans to forge deeper connections.A number of studies show that when we reveal our opinions and feelings rather than just basic facts about our lives, we’re more likely to build close relationships. Self-disclosure is the concept behind a study called “The Experimental Generation of Interpersonal Closeness,” led by Arthur Aron, a scientist at State University of New York at Stony Brook. Dr.

Aron’s goal was to create closeness between two strangers in a laboratory setting for research purposes.Knowing that self-disclosure fosters closeness, Dr. Aron and his colleagues theorized that they could accelerate the process of getting closer by getting strangers to talk for 45 minutes about a series of personal questions, each more revealing than the last. They called it, “sustained, escalating, reciprocal, personal self-disclosure.” (They soon learned that their questionnaire had a lasting effect after reports of ongoing closeness between the pairs in the study — including one couple who got married.)“The questions were designed to get increasingly revealing,” said Dr. Aron. €œWe also throw in items where you let the other person know you like them.

That turns out to be a very important thing in establishing closeness.”Although the questions became known as the 36 questions that lead to love, Dr. Aron points out that the goal of the questions is not to spur romance. Most of the time, the questions will help strangers to become friends, friends to become closer and romantic partners to feel more connected.“One of the main reasons self-disclosure is a good thing for friendships or romantic relationships is that it gives the other person the opportunity to be responsive,” said Dr. Aron. Asking and answering the questions lets you know “they understand, and they hear, and they value what you’re feeling.”The questions are broken up into three sets.

The early questions help people get comfortable with each other, and the later questions are more probing. You can pick one question or choose a few from each set. Here are some of the questions from the study. You can find the complete list here.Set I1. Given the choice of anyone in the world, whom would you want as a dinner guest?.

2. What would constitute a “perfect” day for you?. 3. What are three things you and the person you’re talking to appear to have in common.4. If you could wake up tomorrow having gained any one quality or ability, what would it be?.

Set II5. Is there something that you’ve dreamed of doing for a long time?. Why haven’t you done it?. 6. What is the greatest accomplishment of your life?.

7. What is your most treasured memory?. 8. Alternate sharing something you consider a positive characteristic of your conversation partner. Share a total of five items.Set III9.

Make three true “we” statements about yourself and the person you’re talking to. For instance, you could finish this sentence. €œWe are both in this room feeling … ”10. Share with your friend or partner an embarrassing moment in your life.11. Your house, containing everything you own, catches fire.

After saving your loved ones and pets, you have time to safely make a final dash to save any one item. What would it be?. Why?. 12. Share a personal problem and ask your friend or partner’s advice on how he or she might handle it.

Ask them to reflect back to you how you seem to be feeling about the problem you have chosen.AdvertisementContinue reading the main story.

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CLEVELAND — CVS, Walgreens, and Walmart pharmacies recklessly distributed massive amounts of pain http://resistrevive.com/generic-cialis-price/ pills in two Ohio counties, a federal jury said Tuesday in a kamagra prices walmart verdict that could set the tone for U.S. City and county governments that want to hold pharmacies accountable for their roles in the opioid crisis.Lake and Trumbull counties blamed the three chain pharmacies for not stopping the flood of pills that caused hundreds of overdose deaths and cost each kamagra prices walmart of the two counties about $1 billion, their attorney said.How much the pharmacies must pay in damages will be decided in the spring by a federal judge.advertisement It was the first time pharmacy companies had completed a trial to defend themselves in a drug crisis that has killed a half-million Americans over the past two decades. The counties were able to convince the jury that the pharmacies played an outsized role in creating a public nuisance in the way they dispensed pain medication into their communities.advertisement “The law requires pharmacies to be kamagra prices walmart diligent in dealing drugs. This case should be a wake-up call that failure will not be accepted,” said Mark Lanier, an attorney for the counties.“The jury sounded a bell that should be heard through all pharmacies in America,” Lanier said.Attorneys for the three pharmacy chains maintained they had policies to stem the flow of pills when their pharmacists had any concerns and would notify authorities about suspicious orders from doctors.

They also said it was the doctors who controlled how many pills were being prescribed for kamagra prices walmart legitimate medical needs.Spokespeople for CVSHealth and Walgreen Co. Said the companies disagree with the verdict and will appeal.“As plaintiffs’ own experts testified, many factors have contributed to the opioid abuse issue, and solving this problem will require involvement from all stakeholders in kamagra prices walmart our health care system and all members of our community,” CVS spokesperson Mike DeAngelis said in a statement. Related. Her husband kamagra prices walmart died by suicide.

She sued his pain doctors — a rare challenge over an opioid dose reduction Walgreen spokesperson Fraser Engerman kamagra prices walmart said the company believes the court erred “in allowing the case to go before a jury on a flawed legal theory that is inconsistent with Ohio law.”“As we have said throughout this process, we never manufactured or marketed opioids nor did we distribute them to the ‘pill mills’ and internet pharmacies that fueled this crisis,” Engerman said in a statement. €œThe plaintiffs’ attempt to resolve the opioid crisis with an unprecedented expansion of public nuisance law is misguided and unsustainable.”Two other chains — Rite Aid and Giant Eagle — already had settled lawsuits with the two Ohio counties.Lanier said during the trial that the pharmacies were attempting to blame everyone but themselves.The opioid crisis has overwhelmed courts, social services agencies, and law enforcement in Ohio’s blue-collar corner east of Cleveland, leaving behind heartbroken families and babies born to addicted mothers, Lanier told jurors.Roughly 80 million prescription painkillers were dispensed in Trumbull County alone between 2012 and 2016 — equivalent to 400 for every resident.In Lake County, some 61 million pills were distributed during that period.The rise in physicians prescribing pain medications such as oxycodone and hydrocodone came at a time when medical groups began recognizing that patients have the right to be treated for pain, Kaspar Stoffelmayr, an attorney for Walgreens, said at the opening of the trial.The problem, he said, was that “pharmaceutical manufacturers tricked doctors into writing way too many pills.” Related. In a first, a California judge rules drug makers kamagra prices walmart are not liable for the opioid crisis The counties said pharmacies should be the last line of defense to prevent the pills from getting into the wrong hands.They didn’t hire enough pharmacists and technicians or train them to stop that from happening and failed to implement systems that could flag suspicious orders, Lanier said.The trial before U.S. District Judge Dan Polster in Cleveland was part of a broader constellation of federal opioid lawsuits — about 3,000 in all — that have been kamagra prices walmart consolidated under the judge’s supervision.

Other cases are moving ahead in state courts.Kevin Roy, chief public policy officer at Shatterproof, an organization that advocates for solutions to addiction, said the verdict could lead pharmacies to follow the path of major distribution companies and some drug makers that have reached nationwide settlements of opioid cases worth billions.So far, no pharmacy has reached a nationwide settlement.“It’s a signal that the public, at least in select places, feels that there’s been exposure and needs to be remedied,” Roy said.The committee of lawyers for the local governments suing the drug industry in federal courts called Tuesday’s verdict “a milestone victory.”“For decades, pharmacy chains have watched as the pills flowing out of their doors cause harm and failed to take action as required by law,” the plaintiffs’ executive committee said in a statement. €œInstead, these companies responded by opening up more locations, flooding communities with pills, and facilitating the flow of opioids into an illegal, kamagra prices walmart secondary market. The judgment today against Walmart, Walgreens and CVS represents the overdue reckoning for their complicity in creating a public nuisance.”The government claims against drug makers, distributors and pharmacies hinge on state and local public kamagra prices walmart nuisance laws.Roy noted that courts have not been consistent on whether those laws apply to such cases. €œThere’s been a variety of different decisions lately that should give us reason to be cautious about what this really means in the grand scheme,” he said.Two recent rulings have gone against the theory.

And more cases are heading toward rulings.Trials against drug makers in New York and distribution kamagra prices walmart companies in Washington state are underway now. A trial of claims against distribution companies in West Virginia has wrapped up, but the judge has not yet kamagra prices walmart given a verdict.Earlier in November, a California judge ruled in favor of top drug manufacturers in a lawsuit with three counties and the city of Oakland. The judge said the governments hadn’t proven that the pharmaceutical companies used deceptive marketing to increase unnecessary opioid prescriptions and create a public nuisance.Also in November, Oklahoma’s supreme court overturned a 2019 judgment for $465 million in a suit brought by the state against drugmaker Johnson &. Johnson.Other lawsuits kamagra prices walmart have resulted in big settlements or proposed settlements before trials were completed.The jury’s decision in Cleveland had little effect on the stock of CVS, Walgreens, and Walmart.

Shares of all three companies kamagra prices walmart rose Tuesday. Shares of CVS and Walgreens are up by 36% and 19% this year, respectively.Associated Press writer Geoff Mulvihill in Cherry Hill, New Jersey, contributed to this report.You’re reading the web edition of D.C. Diagnosis, STAT’s weekly newsletter about the politics and policy of health kamagra prices walmart and medicine. Sign up here to receive it in your inbox.Biden’s big bet on kamagra prices walmart antiviralsIn a little-noticed regulatory move in September, the federal government moved to give pharmacists a much larger kamagra-response role — specifically, allowing them to prescribe and administer erectile dysfunction treatments.Now, with erectile dysfunction treatment antivirals from Pfizer and Merck on the way, the change could go a long way toward solving the biggest issue with the forthcoming rollout of those new medications.

Logistics.advertisement Even though the drugs have been cast as kamagra game-changers, my colleague Lev Facher writes this morning, kamagra prices walmart basic infrastructural issues with the U.S. Health system may prevent them from reaching the hands of those who need them most.The antivirals need to be taken as soon as possible after symptom onset — ideally within three days, in many cases. But that kamagra prices walmart requires four steps. Recognizing symptoms, testing positive for erectile dysfunction treatment, getting kamagra prices walmart a prescription, and picking up the pills at a pharmacy.

It’s a lot of hoops to jump through, and as a result, many public health experts are skeptical the treatments will make much of a dent in hospitalizations and deaths. The Biden administration has kamagra prices walmart a plan, though. Read more here.advertisement What does kamagra prices walmart the Build Back Better Act actually mean for the health care industry?. If you’re like me you’ve spent the last several weeks so enmeshed in the day-to-day negotiations around Democrats’ signature drug pricing bill that you haven’t had the time to take a breath and actually think about what this package of policies actually means for the health care industry.

Now that the kamagra prices walmart House has passed their bill and has taken off for the Thanksgiving holiday, I figure it’s time to do just that. Here are a few of my biggest questions about the Build Back Better Act.Is the kamagra prices walmart Build Back Better Act a death knell for insulin makers?. Don’t count on it.The legislation definitely takes aim at lowering insulin prices. It would kamagra prices walmart let Medicare negotiate the price of any insulin, and it would require drug makers to offer the federal government at least a 60% discount off the average price they offer other drug wholesalers for the three most popular insulins.

And there’s the popular $35 cap on out-of-pocket insulin costs for many patients, which my colleague Rachel has more on below.But financial analysts and drug pricing experts guessed the policy would have a minimal impact on insulin makers’ bottom lines (though kamagra prices walmart several cautioned that the exact impact of the policy will depend on how hard the federal government negotiates with insulin makers).That’s because insulin makers already offer sizable discounts to private insurance plans that offer Medicare drug coverage. Drug makers don’t disclose the exact discounts they offer — so it’s impossible to discern the exact impact of Democrats’ bill. But insulin makers have released reports in recent years showing that the existing discounts keep growing, and that the average discounts on insulin range from 50% to nearly 80%.Are drug makers going to stop hiking their list prices every year? kamagra prices walmart. It seems likely.Craig Garthwaite, a professor at Northwestern University, told STAT it won’t make rational sense for drug makers to hike their prices more than inflation if the Democrats’ bill passes, kamagra prices walmart because of the provision that would force them to repay taxpayers all the profits they receive from raising their prices more than inflation.But don’t expect the policy to solve all of the United States’ drug pricing problems.

Garthwaite predicted that drug makers will compensate by launching new drugs at even higher prices, even if it means fewer people take those drugs. They could also try to game the system by launching new versions kamagra prices walmart of drugs so that they’re not subjected to the price hike penalty.Does Democrats’ bill hurt insurers?. It’s really hard to say.While all of the attention has been focused on how Democrats’ plan will impact drug makers, the package also includes a massive redesign of the complicated scheme by which drug makers, seniors, the government, and kamagra prices walmart insurance companies divvy up seniors’ drug costs.The bill, for example, will require insurance plans to pick up 60% of seniors’ drug costs once seniors spend $2,000. That’s a hefty increase from the 15% of costs they used to have to cover in the so-called catastrophic coverage phase.Already at least one insurer has hinted that such a serious increase in insurers’ costs will force them to raise their premiums.But drug makers are still complaining that the bill doesn’t actually reform the insurance industry’s role in the U.S.

Drug pricing system kamagra prices walmart. PhRMA lamented recently that the kamagra prices walmart bill “will make a broken insurance system worse” and “doesn’t address perverse incentives in the system that are leading to higher costs for patients.”Insulin cost protections caught in partisan crosshairsOne of Democrats’ most popular provisions in their massive social safety net package is a drug pricing policy that would cap out-of-pocket costs for insulin at $35 per month for patients on Medicare and in private insurers. But that provision is at risk of running afoul of the Senate’s strict budget rules, and Senate Majority Leader Chuck Schumer is already launching a public offensive to save it, my colleague Rachel Cohrs reports.There are a bunch of complicated rules that govern what policy can get lumped into the streamlined budget process Democrats are using to pass legislation without GOP support — but, importantly, a provision will only get knocked out if a senator objects to it.Schumer is hoping the insulin cap is too politically popular for even Republicans to balk, but a Republican aide has already told STAT the party sees it as their responsibility to enforce the rules, regardless of the policy merits.Gordon Gray, the director of fiscal policy at the conservative-leaning American Action Forum, said the provision capping insulin costs in the private insurance market is likely more at risk than the Medicare policy.Sinema on the record on drug pricesSen. Kyrsten Sinema (D-Ariz.) is a woman kamagra prices walmart of few words in public, so it’s rare to get a glimpse into her thinking on any particular policy issue.

Today, we have more insight into her position on drug pricing policy in a letter that her office quietly sent to Arizona state lawmakers last week, my colleague Rachel Cohrs reports.Sinema touts her role in negotiations, particularly taking ownership of pushing the provision mentioned above that would cap monthly costs for insulin to $35 per month — the original framework House moderates had proposed put the cap at $50 per month. She talks in glowing terms of the agreement, echoing her earlier support for the deal.“Our agreement represents a smarter way to lower drug costs compared to earlier plans based on government price-setting for nearly every drug, which could have stifled medical innovation and reduced the development of new cures,” the letter reads..

CLEVELAND — CVS, Walgreens, and Walmart pharmacies recklessly distributed massive amounts of pain pills in two Ohio counties, a federal jury said Tuesday in a buy kamagra with prescription verdict Generic cialis price that could set the tone for U.S. City and county governments that want to hold pharmacies accountable for their roles in the opioid crisis.Lake and Trumbull counties blamed the three chain pharmacies for not stopping the flood of pills that caused hundreds of overdose deaths and cost each of the two counties about $1 billion, their attorney said.How much the pharmacies must pay in damages will be decided in the spring by a federal judge.advertisement It was the first time pharmacy companies buy kamagra with prescription had completed a trial to defend themselves in a drug crisis that has killed a half-million Americans over the past two decades. The counties were able to convince the jury that the pharmacies played an outsized role in creating a public nuisance in the way they dispensed pain medication into their communities.advertisement “The law requires pharmacies buy kamagra with prescription to be diligent in dealing drugs. This case should be a wake-up call that failure will not be accepted,” said Mark Lanier, an attorney for the counties.“The jury sounded a bell that should be heard through all pharmacies in America,” Lanier said.Attorneys for the three pharmacy chains maintained they had policies to stem the flow of pills when their pharmacists had any concerns and would notify authorities about suspicious orders from doctors. They also said it was the doctors who controlled how many pills were being prescribed buy kamagra with prescription for legitimate medical needs.Spokespeople for CVSHealth and Walgreen Co.

Said the companies disagree with the verdict and will appeal.“As plaintiffs’ own experts testified, many factors have buy kamagra with prescription contributed to the opioid abuse issue, and solving this problem will require involvement from all stakeholders in our health care system and all members of our community,” CVS spokesperson Mike DeAngelis said in a statement. Related. Her husband died by suicide buy kamagra with prescription. She sued his pain doctors — a rare challenge over an opioid dose reduction Walgreen spokesperson Fraser Engerman said the company believes the court erred “in allowing the case to go before a jury on a flawed legal theory that is inconsistent with Ohio law.”“As we have said throughout this process, we never manufactured or marketed opioids nor did we distribute them to the ‘pill mills’ and internet pharmacies that fueled this crisis,” buy kamagra with prescription Engerman said in a statement. €œThe plaintiffs’ attempt to resolve the opioid crisis with an unprecedented expansion of public nuisance law is misguided and unsustainable.”Two other chains — Rite Aid and Giant Eagle — already had settled lawsuits with the two Ohio counties.Lanier said during the trial that the pharmacies were attempting to blame everyone but themselves.The opioid crisis has overwhelmed courts, social services agencies, and law enforcement in Ohio’s blue-collar corner east of Cleveland, leaving behind heartbroken families and babies born to addicted mothers, Lanier told jurors.Roughly 80 million prescription painkillers were dispensed in Trumbull County alone between 2012 and 2016 — equivalent to 400 for every resident.In Lake County, some 61 million pills were distributed during that period.The rise in physicians prescribing pain medications such as oxycodone and hydrocodone came at a time when medical groups began recognizing that patients have the right to be treated for pain, Kaspar Stoffelmayr, an attorney for Walgreens, said at the opening of the trial.The problem, he said, was that “pharmaceutical manufacturers tricked doctors into writing way too many pills.” Related.

In a first, a California judge rules drug makers are not liable for the opioid crisis The counties said pharmacies should be the last line of defense to prevent the pills from getting into the wrong hands.They didn’t hire enough pharmacists and technicians or train them to stop that from happening and failed to implement systems that could flag suspicious orders, Lanier said.The trial before buy kamagra with prescription U.S. District Judge Dan Polster in Cleveland was part of a broader buy kamagra with prescription constellation of federal opioid lawsuits — about 3,000 in all — that have been consolidated under the judge’s supervision. Other cases are moving ahead in state courts.Kevin Roy, chief public policy officer at Shatterproof, an organization that advocates for solutions to addiction, said the verdict could lead pharmacies to follow the path of major distribution companies and some drug makers that have reached nationwide settlements of opioid cases worth billions.So far, no pharmacy has reached a nationwide settlement.“It’s a signal that the public, at least in select places, feels that there’s been exposure and needs to be remedied,” Roy said.The committee of lawyers for the local governments suing the drug industry in federal courts called Tuesday’s verdict “a milestone victory.”“For decades, pharmacy chains have watched as the pills flowing out of their doors cause harm and failed to take action as required by law,” the plaintiffs’ executive committee said in a statement. €œInstead, these companies responded by opening up more locations, flooding communities buy kamagra with prescription with pills, and facilitating the flow of opioids into an illegal, secondary market. The judgment today against Walmart, Walgreens and CVS represents the overdue reckoning for their complicity in creating a public nuisance.”The government claims against drug makers, distributors and pharmacies hinge on state and local public nuisance laws.Roy noted that courts have buy kamagra with prescription not been consistent on whether those laws apply to such cases.

€œThere’s been a variety of different decisions lately that should give us reason to be cautious about what this really means in the grand scheme,” he said.Two recent rulings have gone against the theory. And more cases are heading toward rulings.Trials against drug makers in New York and distribution companies in Washington state are underway buy kamagra with prescription now. A trial of claims against distribution companies in West Virginia has wrapped up, but the judge has not yet given a verdict.Earlier in November, a California judge ruled in favor of top drug manufacturers in buy kamagra with prescription a lawsuit with three counties and the city of Oakland. The judge said the governments hadn’t proven that the pharmaceutical companies used deceptive marketing to increase unnecessary opioid prescriptions and create a public nuisance.Also in November, Oklahoma’s supreme court overturned a 2019 judgment for $465 million in a suit brought by the state against drugmaker Johnson &. Johnson.Other lawsuits have resulted in big settlements or proposed settlements before trials were completed.The jury’s decision buy kamagra with prescription in Cleveland had little effect on the stock of CVS, Walgreens, and Walmart.

Shares of all three companies rose buy kamagra with prescription Tuesday. Shares of CVS and Walgreens are up by 36% and 19% this year, respectively.Associated Press writer Geoff Mulvihill in Cherry Hill, New Jersey, contributed to this report.You’re reading the web edition of D.C. Diagnosis, STAT’s weekly buy kamagra with prescription newsletter about the politics and policy of health and medicine. Sign up here to receive it in your inbox.Biden’s big bet on antiviralsIn a little-noticed regulatory move in September, buy kamagra with prescription the federal government moved to give pharmacists a much larger kamagra-response role — specifically, allowing them to prescribe and administer erectile dysfunction treatments.Now, with erectile dysfunction treatment antivirals from Pfizer and Merck on the way, the change could go a long way toward solving the biggest issue with the forthcoming rollout of those new medications. Logistics.advertisement Even though the drugs have been cast as kamagra game-changers, my buy kamagra with prescription colleague Lev Facher writes this morning, basic infrastructural issues with the U.S.

Health system may prevent them from reaching the hands of those who need them most.The antivirals need to be taken as soon as possible after symptom onset — ideally within three days, in many cases. But that requires buy kamagra with prescription four steps. Recognizing symptoms, buy kamagra with prescription testing positive for erectile dysfunction treatment, getting a prescription, and picking up the pills at a pharmacy. It’s a lot of hoops to jump through, and as a result, many public health experts are skeptical the treatments will make much of a dent in hospitalizations and deaths. The Biden administration has a buy kamagra with prescription plan, though.

Read more here.advertisement What does the buy kamagra with prescription Build Back Better Act actually mean for the health care industry?. If you’re like me you’ve spent the last several weeks so enmeshed in the day-to-day negotiations around Democrats’ signature drug pricing bill that you haven’t had the time to take a breath and actually think about what this package of policies actually means for the health care industry. Now that the House has passed their bill and has taken off for the Thanksgiving holiday, I figure it’s time to buy kamagra with prescription do just that. Here are a few of my biggest questions buy kamagra with prescription about the Build Back Better Act.Is the Build Back Better Act a death knell for insulin makers?. Don’t count on it.The legislation definitely takes aim at lowering insulin prices.

It would let Medicare negotiate the price of any insulin, and it would require drug makers to offer the federal government at least a 60% discount off the average price they offer buy kamagra with prescription other drug wholesalers for the three most popular insulins. And there’s the popular $35 cap on out-of-pocket insulin costs for many patients, which my colleague Rachel has more on below.But financial analysts and drug buy kamagra with prescription pricing experts guessed the policy would have a minimal impact on insulin makers’ bottom lines (though several cautioned that the exact impact of the policy will depend on how hard the federal government negotiates with insulin makers).That’s because insulin makers already offer sizable discounts to private insurance plans that offer Medicare drug coverage. Drug makers don’t disclose the exact discounts they offer — so it’s impossible to discern the exact impact of Democrats’ bill. But insulin makers have released reports in recent years showing that the existing discounts keep growing, and that the average discounts on insulin range from buy kamagra with prescription 50% to nearly 80%.Are drug makers going to stop hiking their list prices every year?. It seems likely.Craig Garthwaite, a professor at Northwestern University, told STAT it won’t make rational sense for drug makers to hike their prices more than inflation if the Democrats’ bill passes, because of the provision that would force them to repay taxpayers all the profits they receive from raising their prices more than inflation.But don’t expect the policy buy kamagra with prescription to solve all of the United States’ drug pricing problems.

Garthwaite predicted that drug makers will compensate by launching new drugs at even higher prices, even if it means fewer people take those drugs. They could also try buy kamagra with prescription to game the system by launching new versions of drugs so that they’re not subjected to the price hike penalty.Does Democrats’ bill hurt insurers?. It’s really hard buy kamagra with prescription to say.While all of the attention has been focused on how Democrats’ plan will impact drug makers, the package also includes a massive redesign of the complicated scheme by which drug makers, seniors, the government, and insurance companies divvy up seniors’ drug costs.The bill, for example, will require insurance plans to pick up 60% of seniors’ drug costs once seniors spend $2,000. That’s a hefty increase from the 15% of costs they used to have to cover in the so-called catastrophic coverage phase.Already at least one insurer has hinted that such a serious increase in insurers’ costs will force them to raise their premiums.But drug makers are still complaining that the bill doesn’t actually reform the insurance industry’s role in the U.S. Drug pricing system buy kamagra with prescription.

PhRMA lamented recently that the bill “will make a broken insurance system worse” and “doesn’t address perverse incentives in the system that are leading to higher costs for patients.”Insulin cost protections caught in partisan crosshairsOne of Democrats’ most popular provisions in their massive social safety net package is a drug pricing policy that would cap out-of-pocket costs for insulin at $35 per month for patients on Medicare and in private insurers buy kamagra with prescription. But that provision is at risk of running afoul of the Senate’s strict budget rules, and Senate Majority Leader Chuck Schumer is already launching a public offensive to save it, my colleague Rachel Cohrs reports.There are a bunch of complicated rules that govern what policy can get lumped into the streamlined budget process Democrats are using to pass legislation without GOP support — but, importantly, a provision will only get knocked out if a senator objects to it.Schumer is hoping the insulin cap is too politically popular for even Republicans to balk, but a Republican aide has already told STAT the party sees it as their responsibility to enforce the rules, regardless of the policy merits.Gordon Gray, the director of fiscal policy at the conservative-leaning American Action Forum, said the provision capping insulin costs in the private insurance market is likely more at risk than the Medicare policy.Sinema on the record on drug pricesSen. Kyrsten Sinema (D-Ariz.) is a woman of few words in public, so it’s rare to get a glimpse into buy kamagra with prescription her thinking on any particular policy issue. Today, we have more insight into her position on drug pricing policy in a letter that her office quietly sent to Arizona state lawmakers last week, my colleague Rachel Cohrs reports.Sinema touts her role in negotiations, particularly taking ownership of pushing the provision mentioned above that would cap monthly costs for insulin to $35 per month — the original framework House moderates had proposed put the cap at $50 per month. She talks in glowing terms of the agreement, echoing her earlier support for the deal.“Our agreement represents a smarter way to lower drug costs compared to earlier plans based on government price-setting for nearly every drug, which could have stifled medical innovation and reduced the development of new cures,” the letter reads..

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6 kamagra 100mg oral jelly side effects http://isiwa.com/buy-female-viagra/. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1.

NO ASSET kamagra 100mg oral jelly side effects LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A.

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

B deductibles & kamagra 100mg oral jelly side effects. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application.

18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd kamagra 100mg oral jelly side effects month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA 027.

Can Enroll in MSP and Medicaid at Same kamagra 100mg oral jelly side effects Time?. YES YES NO!. Must choose between QI-1 and Medicaid.

Cannot have both, not kamagra 100mg oral jelly side effects even Medicaid with a spend-down. 2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits.

The income limits are tied to the Federal Poverty Level kamagra 100mg oral jelly side effects (FPL). 2021 FPL levels were released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented.

During this lag period, local Medicaid offices should kamagra 100mg oral jelly side effects continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.

N.Y kamagra 100mg oral jelly side effects. Soc. Serv.

L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded.

The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max).

(b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc.

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

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

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

EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year. 7.

QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations.

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

But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center..

Rules and Household Size buy kamagra with prescription 3. The Three MSP Programs - What are they and how are they Different?. 4.

FOUR Special Benefits of MSP buy kamagra with prescription Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &.

Applications for People who Have Medicare What is Application buy kamagra with prescription 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 buy kamagra with prescription Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP.

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

See “Part A Buy-In” YES YES Pays Part A buy kamagra with prescription &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

Yes - buy kamagra with prescription Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application).

See GIS 07 buy kamagra with prescription MA 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!.

Must choose between buy kamagra with prescription QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2.

INCOME LIMITS and RULES Each buy kamagra with prescription of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2021 FPL levels were released by NYS DOH in GIS 21 MA/06 - 2021 Federal Poverty Levels Attachment II NOTE.

There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then buy kamagra with prescription before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA.

See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by buy kamagra with prescription the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc.

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

Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include. (a) The first $20 of your &.

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

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

You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE.

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

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

He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit.

In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program.

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

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

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

1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits.

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

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

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

3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only.

QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage.

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

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

4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1.

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

The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason.

Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application.

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

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

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

Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP.

AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3.

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

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

Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium.

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

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

New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods.

Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits.

See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply.

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

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

They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033).

Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP.

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

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

Applying for MSP Directly with Local Medicaid 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.

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UC Davis Health just naturals kamagra began notifying its patients http://o-e.me/osmans-top-five-productivity-tips/ today about vaccinations for erectile dysfunction treatment. In order to speed up completion of the U.S Centers for Disease Control and Prevention's (CDC) just naturals kamagra Phase 1a erectile dysfunction treatment vaccinations and move to Phase 1b, where patients can be vaccinated, UC Davis Health is starting to vaccinate other Phase 1a groups in Sacramento. UC Davis Health will soon start vaccinating patients for erectile dysfunction treatment.The health system hopes to begin vaccinating current high-risk UC Davis Health patients very soon, but it is unable to provide specific dates or make appointments for vaccination yet.

Timing depends upon additional erectile dysfunction treatment deliveries, as well as approval from just naturals kamagra public health agencies that Phase 1a has been suitably addressed first. To do this, UC Davis Health is partnering with public health agencies to focus on three populations:Sierra Sacramento Valley Medical Society members who are practicing physicians, working with or in Sacramento County, and who aren’t affiliated with other health systems;Dentists in Sacramento County, as determined by Sacramento County and the California Dental Association;UC Davis Health patients who are health care workers and not affiliated with other health systems.It is anticipated that vaccinations for at-risk patients in Phase 1b could start within one or two weeks, with erectile dysfunction treatments available to most healthy patients sometime this spring.Learn more about the erectile dysfunction treatment from UC Davis Health In these early stages of erectile dysfunction treatment distribution, priorities for patient vaccinations are set by federal and state authorities. The CDC and the California Department of Public just naturals kamagra Health (CDPH).

UC Davis Health receives erectile dysfunction treatments from CDPH and will begin vaccinating patients as soon as additional supplies arrive and approval is received to proceed to additional groups, including patients.“UC Davis Health is eager to begin vaccinating our patients,” said David Lubarsky, CEO of UC Davis Health. €œWe have a highly skilled team that’s already vaccinated nearly 10,000 of our health care just naturals kamagra workers and students. Being able to now provide vaccinations to our patients is critical to reducing kamagra spread, beating the patient surge, and bringing an end to the kamagra.”Using a tiered approach to prioritize erectile dysfunction treatment vaccinationsTo strategically manage the erectile dysfunction treatment vaccination process, UC Davis Health has developed a tiered approach.

Just as health care workers were prioritized during the initial rollout of treatments because of their risk for erectile dysfunction treatment exposure, individuals who are more vulnerable – because of age or a chronic health condition that places them at-risk – will be among the first patients to be vaccinated.At UC Davis Health, priority for erectile dysfunction treatment vaccinations will go first to those UC Davis Health patients who are 75 years just naturals kamagra and older. The next group, as treatment supplies and arrival dates are firmed up, will include patients 65 years and older, those with heart disorders, sickle cell disease, diabetes, cystic fibrosis, cancer, stroke and other conditions.For patients with most forms of cancer, the timing for their vaccination will be guided by their oncologist. Additional groups in just naturals kamagra line for the erectile dysfunction treatments include patients under the age of 64 years.10,000 UC Davis Health employees vaccinatedUC Davis Health has been working quickly to vaccinate its health care workforce, since that step must be completed before patient vaccinations can begin.

Since receiving the first doses of erectile dysfunction treatment in Sacramento on December 15, UC Davis Health has vaccinated more than 10,000 employees, with no reports of any serious side effects or reactions. With this work now nearly complete, UC Davis Health is ready to start vaccinating patients as soon as erectile dysfunction treatment supplies allow, and permissions are given to move to Phase 1b groups.Patients who already receive their care at UC Davis Health will be among the first to be notified in each patient group, since their health and contact information is already in the system’s electronic medical record.Advancing erectile dysfunction treatment vaccinations in the communityUC Davis Health is also working to help others in the community get vaccinated, including first responders, nursing home residents and just naturals kamagra employees, non-affiliated community health providers, and other essential workers. UC Davis Health has offered to assist Sacramento County Public Health with vaccinations of community health providers and others at risk.

Caretakers of very high-risk UC Davis Health patients may also meet the criteria for vaccinations at the just naturals kamagra health system.As more erectile dysfunction treatments are delivered to UC Davis Health, patients will be notified that they can self-schedule an appointment through the MyUCDavisHealth app or website, or by calling their provider’s office. Vaccinations for patients will be by appointment only, and only for patients who are notified they are eligible.Patient tiers for erectile dysfunction treatment vaccinationsPhase 1b75 years and olderPhase 1c65-74 yearsChronic kidney disease (3 or greater)Chronic obstructive pulmonary disease (COPD)Heart disorders (heart failure, cardiomyopathy, Coronary artery disease)Immunocompromised state (due to medication or underlying just naturals kamagra disease)Body Mass Index (BMI. 35 or greater)Sickle cell diseaseSmoker, active dailyDiabetes type 1 and 2Cystic fibrosisPulmonary fibrosisPregnancyStrokeCancer (excluding history of cancer and non-melanoma skin cancers) timing of treatment to be directed by treating cancer specialist.Phase 1c(2)50-64 years (CDPH guideline 1/4/2021)Patients from communities with disproportional disease impact will be considered for prioritization within these groups.

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Farmworkers are part of the rural population included in a study on the impact of erectile dysfunction treatment on cancer care.The UC Davis cancer center’s grant is focused on diverse communities.“We are the only center being funded to study six different populations for a total of 1,000 people. African Americans, Chinese, Hmong, Latinos, Native Americans, Vietnamese and rural residents to determine just naturals kamagra the impact erectile dysfunction treatment is having on cancer-related behaviors,” said co-director of the study Moon S. Chen, Jr., associate director for Community Outreach and Engagement.The study is the first of its kind and will allow the outreach and engagement team and clinicians to better tailor how they communicate and partner with these vulnerable populations to enhance trust and better serve them.

The research team’s theory is that one size does not fit all.In some instances, the researchers are making contact by phone just naturals kamagra or virtual conversations. For others, online surveys and even in-person contact is helpful. For instance, Native Americans living in rural communities often come to community health centers to pick up their medications, providing an opportunity for direct outreach.To improve outreach and engagement of African Americans, the study team is conducting focus groups to better understand how to enhance video visits for cancer care.“We recognize that, in terms of our approach to each of these vulnerable groups, just naturals kamagra what may work in one population may not work in others,” said Associate Professor David Cooke, who heads General Thoracic Surgery and is co-directing the study.

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UC Davis Health can u buy kamagra over the counter began notifying its patients buy kamagra with prescription today about vaccinations for erectile dysfunction treatment. In order to speed up completion of the U.S Centers for Disease Control and Prevention's (CDC) Phase 1a erectile dysfunction treatment vaccinations and buy kamagra with prescription move to Phase 1b, where patients can be vaccinated, UC Davis Health is starting to vaccinate other Phase 1a groups in Sacramento. UC Davis Health will soon start vaccinating patients for erectile dysfunction treatment.The health system hopes to begin vaccinating current high-risk UC Davis Health patients very soon, but it is unable to provide specific dates or make appointments for vaccination yet.

Timing depends upon additional erectile dysfunction treatment buy kamagra with prescription deliveries, as well as approval from public health agencies that Phase 1a has been suitably addressed first. To do this, UC Davis Health is partnering with public health agencies to focus on three populations:Sierra Sacramento Valley Medical Society members who are practicing physicians, working with or in Sacramento County, and who aren’t affiliated with other health systems;Dentists in Sacramento County, as determined by Sacramento County and the California Dental Association;UC Davis Health patients who are health care workers and not affiliated with other health systems.It is anticipated that vaccinations for at-risk patients in Phase 1b could start within one or two weeks, with erectile dysfunction treatments available to most healthy patients sometime this spring.Learn more about the erectile dysfunction treatment from UC Davis Health In these early stages of erectile dysfunction treatment distribution, priorities for patient vaccinations are set by federal and state authorities. The CDC and the buy kamagra with prescription California Department of Public Health (CDPH).

UC Davis Health receives erectile dysfunction treatments from CDPH and will begin vaccinating patients as soon as additional supplies arrive and approval is received to proceed to additional groups, including patients.“UC Davis Health is eager to begin vaccinating our patients,” said David Lubarsky, CEO of UC Davis Health. €œWe have a highly skilled team that’s already vaccinated nearly 10,000 of our health care workers and students buy kamagra with prescription. Being able to now provide vaccinations to our patients is critical to reducing kamagra spread, beating the patient surge, and bringing an end to the kamagra.”Using a tiered approach to prioritize erectile dysfunction treatment vaccinationsTo strategically manage the erectile dysfunction treatment vaccination process, UC Davis Health has developed a tiered approach.

Just as health care workers were prioritized during the initial rollout of treatments because of their risk for erectile dysfunction treatment exposure, individuals who are more vulnerable – because of age or a chronic health condition that places them at-risk – will be among buy kamagra with prescription the first patients to be vaccinated.At UC Davis Health, priority for erectile dysfunction treatment vaccinations will go first to those UC Davis Health patients who are 75 years and older. The next group, as treatment supplies and arrival dates are firmed up, will include patients 65 years and older, those with heart disorders, sickle cell disease, diabetes, cystic fibrosis, cancer, stroke and other conditions.For patients with most forms of cancer, the timing for their vaccination will be guided by their oncologist. Additional groups in line for the erectile dysfunction treatments include patients under the age of 64 years.10,000 UC Davis Health employees vaccinatedUC Davis Health has been working quickly to vaccinate its health care workforce, since that step must buy kamagra with prescription be completed before patient vaccinations can begin.

Since receiving the first doses of erectile dysfunction treatment in Sacramento on December 15, UC Davis Health has vaccinated more than 10,000 employees, with no reports of any serious side effects or reactions. With this work now nearly complete, UC buy kamagra with prescription Davis Health is ready to start vaccinating patients as soon as erectile dysfunction treatment supplies allow, and permissions are given to move to Phase 1b groups.Patients who already receive their care at UC Davis Health will be among the first to be notified in each patient group, since their health and contact information is already in the system’s electronic medical record.Advancing erectile dysfunction treatment vaccinations in the communityUC Davis Health is also working to help others in the community get vaccinated, including first responders, nursing home residents and employees, non-affiliated community health providers, and other essential workers. UC Davis Health has offered to assist Sacramento County Public Health with vaccinations of community health providers and others at risk.

Caretakers of very high-risk UC Davis Health patients may also meet the criteria for vaccinations at the health system.As more erectile dysfunction treatments are delivered to UC Davis Health, patients will be notified that they can self-schedule an appointment through the MyUCDavisHealth app or website, or by calling their provider’s office buy kamagra with prescription. Vaccinations for patients will be by appointment only, and only for patients who are notified they are eligible.Patient tiers for erectile dysfunction treatment vaccinationsPhase buy kamagra with prescription 1b75 years and olderPhase 1c65-74 yearsChronic kidney disease (3 or greater)Chronic obstructive pulmonary disease (COPD)Heart disorders (heart failure, cardiomyopathy, Coronary artery disease)Immunocompromised state (due to medication or underlying disease)Body Mass Index (BMI. 35 or greater)Sickle cell diseaseSmoker, active dailyDiabetes type 1 and 2Cystic fibrosisPulmonary fibrosisPregnancyStrokeCancer (excluding history of cancer and non-melanoma skin cancers) timing of treatment to be directed by treating cancer specialist.Phase 1c(2)50-64 years (CDPH guideline 1/4/2021)Patients from communities with disproportional disease impact will be considered for prioritization within these groups.

Patients who receive primary care at UC Davis Health will also be prioritized.Exceptions to tiers (patients will not be actively reached out to, but may be vaccinated):UC Davis Health patients who are health care buy kamagra with prescription workers who cannot be vaccinated by their employer or local public health departmentsCaretakers of very high-risk UC Davis Health patientsGuidance for erectile dysfunction treatment vaccination prioritiesUC Davis Health established its tiered priority system for patient vaccinations based on the following guidelines and recommendations. Related erectile dysfunction treatment stories from UC Davis Health:What impact is erectile dysfunction treatment having on cancer prevention, control and survival?. The buy kamagra with prescription UC Davis Comprehensive Cancer Center is collaborating with 17 other cancer centers to study and try to answer that question, thanks to funding from the National Cancer Institute.

Farmworkers are part of the rural population included in a study on the impact of erectile dysfunction treatment on cancer care.The UC Davis cancer center’s grant is focused on diverse communities.“We are the only center being funded to study six different populations for a total of 1,000 people. African Americans, Chinese, Hmong, Latinos, Native Americans, Vietnamese and rural residents to determine the impact erectile dysfunction treatment is having on cancer-related behaviors,” said co-director of the buy kamagra with prescription study Moon S. Chen, Jr., associate director for Community Outreach and Engagement.The study is the first of its kind and will allow the outreach and engagement team and clinicians to better tailor how they communicate and partner with these vulnerable populations to enhance trust and better serve them.

The research team’s theory is that one size does not fit all.In some instances, the researchers are buy kamagra with prescription making contact by phone or virtual conversations. For others, online surveys and even in-person contact is helpful. For instance, Native Americans living in rural communities often come to community health centers to pick up their medications, providing an opportunity for direct outreach.To improve outreach and engagement of African Americans, the study team is conducting focus groups to better understand how to enhance video visits for cancer care.“We recognize that, in terms of our approach to each of these vulnerable groups, what may work in one population may not work in others,” said Associate Professor David Cooke, who heads General buy kamagra with prescription Thoracic Surgery and is co-directing the study.

€œWe’re attempting to meet people where they live. If they’re comfortable with telemedicine, we will use telemedicine buy kamagra with prescription. If they prefer in-person contact, we will do that.”.

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I’ve never understood striving for perfection. It’s unattainable. It’s the pinnacle I never want to reach. For if it’s attained, what more is there to achieve?

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Most know that working and working to achieve perfection is a waste of time, but somewhere along the way striving for perfection was drilled into us. It’s at the very core of our existence. When we were young, we worked and worked at achieving something for the accolades we knew would be coming our way. If only we did it right. If only we worked more, we’d hit the mark and hear our praises sung. Our self-worth became dependent on the compliment or two thrown our way. But in doing so, we hung onto the words of others and worked our hands raw, because as children the mark kept moving higher. You could never, ever truly hit the mark. You just kept working and working toward perfection. As an adult I’m telling you, perfection is unattainable. The mark never stops moving.

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Striving for perfection is an addiction. Most perfection addicts falsely believe that achieving perfection indicates excellence. But perfection and excellence are two different things.

The Merriam-Webster Dictionary states perfection as a) freedom from fault or defect, flawlessness, b) the quality or state of being saintly, c) an unsurpassable degree of accuracy or excellence. Excellence on the other hand is a) very good of its kind, b) eminently good, c) first class. Two similar, but totally different degrees in terms.

Who wants to be saintly or flawless anyway? Not I. No siree. I like being a little devilish, a little flawed. Ok, depending on who you ask, quite flawed. Regardless, I don’t demand perfection, but I do demand excellence.

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The driving force of my excellence comes from within. I know I want to be eminently good. First-class. First rate in anything I do. But I could care less what other people demand of or expect from me. I don’t live for them. I live for me. I answer to my own higher conscience, and if it’s good enough for me, then by golly, I’ve hit my mark. If it’s not good enough for them. No worries, they can spend the time to work it and work it to get it perfect. No skin off my nose.

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As a member of Toastmasters International, a public speaking club, in both my leadership and speaking roles, I strive for excellence to the best of my abilities. And therein lies the difference between excellence and perfection. To the best of your ability.

I was terrified when I stood up to give my first speech. Just tell the audience a little bit about myself. If I had strived for perfection that first time up, I never would have gone back to Toastmasters. I would have run out the door with my tail between my legs, or my hand over my mouth, never to look back. In expecting perfection, I never would have become president of the club, nor gone onto win public speaking contests. But because there were goals outlined in the manual, for newbie speakers, I just wanted to hit the mark for those goals. And I did. I had attained excellence for what I was aiming to achieve that night. Looking back now, I’m sure there were countless ums and ahs, long pauses and stuttering in that first speech. But in the end, who cares? I wasn’t laughed off the stage. I hit my mark. I achieved excellence. But not perfection. And that’s ok. If I had walked off that stage as Little Miss Perfect, I would have missed out on so much in learning from others, in pushing my comfort zone, and in becoming a better speaker.

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A fellow Toastmaster gave his third speech this past Tuesday. Was it perfect? Hell no. But was it excellent? You betcha. Even the content of the speech was right on the mark. He said in this day and age, if you ask an audience how many members believe they give 100% at work, guess how many people raise their hands? One hundred percent raise their hands. Know what that means? The average Joe gives 100%. Everybody does. Or so we think. With those odds, in order to be noticed or to move forward, then you better be giving 110%. Do you need to be perfect? Nope. But do you need to demand excellence? Absolutely.

Excellence I can handle. But I don’t ever want to be perfect. No siree, not me. I rather like being Little Miss un-Perfect.