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asthma treatment has where can i buy ventolin nebules created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were where can i buy ventolin nebules forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test.
They have taken a crisis and turned it into a tragedy.The magnitude where can i buy ventolin nebules of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in asthma treatment cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs where can i buy ventolin nebules the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000. asthma treatment is an overwhelming challenge, and many factors contribute to its severity.
But the one where can i buy ventolin nebules we can control is how we behave. And in the United States we have consistently behaved poorly.We know that we could have done better. China, faced where can i buy ventolin nebules with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States.
Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small where can i buy ventolin nebules outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a preventolin level. In general, not only have many democracies done better than the United States, but they where can i buy ventolin nebules have also outperformed us by orders of magnitude.Why has the United States handled this ventolin so badly?. We have failed at almost every step.
We had where can i buy ventolin nebules ample warning, but when the disease first arrived, we were incapable of testing effectively and couldnât provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more where can i buy ventolin nebules useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have.2 Moreover, a lack of emphasis on developing capacity has meant that U.S. Test results are often long delayed, rendering the results useless for disease control.Although we tend to focus on technology, most of the interventions that have large effects are not complicated.
The United States instituted quarantine and isolation measures where can i buy ventolin nebules late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved. And in much of the country, people simply donât where can i buy ventolin nebules wear masks, largely because our leaders have stated outright that masks are political tools rather than effective control measures. The government has appropriately invested heavily in treatment development, but its rhetoric has politicized the development process and led to growing public distrust.The United States came into this crisis with enormous advantages.
Along with tremendous manufacturing where can i buy ventolin nebules capacity, we have a biomedical research system that is the envy of the world. We have enormous expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that where can i buy ventolin nebules national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and even denigrate experts.The response of our nationâs leaders has been consistently inadequate.
The federal where can i buy ventolin nebules government has largely abandoned disease control to the states. Governors have varied in their responses, not so much by party as by competence. But whatever their competence, where can i buy ventolin nebules governors do not have the tools that Washington controls. Instead of using those tools, the federal government has undermined them.
The Centers for Disease Control and Prevention, which was the worldâs leading disease response organization, has been eviscerated and has suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in treatment development but have been excluded from much crucial government where can i buy ventolin nebules decision making. And the Food and Drug Administration has been shamefully politicized,3 appearing to respond to pressure from the administration rather than scientific evidence. Our current where can i buy ventolin nebules leaders have undercut trust in science and in government,4 causing damage that will certainly outlast them.
Instead of relying on expertise, the administration has turned to uninformed âopinion leadersâ and charlatans who obscure the truth and facilitate the promulgation of outright lies.Letâs be clear about the cost of not taking even simple measures. An outbreak that has disproportionately affected communities of color where can i buy ventolin nebules has exacerbated the tensions associated with inequality. Many of our children are missing school at critical times in their social and intellectual development. The hard work of health care professionals, who have put their lives on where can i buy ventolin nebules the line, has not been used wisely.
Our current leadership takes pride in the economy, but while most of the world has opened up to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs. And more than 200,000 Americans have where can i buy ventolin nebules died. Some deaths from asthma treatment were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a ventolin that has already killed more Americans than any conflict since World War II.Anyone else who recklessly squandered lives and money in this way where can i buy ventolin nebules would be suffering legal consequences.
Our leaders have largely claimed immunity for their actions. But this election gives where can i buy ventolin nebules us the power to render judgment. Reasonable people will certainly disagree about the many political positions taken by candidates. But truth is neither liberal where can i buy ventolin nebules nor conservative.
When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.Patients Figure 1 where can i buy ventolin nebules. Figure 1. Enrollment and where can i buy ventolin nebules Randomization.
Of the 1114 patients who were assessed for eligibility, 1062 underwent randomization. 541 were assigned to the remdesivir group and 521 to the placebo group (intention-to-treat population) where can i buy ventolin nebules (Figure 1). 159 (15.0%) were categorized as having mild-to-moderate disease, and 903 (85.0%) were in the severe disease stratum. Of those assigned to receive remdesivir, 531 where can i buy ventolin nebules patients (98.2%) received the treatment as assigned.
Fifty-two patients had remdesivir treatment discontinued before day 10 because of an adverse event or a serious adverse event other than death and 10 withdrew consent. Of those assigned to receive placebo, 517 patients (99.2%) received where can i buy ventolin nebules placebo as assigned. Seventy patients discontinued placebo before day 10 because of an adverse event or a serious adverse event other than death and 14 withdrew consent. A total of 517 patients in the remdesivir group and 508 in the placebo group completed the trial through where can i buy ventolin nebules day 29, recovered, or died.
Fourteen patients who received remdesivir and 9 who received placebo terminated their participation in the trial before day 29. A total of 54 of the patients who were in the mild-to-moderate stratum at randomization were subsequently determined to meet the criteria for severe disease, resulting where can i buy ventolin nebules in 105 patients in the mild-to-moderate disease stratum and 957 in the severe stratum. The as-treated population included 1048 patients who received the assigned treatment (532 in the remdesivir group, including one patient who had been randomly assigned to placebo and received remdesivir, and 516 in the placebo group). Table 1 where can i buy ventolin nebules.
Table 1. Demographic and Clinical Characteristics of the Patients at Baseline. The mean age of where can i buy ventolin nebules the patients was 58.9 years, and 64.4% were male (Table 1). On the basis of the evolving epidemiology of asthma treatment during the trial, 79.8% of patients were enrolled at sites in North America, 15.3% in Europe, and 4.9% in Asia (Table S1 in the Supplementary Appendix).
Overall, 53.3% of the patients were White, 21.3% were Black, 12.7% were Asian, and 12.7% where can i buy ventolin nebules were designated as other or not reported. 250 (23.5%) were Hispanic or Latino. Most patients had either one (25.9%) or two or more (54.5%) of the prespecified coexisting conditions at enrollment, most commonly hypertension (50.2%), where can i buy ventolin nebules obesity (44.8%), and type 2 diabetes mellitus (30.3%). The median number of days between symptom onset and randomization was 9 (interquartile range, 6 to 12) (Table S2).
A total of 957 patients (90.1%) had where can i buy ventolin nebules severe disease at enrollment. 285 patients (26.8%) met category 7 criteria on the ordinal scale, 193 (18.2%) category 6, 435 (41.0%) category 5, and 138 (13.0%) category 4. Eleven patients (1.0%) had missing ordinal scale data at where can i buy ventolin nebules enrollment. All these patients discontinued the study before treatment.
During the study, 373 patients (35.6% of the 1048 patients in the as-treated population) received hydroxychloroquine and 241 (23.0%) received a glucocorticoid (Table S3) where can i buy ventolin nebules. Primary Outcome Figure 2. Figure 2 where can i buy ventolin nebules. KaplanâMeier Estimates of Cumulative Recoveries.
Cumulative recovery estimates where can i buy ventolin nebules are shown in the overall population (Panel A), in patients with a baseline score of 4 on the ordinal scale (not receiving oxygen. Panel B), in those with a baseline score of 5 (receiving oxygen. Panel C), in those with where can i buy ventolin nebules a baseline score of 6 (receiving high-flow oxygen or noninvasive mechanical ventilation. Panel D), and in those with a baseline score of 7 (receiving mechanical ventilation or extracorporeal membrane oxygenation [ECMO].
Panel E).Table 2 where can i buy ventolin nebules. Table 2. Outcomes Overall and According to Score on the Ordinal Scale in the Intention-to-Treat Population where can i buy ventolin nebules. Figure 3.
Figure 3 where can i buy ventolin nebules. Time to Recovery According to Subgroup. The widths of the confidence where can i buy ventolin nebules intervals have not been adjusted for multiplicity and therefore cannot be used to infer treatment effects. Race and ethnic group were reported by the patients.Patients in the remdesivir group had a shorter time to recovery than patients in the placebo group (median, 10 days, as compared with 15 days.
Rate ratio where can i buy ventolin nebules for recovery, 1.29. 95% confidence interval [CI], 1.12 to 1.49. P<0.001) (Figure 2 and Table where can i buy ventolin nebules 2). In the severe disease stratum (957 patients) the median time to recovery was 11 days, as compared with 18 days (rate ratio for recovery, 1.31.
95% CI, where can i buy ventolin nebules 1.12 to 1.52) (Table S4). The rate ratio for recovery was largest among patients with a baseline ordinal score of 5 (rate ratio for recovery, 1.45. 95% CI, 1.18 to 1.79). Among patients with a baseline score where can i buy ventolin nebules of 4 and those with a baseline score of 6, the rate ratio estimates for recovery were 1.29 (95% CI, 0.91 to 1.83) and 1.09 (95% CI, 0.76 to 1.57), respectively.
For those receiving mechanical ventilation or ECMO at enrollment (baseline ordinal score of 7), the rate ratio for recovery was 0.98 (95% CI, 0.70 to 1.36). Information on interactions of treatment where can i buy ventolin nebules with baseline ordinal score as a continuous variable is provided in Table S11. An analysis adjusting for baseline ordinal score as a covariate was conducted to evaluate the overall effect (of the percentage of patients in each ordinal score category at baseline) on the primary outcome. This adjusted analysis produced a similar treatment-effect estimate (rate ratio where can i buy ventolin nebules for recovery, 1.26.
95% CI, 1.09 to 1.46). Patients who underwent randomization during the first 10 days after the onset of symptoms had a rate ratio for recovery of 1.37 (95% CI, 1.14 to 1.64), whereas patients who underwent randomization more than 10 days after the onset of symptoms had a rate ratio for recovery of 1.20 (95% CI, 0.94 to 1.52) (Figure where can i buy ventolin nebules 3). The benefit of remdesivir was larger when given earlier in the illness, though the benefit persisted in most analyses of duration of symptoms (Table S6). Sensitivity analyses in which data where can i buy ventolin nebules were censored at earliest reported use of glucocorticoids or hydroxychloroquine still showed efficacy of remdesivir (9.0 days to recovery with remdesivir vs.
14.0 days to recovery with placebo. Rate ratio, where can i buy ventolin nebules 1.28. 95% CI, 1.09 to 1.50, and 10.0 vs. 16.0 days to where can i buy ventolin nebules recovery.
Rate ratio, 1.32. 95% CI, where can i buy ventolin nebules 1.11 to 1.58, respectively) (Table S8). Key Secondary Outcome The odds of improvement in the ordinal scale score were higher in the remdesivir group, as determined by a proportional odds model at the day 15 visit, than in the placebo group (odds ratio for improvement, 1.5. 95% CI, 1.2 to 1.9, adjusted for disease severity) where can i buy ventolin nebules (Table 2 and Fig.
S7). Mortality KaplanâMeier estimates of mortality by day 15 were 6.7% in the where can i buy ventolin nebules remdesivir group and 11.9% in the placebo group (hazard ratio, 0.55. 95% CI, 0.36 to 0.83). The estimates by day 29 were 11.4% and 15.2% in where can i buy ventolin nebules two groups, respectively (hazard ratio, 0.73.
95% CI, 0.52 to 1.03). The between-group differences in mortality varied considerably according to baseline where can i buy ventolin nebules severity (Table 2), with the largest difference seen among patients with a baseline ordinal score of 5 (hazard ratio, 0.30. 95% CI, 0.14 to 0.64). Information on interactions of treatment with where can i buy ventolin nebules baseline ordinal score with respect to mortality is provided in Table S11.
Additional Secondary Outcomes Table 3. Table 3 where can i buy ventolin nebules. Additional Secondary Outcomes. Patients in the remdesivir group had a shorter time to improvement where can i buy ventolin nebules of one or of two categories on the ordinal scale from baseline than patients in the placebo group (one-category improvement.
Median, 7 vs. 9 days where can i buy ventolin nebules. Rate ratio for recovery, 1.23. 95% CI, 1.08 to 1.41.
Two-category improvement where can i buy ventolin nebules. Median, 11 vs. 14 days where can i buy ventolin nebules. Rate ratio, 1.29.
95% CI, where can i buy ventolin nebules 1.12 to 1.48) (Table 3). Patients in the remdesivir group had a shorter time to discharge or to a National Early Warning Score of 2 or lower than those in the placebo group (median, 8 days vs. 12 days where can i buy ventolin nebules. Hazard ratio, 1.27.
95% CI, where can i buy ventolin nebules 1.10 to 1.46). The initial length of hospital stay was shorter in the remdesivir group than in the placebo group (median, 12 days vs. 17 days) where can i buy ventolin nebules. 5% of patients in the remdesivir group were readmitted to the hospital, as compared with 3% in the placebo group.
Among the 913 patients receiving oxygen at enrollment, those in the remdesivir group continued to receive oxygen for fewer days than patients in the where can i buy ventolin nebules placebo group (median, 13 days vs. 21 days), and the incidence of new oxygen use among patients who were not receiving oxygen at enrollment was lower in the remdesivir group than in the placebo group (incidence, 36% [95% CI, 26 to 47] vs. 44% [95% where can i buy ventolin nebules CI, 33 to 57]). For the 193 patients receiving noninvasive ventilation or high-flow oxygen at enrollment, the median duration of use of these interventions was 6 days in both the remdesivir and placebo groups.
Among the 573 patients who were not receiving noninvasive ventilation, high-flow oxygen, invasive ventilation, or ECMO at baseline, the incidence of new noninvasive ventilation or high-flow oxygen where can i buy ventolin nebules use was lower in the remdesivir group than in the placebo group (17% [95% CI, 13 to 22] vs. 24% [95% CI, 19 to 30]). Among the 285 patients who were receiving mechanical ventilation or ECMO at enrollment, patients in the remdesivir group received these interventions for fewer subsequent days than where can i buy ventolin nebules those in the placebo group (median, 17 days vs. 20 days), and the incidence of new mechanical ventilation or ECMO use among the 766 patients who were not receiving these interventions at enrollment was lower in the remdesivir group than in the placebo group (13% [95% CI, 10 to 17] vs.
23% [95% CI, 19 to 27]) (Table where can i buy ventolin nebules 3). Safety Outcomes In the as-treated population, serious adverse events occurred in 131 of 532 patients (24.6%) in the remdesivir group and in 163 of 516 patients (31.6%) in the placebo group (Table S17). There were 47 serious respiratory failure adverse events in the remdesivir group (8.8% of patients), including acute respiratory failure and the need for endotracheal intubation, and 80 in where can i buy ventolin nebules the placebo group (15.5% of patients) (Table S19). No deaths were considered by the investigators to be related to treatment assignment.
Grade 3 or 4 adverse events occurred on or before day 29 in 273 patients (51.3%) in the remdesivir group and in 295 (57.2%) in where can i buy ventolin nebules the placebo group (Table S18). 41 events were judged by the investigators to be related to remdesivir and 47 events to placebo (Table S17). The most common nonserious adverse events occurring in at least 5% of all patients included decreased glomerular filtration rate, decreased where can i buy ventolin nebules hemoglobin level, decreased lymphocyte count, respiratory failure, anemia, pyrexia, hyperglycemia, increased blood creatinine level, and increased blood glucose level (Table S20). The incidence of these adverse events was generally similar in the remdesivir and placebo groups.
Crossover After the data and safety monitoring board recommended that the preliminary primary analysis report be provided to the sponsor, data on a total of 51 patients (4.8% of the total study enrollment) â 16 (3.0%) in the remdesivir group and 35 (6.7%) in where can i buy ventolin nebules the placebo group â were unblinded. 26 (74.3%) of those in the placebo group whose data were unblinded were given remdesivir. Sensitivity analyses evaluating the unblinding (patients whose treatment assignments were unblinded had their data censored at the time of unblinding) and crossover (patients in the placebo group treated with remdesivir had their data censored at the initiation of remdesivir treatment) produced results similar to those of the primary analysis (Table S9)..
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Highlights and updates Tennessee exchange overviewTennessee is among the states that have ventolin dosage uk done the least to preserve the Affordable Care Actâs gains.Tennessee has a federally run exchange, so enrollees use HealthCare.gov to sign up for exchange plans. During the first five weeks of open enrollment for 2021 coverage (through December 5, 2020), 87,930 people had made plan selections through the Tennessee marketplace. At that point, ventolin dosage uk there were still 10 days remaining in the open enrollment period. Enrollment always increases towards the end of the enrollment window, and HealthCare.gov will process auto-renewals after December 15, for people with existing coverage who donât return to the exchange to pick a new plan or manually renew their coverage for 2021.Last year, total enrollment during the open enrollment period for 202 coverage (including auto-renewals) reached 200,445 people. That was down from 221,553 people who had enrolled the year before, for 2019 coverage.Tennessee continues to refuse federal funding to expand its Medicaid program to ventolin dosage uk cover low-income adults in the state (13 other states have also refused to expand their Medicaid programs, although some of them will expand coverage, either fully or partially, by mid-2021).
As a result, there are an estimated 117,000 people in the coverage gap in Tennessee â ineligible for Medicaid, but also ineligible for premium subsidies in the exchange because their income is too low.Insurer participation in Tennesseeâs exchange has been fairly volatile over the years, but there are six insurers offering plans for 2021, up from five in 2020 (UnitedHealthcare joined the exchange for 2021, after previously only offering coverage in 2016. Unitedâs plans ventolin dosage uk are available in much of the central and western parts of the state for 2021). Although their coverage areas donât all overlap, most Tennessee residents have a choice of insurers for 2021, as much of the state has at least three participating exchange insurers.Family and Childrenâs Service is the Tennessee Navigator organization, and brokers certified with the exchange can be found here.How are insurance premiums in Tennessee changing for 2021?. Insurers had to submit ventolin dosage uk rate filings in Tennessee by July 15, 2020. Some of the rates were approved as-filed, but the Tennessee Department of Commerce and Insurance worked with some of the insurers to reduce their proposed rates for 2021, with revised rate filings submitted by some insurers in August.
By the time the rate review process was complete, the following average rate changes were approved for 2021 for the stateâs individual market insurers:Blue Cross Blue Shield of Tennessee. Average premium increase of 9.8 percent (BCBSTN had ventolin dosage uk initially proposed an average rate increase of 12.9 percent). BCBSTNâs filing cover letter notes that they have about 93,000 members, although another area of the filing indicates 97,222 members. SERFF filing ventolin dosage uk number. BCTN-132455585Cigna.
Average premium decrease of 6.1 percent (Cignaâs filing notes that they expect the asthma treatment ventolin to increase their costs by about 1 percent in 2021, so the rate increase would ventolin dosage uk be more significant without asthma treatment as a factor). Cigna has 64,230 members. SERFF filing ventolin dosage uk number. CCGH-132359549Oscar. Average premium increase of 9.9 percent (Oscar had initially proposed an average rate increase of 12.4 percent).
Oscar has ventolin dosage uk 7,704 members. SERFF filing number. OHIN-132442088Bright. Average premium increase of 3 percent (Brightâs filing notes that the average rate increase would have been larger â at about 4.2 percent â without the asthma treatment ventolin. Other insurers in other states have also predicted reduced overall costs in 2021 due to asthma treatmentâs reduction in non-emergency medical services) Bright has 26,746 members.
SERFF filing number. BRHP-132308159Celtic/Ambetter. Average premium decrease of 2.5 percent (Celtic had initially proposed an average premium decrease of 0.3 percent, but the approved decrease ended up being more substantial). Celtic has 10,716 members, and has expanded into the Jackson and Tri-City areas for 2021. SERFF filing number.
CELT-132409373UnitedHealthcare. New to the market for 2021, so no applicable rate change (UHC previously offered coverage in the Tennessee exchange in 2016. The insurer is also rejoining the exchange in Maryland for 2021). UnitedHealthcare plans to offer coverage in all counties in rating areas 3, 4, 5, 6, and 8 (Figure 13 on this page shows the rating areas in map format. UHCâs plans will be available in southern/central and western Tennessee).
UHCâs filing does not include a specific rate adjustment for asthma treatment factors, but notes that they may revise this as the summer continues and more data become available. SERFF filing number. UHLC-132400597In Tennessee, each insurer filed a separate form to detail the anticipated impact of asthma treatment on 2021 claims costs. Where they had data and projections available, insurers broke it down into cost changes (either an increase or a decrease) associated with pent-up demand for elective services that were postponed this year, the cost of a asthma treatment, the cost of treating members who are diagnosed with asthma treatment, and the cost changes associated with the transition of people from the employer-sponsored market to the individual market (ie, there are expected to be more people purchasing coverage in the individual market for 2021, due to job losses amid the asthma treatment ventolin). Premiums in the Tennessee exchange started out as some of the lowest in the country in 2014, but increased rapidly in the subsequent years.
As of 2020, the average full-price premium in Tennesseeâs exchange is $641/month. Thatâs higher than the $595/month average across the 38 states that use HealthCare.gov. But 86 percent of Tennesseeâs exchange enrollees are receiving premium subsidies in 2020, and their after-subsidy premiums average $145/month â which is exactly the same as the after-subsidy average premium across those 38 states. Hereâs a summary of how full-price rates have changed in Tennesseeâs exchange over the years (keeping in mind that premium subsidies are designed to keep pace with full-price premiums, so they have grown over time as well):2014. In 2014 Tennessee had among the lowest overall average rates in the country for individual market health plans.
That was the first year that ACA-compliant plans were available, and rates were essentially educated actuarial guesses, since there was no claims experience on which to base them.2015. Average rate increase of 12.5 percent (another analysis indicated a 9 percent increase for a 40-year-old non-smoker). This included an average rate increase of 19 percent for BCBSTN, 7.5 percent for Cigna, and 14.4 percent for Humana. Tennessee was one of just eight states in a PricewaterhouseCooper analysis with double-digit average rate increases for 2015. But because Tennessee had rates so much lower than the national average in 2014, their rates were still much lower than most states in 2015, even after the rate hikes.
A Kaiser Family Foundation analysis of benchmark plan (second-lowest-cost silver plan) premium changes in major metropolitan areas in all 50 states found that the Nashville area still has the fifth-lowest average benchmark premium in the country in 2015, even after an increase of nearly 8 percent.2016. Average increase of 28.2 percent. Average premium increases ranged from just 0.4 percent for Cigna to more than 36 percent for Blue Cross Blue Shield of Tennessee (BCBSTN had 70 percent of the market share). The overall increase was substantial, but it essentially just brought Tennesseeâs lower-than-average rates more in line with rates in the rest of the country. Community Health Alliance had initially proposed a rate increase of nearly 45 percent, but the CO-OP ended up shutting down at the end of 2015, so that rate increase was not applicable.2017.
Average rate increase of 56 percent. The average rate increases ranged from 44.3 percent for Humana, to 62 percent for BCBSTN.Tennesseeâs individual market rate increase was roughly tied with Minnesotaâs for 2017, and both states trailed only Oklahoma, which had the highest weighted average increase for 2017.Cigna and Humana had originally filed average rate increases of 23 percent and 29 percent, respectively. But in early August 2016, regulators in Tennessee agreed to allow the carriers to refile new rates, after both carriers had told the state that the rates they had originally filed wouldnât be adequate to cover claims costs. Several carriers across the country made headlines in August and September with announcements that they would exit the exchanges at the end of 2016, but UnitedHealthcare was the only insurer to exit the Tennessee exchange altogether. The fact that regulators in Tennessee allowed new rates to be filed helped to keep the carriers in the market, but it also resulted in more significant premium hikes for 2017.
Carriers had asked to refile rates for 2016 during the summer of 2015, but state regulators would not allow them to do so. For 2017, regulators softened their stance in an effort to keep Cigna and Humana in the marketplace.2018. Average rate increase of 28.5 percent. BCBSTN increased average premiums by 21.4 percent. Cigna increased average premiums by 36.5 percent.
Silver plans became disproportionately expensive in 2018 in Tennessee (driving a significant chunk of the overall rate increase), as the Trump administration eliminated funding for cost-sharing reductions (CSRs). Although the official notice of the funding cut didnât come until mid-October, TDCI confirmed in September that the additional premiums necessary to cover CSR in 2018 had already been added to silver plan rates for 2018 (pre-emptively, but presciently, since the funding was cut off by the federal government a few weeks later). The higher premiums for silver plans resulted in even larger premium subsidies for 2018. So although the federal government is no longer directly reimbursing insurers for the cost of CSR, they are indirectly continuing to fund CSR, via larger premium subsidies.TDCI published a document showing average premiums for 35-year-olds and 55-year-olds in each rating area of the state, but most enrollees pay far lower premiums, as their premiums subsidies cover a large portion of the premiums.Blue Cross Blue Shield of Tennessee issued a press release in June 2017, going into great detail about their proposed rate increase for 2018. Their actuarial memo in their rate filing indicated that their average proposed rate increase was 21.4 percent, but that the majority of that was due to concerns that the Trump Administration wouldnât continue to enforce the individual mandate, and the uncertainty surrounding ongoing funding for cost-sharing reductions (CSR).The press release from Blue Cross Blue Shield of Tennessee noted that of the 21.4 percent rate increase they proposed (which was later approved by TDCI), 14 percentage points were due to the possible lack of funding for cost-sharing subsidies, and 7 percentage points were due to concerns that the individual mandate wouldnât be well enforced, resulting in a sicker risk pool (healthy people are the ones likely to drop coverage if the mandate isnât enforced.
Sick people will maintain their coverage regardless). So the rate increase for 2018 would apparently have been just 0.4 percent if it werenât for the Trump administrationâs refusal to commit to funding cost-sharing reductions and enforcing the individual mandate. Instead, BCBSTN proposed an average rate increase of 21.4 percent, and state regulators had no choice but to approve it.Cigna noted that 14.1 percentage points of their rate increase was due to the fact that the Trump Administration had not committed to funding cost-sharing subsidies.2019. Average rate decrease of 12.4 percent. But the average benchmark plan premium decreased by 26 percent in 2019, which was the largest percentage decrease in the nation.
The average, across all states, was a 1.5 percent decrease. Premium subsidies are based on the cost of the benchmark plan, so subsidies decreased by a larger margin than average premiums.In August 2018, the Tennessee Insurance Department announced approved 2019 rate changes, including rate decreases for Blue Cross Blue Shield and Cigna, which had the bulk of the stateâs individual market enrollees:Blue Cross Blue Shield of Tennessee. Average premium decrease of 14.9 percent (113,000 membes)Cigna. Average premium decrease of 12.8 percent (75,568 members)Oscar. Average increase of 7.2 percent to 10.84 percent (14,107 members)Bright.
New to the marketCeltic. New to the market 2020. Average rate decrease of about 1.1 percent. But benchmark premiums dropped by 7 percent, leading to some people paying higher after-subsidy premiums for their coverage in 2020. In 2019, when Bright and Celtic joined the marketplace in Tennessee and Cigna and Oscar expanded their coverage areas, benchmark premiums decreased much more significantly than overall average premiums, resulting in smaller premium subsidies.
So 2020 was the second year in a row that subsidy amounts dropped by more than the average premium amounts in Tennesseeâs exchange (which could partially explain the decrease in enrollment since 2018. Plans become less affordable when subsidies decrease by more than average premiums).Tennesseeâs exchange insurers implemented the following average rate changes for 2020:Blue Cross Blue Shield of Tennessee. Average premium increase of 1.4 percentCigna. Average premium decrease of 5.7 percentOscar. Average premium decrease of 8.3 percentBright.
Average premium increase of 2.93 percentCeltic. Average premium decrease of 1.6 percent Enrollment in Tennesseeâs exchange. 2014 through 2020As has been the case in the majority of states that use HealthCare.gov, enrollment in Tennesseeâs exchange peaked in 2016, and has declined each year since then.2014. The first open enrollment period, for 2014 coverage, was six months long and had an additional extension tacked onto the end. By April 19, 2014, total enrollment in the Tennessee exchange stood at 151,352 people.2015.
Enrollment grew significantly the next year, with 231,440 people enrolling through the exchange during the open enrollment period for 2015 coverage.2016. Enrollment peaked in the third year, with 268,867 people enrolling through the exchange in Tennessee.2017. President Trump took office just days before the end of the open enrollment period for 2017 coverage, and immediately cut HealthCare.govâs marketing campaign. 2017 rates were also sharply higher for people who didnât qualify for premium subsidies. So it wasnât surprising that enrollment dropped to 234,125 people.2018.
The Trump Administration reduced the marketing and outreach budget for HealthCare.gov, rates again increased sharply for people who didnât qualify for premium subsidies (due mostly to uncertainty over the future of the individual mandate and the Trump Administrationâs decision to cut off funding for cost-sharing reductions), and open enrollment was only half as long as it had been the year before (Nov 1 to Dec 15, which is the schedule thatâs currently being used). So again, it wasnât surprising that enrollment decreased, with 228,646 people buying plans during open enrollment.2019. Although rates decreased for 2019, theyâre still quite high for people who donât qualify for premium subsidies. The GOP tax bill ended the individual mandate penalty at the end of 2018, and the Trump Administration has made it easier for people to opt for coverage under short-term health plans instead of ACA-compliant plans. So enrollment dropped again during the open enrollment period for 2019 coverage, with 221,553 people buying plans.2020.
Enrollment stood at 200,445 at the end of the open enrollment period for 2020 coverage. As noted above, benchmark premiums decreased more significantly than overall average premiums in Tennesseeâs exchange, making after-subsidy premiums less affordable for many enrollees.Which insurers offer coverage in Tennessee's exchange?. There are six insurers offering coverage in Tennesseeâs exchange in 2021, up from just three in 2018. Hereâs a summary of how insurer participation in the stateâs exchange has changed over the years.2014. When the exchanges launched for 2014, plans were available in Tennesseeâs exchange from Blue Cross Blue Shield of Tennessee, Community Health Alliance (an ACA-created CO-OP), Cigna, and Humana, although only BCBSTN offered plans statewide.2015.
Time/Assurant joined the Tennessee exchange statewide in 2015, bringing the total number of participating insurers to five.2016. Four insurers offered plans. BCBSTN, Cigna, Humana, and UnitedHealthcare. UnitedHealthcare was new to the exchange for 2016, and according to Kaiser Family Foundationâs analysis, UnitedHeathcare offered at least one of the two lowest-priced silver plans in the exchange in 73 of Tennesseeâs 95 counties in 2016. But Assurant and Community Health Alliance both stopped selling plans at the end of 2015.
The CO-OPâs demise was due in part to the severe shortfall in federal risk corridor funding, although the CO-OP had stopped selling 2015 plans as of January 15, 2015, noting that they had already met their enrollment goal for the year. Community Health Alliance had planned to begin selling plans again during the 2016 open enrollment, but instead they ceased operations altogether at the end of 2015, leaving 27,000 enrollees who needed to select new coverage for 2016 from a different carrier.2017. Plans were available from Humana, Cigna, and BCBSTN. Like Assurantâs brief stint in the exchange, UnitedHealthcareâs participation was also short-lived, as they exited the entire individual market in Tennessee at the end of 2016. The Department of Commerce and Insurance confirmed that the exit applied to both the exchange (UnitedHealthcare Insurance Company) and off-exchange (UnitedHealthcare Life Insurance Company).
The state reported that 40,879 people needed to secure new coverage for 2017 as a result of Unitedâs exit (the large majority of these enrollees had their United coverage through the exchange). 2017 was also the first year that BCBSTN opted not to offer statewide coverage. As of 2017, BCBSTN stopped offering coverage in the metro areas of Knoxville, Nashville, and Memphis, which are the three largest metropolitan areas in the state.Blue Cross Blue Shield of Tennessee had the lionâs share of the Tennessee exchange market in 2016, covering almost 69 percent of the enrollees. Because of BCBSTâs exit from the three metropolitan areas, approximately 52,000 people in Nashville, 31,000 people in Knoxville, and 29,000 in Memphis had to switch to a different plan for 2017. So although there were three insurers offering plans in Tennesseeâs exchange for 2017, residents in 73 of the stateâs 95 counties had only one carrier option in the exchange.
Cigna offered coverage in the Memphis and Nashville areas. Humana offered coverage in the Memphis, Nashville, and Knoxville areas, and BCBSTN offered coverage in the rest of the state.2018. There was quite a bit of upheaval in the Tennessee exchange for 2018, in terms of insurer participation. Humana stopped offering individual market coverage in any states at the end of 2017. Humanaâs exit meant that residents in the Knoxville area were facing the possibility of having no exchange insurers at all in 2018.
Humana insured about 40,000 people in the Knoxville area, and about 79,000 people across all three metropolitan areas in the state. State regulators scrambled to reach a solution, and succeeded. In May 2017, Blue Cross Blue Shield of Tennessee agreed to once again offer coverage in 2018 in the Knoxville area in order to ensure that all areas of the state would have insurance plans available in the exchange.While it initially appeared that there would only be two insurers in the Tennessee exchange for 2019, Oscar Healthâs entry to the market meant that three insurers offered plans:Cignaâs plans were available in a total of 22 counties in Memphis, Nashville, and the Tri-City area (the eight eastern-most counties in the state), just as they were in 2017.BCBS of Tennessee had plans available everywhere except Memphis and Nashville. They continued to offer coverage in the non-metro areas of the state where they offered plans in 2017, and expanded back into the Knoxville area.Oscar Health has plans available in nine counties in the Nashville area.Nashville and the Tri-City areas were the only parts of the state where enrollees had a choice between two insurers, with both BCBSTN and Cigna offering plans in the Tri-City area, and Oscar and Cigna offering plans in the Nashville area.Tennessee Insurance Commissioner, Julie Mix McPeak, expressed satisfaction that all areas of the state would have at least one insurer offering coverage in the exchange in 2018, but she reiterated how the uncertainty caused by the Trump Administration and Congress was damaging the individual health insurance market, noting that âthe uncertainty about the future of the exchange, cost-sharing reduction payments, and enforcement of the individual mandate will likely increase carrier rate requests by 15 to 20 percent above what they would have otherwise filed. I share consumersâ frustrations about federal uncertainty and how that is impacting their ability to afford insurance.â2019.
Bright Health joined the Tennessee exchange for 2019, offering coverage in 16 counties in the Knoxville area, nine counties in the Nashville area, and five counties in the Memphis area.Celtic (Centene) also joined the Tennessee exchange for 2019, with plans available in Memphis and Chattanooga. Much of the state had multiple carrier options for 2019 coverage:Nashville. Oscar, Cigna, BrightKnoxville. BCBSTN, Bright, and CignaMemphis. Bright, Oscar, Cigna, and CelticTri-City area.
BCBSTN and CignaChattanooga area. Celtic and BCBSTN2020. Tennessee continues to have five exchange insurers in 2020, but three have larger coverage areas. Blue Cross Blue Shield of Tennessee came back to the Memphis and Nashville areas for 2020. Celtic expanded into the Nashville and Knoxville areas, and Cigna expanded into the Chattanooga and Jackson areas.2021.
UnitedHealthcare rejoined the exchange in Tennessee for 2021, after leaving at the end of 2016. That brings the state to six insurers. UnitedHealthcareâs plans are available in all counties in rating areas 3, 4, 5, 6, and 8 (southern/central and western Tennessee). Tennessee Insurance Commissionerâs reform proposalsJulie Mix McPeak was the Insurance Commissioner for Tennessee from 2011 through mid-2019, and also served as the President of the National Association of Insurance Commissioners. In February 2017, Mix McPeak spoke before the Senate Committee on Health, Education, Labor, &.
Pensions, presenting her recommendations for health care reform. Among her proposals were:Allowing states to define essential health benefits, rather than requiring all plans sold in every state to conform to the ACAâs essential health benefits (this has been part of most of the GOP proposals to repeal or change the ACA, although it has not been implemented. As of 2019, essential health benefits are still defined at the federal level).Relaxing the age band ratio from the 3:1 level set by the ACA, to a 5:1 or 6:1 cap. The ACA limits premiums for older enrollees to no more than three times those of younger enrollees. Mix McPeak suggested that insurers should be able to charge older enrollees five or six times as much as younger enrollees, in an effort to reduce premiums for younger enrollees and incentivize them to enroll (this is another provision that was included in most of the GOP efforts to repeal or change the ACA in 2017, but none of those efforts were successful.
Itâs worth noting that adjusting the age rating bands would result in lower premiums for younger people, but markedly higher premiums for older people. For those who receive premium subsidies, the subsidies would grow to offset the increase. But for those who donât get subsidies, coverage could become unaffordable).Tighter restrictions and increased verification of eligibility for special enrollment periods (HHS finalized a market stabilization rule in April 2017 that included increased eligibility verification, and restrictions such as limiting enrolleesâ ability to use a special enrollment period to switch to a plan at a different metal level).Reducing the current 90-day grace period for people with premium subsidies down to a 30-day grace period (the market stabilization rule kept the 90-day grace period, but allows insurers to apply new enrollment premiums to past-due balances from the previous 12 months if the person seeks to re-enroll after losing coverage for non-payment of premium).Senator Alexander. 2017 legislation to protect bare counties, and a plea for CSR fundingIn 2017, the U.S. Senators from Tennessee, Lamar Alexander and Bob Corker, both Republicans, introduced legislation (S.761, the Health Care Options Act of 2017) that would allow people in counties without any participating exchange insurers to use ACA subsidies for off-exchange plans.
That scenario has never come to pass, but there were concerns at that point that some areas of the country, including the Knoxville, Tennessee area, might not have had any ACA-compliant plans available.Senator Alexander also, notably, stated in early 2017 that Congress or the Trump administration should commit to funding cost-sharing reductions (CSRs) through 2019, in an effort to stabilize the individual health insurance market. CSRs lower out-of-pocket costs for low-income exchange enrollees who pick silver plans, and 57 percent of Tennessee exchange enrollees have plans that include CSRs in 2017.CSR funding was ultimately eliminated by the Trump administration in October 2017, but the uncertainty (during the rate filing season of spring/summer 2017) around whether or not the funding would continue resulted in premium proposals for 2018 that were higher than they would otherwise have been. Without a federal commitment to fund CSR, Tennessee Insurance Commissioner, Julie Mix McPeak estimated that premiums in Tennessee would be 15 to 20 percent higher than they would otherwise have been in 2018.Senator Alexander joined forces with Senator Patty Murray (D, Washington) in an effort to pass bipartisan legislation aimed at stabilizing the individual insurance markets nationwide, with a proposal that included CSR funding. However, Republican leadership in the Senate opted to push forward on their efforts to repeal the ACA (via the Graham-Cassidy legislation) and pulled the plug on Alexander and Murrayâs bipartisan approach in September 2017.In the announcement about the approved rates for 2018, Mix McPeak said âIâm disappointed by yesterdayâs announcement out of Washington [about Alexander and Murrayâs bipartisan approach being abandoned by Senate leadership]. While Tennessee is supportive of long-term strategies such as the Graham-Cassidy Amendment introduced in Congress, I appreciate the diligent efforts of Senators Lamar Alexander and Patty Murray to find common ground in providing more immediate stabilization in the marketplace.
Instead, it appears more likely that Tennesseans must prepare themselves for a round of actuarially justified rates for 2018 that are far higher than could be necessary as a result of uncertainty in Washington.â Farm Bureau plans arenât compliance with the ACA, but theyâre still allowed to be sold in TennesseeAs of 2017, there were about 73,000 people in Tennessee who were covered under Farm Bureau plans that arenât ACA-compliant. About 50,000 of those were grandfathered plans, but the rest are medically underwritten âtraditionalâ plans that are still available for purchase. Medical underwriting means that the insurer uses the applicantâs medical history to determine whether to offer coverage and at what price. That practice is no longer allowed under the ACA â on or off-exchange â for any plans that are considered individual major medical health insurance.But in Tennessee, the state doesnât consider Farm Bureau to be a licensed health insurer. Thatâs been the case for more than two decades â Farm Bureau plans operate outside of the regulatory structure imposed by the state (and the ACA) on health insurers.
As a result, Farm Bureauâs âtraditionalâ plans, which are less expensive than regular health insurance but only available to healthy people, are being sold to healthy people in Tennessee, effectively removing them from the ACA-compliant risk pool.People who enroll in Farm Bureauâs âtraditionalâ plans are not in compliance with the ACAâs individual mandate, so from 2014 through 2018, they were assessed a penalty for being uninsured unless they were exempt from the individual mandate (this is the same as the rule that required people with short-term health insurance to pay the individual mandate penalty. Just like the Tennessee Farm Bureau âtraditionalâ plans, short-term health insurance is not regulated by the ACA). But the individual mandate penalty no longer applies in 2019 and future years, so there is no longer a penalty for relying on a Farm Bureau plan.Farm Bureauâs plans are not as robust as regular health insurance, and arenât helpful for people with pre-existing conditions. But the fact that Tennessee has allowed them to continue to be sold outside the scope of the stateâs insurance regulations could be part of the reason the state has a risk pool in the ACA-compliant market thatâs sicker than most states.Iowa has decided to follow Tennesseeâs lead, enacting legislation in 2018 that allows Farm Bureau to partner with Wellmark to offer non-ACA-compliant plans in Iowa.BCBSTN losses pre-2017 and rate hike request â some backgroundDuring open enrollment for 2016 coverage, 166,425 exchange enrollees (62 percent of the total) signed up with Blue Cross Blue Shield of Tennessee for 2016. This was an increase of 16 percent over BCBSTNâs exchange enrollment in 2015, despite the fact that the carrier raised its premiums by an average of 36 percent for 2016.
The remaining 38 percent of the exchange enrollees selected plans from Humana, Cigna, and United Healthcare.Blue Cross Blue Shield of Tennessee had the lowest priced plans in the Tennessee exchange â and the nation â in 2014. Although BCBSTNâs average rate increase was 19 percent for 2015 and 36 percent for 2016 (and their competitors had significantly smaller rate hikes), they still had among the lowest premiums in many areas of Tennessee in 2016. In the Memphis area, a search on Healthcare.gov indicated that the five least expensive bronze plans and the four least expensive silver plans were all offered by BCBSTN in 2016. Their lower premiums and brand-name recognition likely played a role in their outsized market share. But because enrollees have been sicker than expected, the carrier lost $300 million during 2014 and 2015, and projected total losses to reach $500 million by the end of 2016.
Losses of that magnitude are not sustainable.In order to continue working towards long-term sustainability in the ACA-compliant individual market, BCBSTN had indicated earlier in 2016 that they were expecting to propose significant rate increases for 2017, although the expectation in early 2016 was that the proposed rate increases for 2017 would be comparable to the 36 percent average increase that the carrier implemented for 2016. Ultimately, BCBSTN requested a much higher average increase â 62 percent â for 2017, and regulators approved it in order to keep the insurer in the marketplace.Joe Sullivan of The Knoxville Mercury tracked down some 2016 data that adds perspective to the rate changes for 2017, particularly in the Memphis and Nashville metropolitan areas, where Humana, Cigna, and BCBS all offered plans in the exchange in 2016:BCBS had two networks, and offered 10 silver PPO plans in Nashville and in Memphis in 2016. The plans included out-of-network coverage. BCBST did not offer plans in either area in 2017.Humana had one silver PPO plan in Nashville and in Memphis.Cigna had three silver EPO plans in Nashville (no out-of-network coverage) and three silver PPO plans in Memphis.In Memphis, all three carriers offered silver PPO plans, and BCBS had the lowest prices (BCBST stopped offering coverage in Memphis in 2017).In Nashville, Cignaâs silver prices were lower than BCBS, but the Cigna plans were EPOs, without coverage for out-of-network care (BCBST stopped offering plans in Nashville in 2017).Grandmothered/Transitional health plansTennessee has allowed transitional (grandmothered) plans to remain in force, but the Tennessee Department of Commerce and Insurance confirmed in 2017 that they no longer had any grandmothered plans remaining in the individual market, as insurers had opted to end those plans and replace them with ACA-compliant plans instead.History of the Tennessee exchangeIn December 2012, then-Gov. Bill Haslam announced Tennessee would not develop its own health insurance exchange, citing a lack of information from the federal government.Prior to his 2012 announcement, Haslam had leaned toward a state-run exchange.
He believed local state control was preferable and that the state could run the exchange more cost-effectively that the federal government.However, Republican legislators opposed the exchange, Tea Party supporters staged repeated protests, and Tennessee eventually ended up with an exchange run by HHS.Tennessee health insurance exchange linksHealthCare.gov800-318-2596State Exchange Profile. TennesseeThe Henry J. Kaiser Family Foundation overview of Tennesseeâs progress toward creating a state health insurance exchange.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 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.Key takeawaysNearly 4.3 million people in Texas have Medicare plans, but thatâs only a little more than 14 percent of the stateâs population.Nearly 43% Texas Medicare beneficiaries had Medicare Advantage plans (or other private Medicare plans, including Medicare Cost plans) as of 2020.
Medicare Advantage plan availability ranges from eight plans to 60 plans, depending on the county.In Texas, 70 insurers offer Medigap plans and more than 873,000 Texas residents are enrolled in Medigap plans. Medigap insurers in Texas are required to offer at least Medigap Plan A to disabled beneficiaries under the age of 65.Premiums for stand-alone Part D prescription plans in Texas range from about $7 to $155 per month for 2021 coverage. 1.65 million Texas Medicare beneficiaries have stand-alone Part D plans, plus 1.54 million with Part D integrated with Medicare Advantage.Per-enrollee Original Medicare spending in Texas is the second-highest in the nation (Louisiana is the only state where average per-beneficiary spending is higher).Extended enrollment opportunity for Texas residents affected by 2020 tropical stormsThe regular annual open enrollment period for 2021 Medicare Advantage and Part D plans ended on December 7. But Texas residents who live in counties affected by tropical storms Marco and Laura have additional time to enroll in a Part D or Advantage plan for 2021. This window in Texas continues until December 31, 2020 (four calendar months after the tropical storm disaster incident in Texas).This extended enrollment opportunity applies to people who live in the counties in eastern Texas where FEMA declared a disaster, as well as those who live elsewhere but rely on a friend or family member for assistance with the enrollment process, and that person lives in one of the affected counties.
If youâre eligible for the enrollment period extension and you sign up for a Part D or Medicare Advantage plan by December 31, your new coverage will take effect January 1, the same as it would have if youâd enrolled by December 7. Medicare enrollment in TexasThe number of Medicare beneficiaries in Texas stood at 4,292,236 as of October 2020. Only Florida and California have more residents enrolled in Medicare.CMS has extended Medicare open enrollment through December 31 in 54 Texas counties in response to the natural disasters in 2020.But only a little more than 14 percent of Texas residents are enrolled in Medicare, compared with almost 19 percent of the United States population enrolled in Medicare. Texas has among the youngest populations in the country, and since most people become eligible for Medicare enrollment when they turn 65, the stateâs lower median age results in a smaller percentage of its residents filing for Medicare benefits.Although most people become eligible for Medicare coverage enrollment when they turn 65, Medicare also provides coverage for people under age 65. Those who have been receiving disability benefits for 24 months, have ALS, or have end-stage renal disease are eligible for Medicare.
Fifteen percent of all Medicare beneficiaries in Texas â and nationwide â are under the age of 65.Medicare health insurance optionsIn most areas of the country, Medicare beneficiaries can choose Original Medicare or a Medicare Advantage plan.Original Medicare is provided directly by the federal government and includes Medicare Parts A and B. Medicare Part A, also called hospital insurance, helps to pay for inpatient stays at a hospital, skilled nursing facility, or hospice center. Part B, also called medical insurance, helps pay for outpatient care like physician services, kidney dialysis, preventive care, durable medical equipment, etc.Medicare Advantage plans are administered by private insurance companies that have contracts with the federal government. Medicare Advantage plans include all of the benefits of Original Medicare (albeit with different cost-sharing, as the plans set their own deductibles, coinsurance, and copays, within the limits established by the federal government), and they typically have additional benefits, such coverage for prescription drugs, dental, and vision. But provider networks are often limited with Medicare Advantage plans, and out-of-pocket costs are typically higher than a person would have if they opted for Original Medicare plus a Medigap plan.
In short, there are pros and cons either way, and no one-size-fits-all solution. Medicare Advantage in TexasMedicare Advantage plans are available in all 254 counties in Texas in 2021, but plan availability ranges from as few as nine plans some of the stateâs service areas to as many as 90 plans for sale in Harris County.A little more than a third of Texas Medicare beneficiares â just slightly more than the national average â were enrolled in private Medicare plans in 2018. These were mostly Medicare Advantage plans, but some residents in Texas have Medicare Cost plans, which are another form of private coverage. By late 2020, however, the share of Texas Medicare beneficiaries enrolled in private plans had grown to more than 43 percent. The other 57 percent of Medicare beneficiaries in Texas were enrolled in Original Medicare instead.Medicare beneficiaries can switch between Medicare Advantage enrollment and Original Medicare (and can add or drop a Medicare Part D prescription plan) during the Medicare annual election period, which runs from October 15 to December 7 each year.
Medicare Advantage enrollees also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.Medigap in TexasMore than half of Original Medicare beneficiaries have supplemental coverage provided by an employer-sponsored plan or Medicaid. But for those who donât, Medigap plans (also known as Medicare supplement plans) are designed to pay some or all of the out-of-pocket costs (deductibles and coinsurance) that enrollees would otherwise have to pay themselves. Since Original Medicare does not include a cap on out-of-pocket costs, most enrollees maintain some form of supplemental coverage, and Medigap plans are one way to do this.According to an AHIP analysis, there were 873,514 Texas Medicare beneficiaries with Medigap coverage as of 2018.There are 70 insurers licensed to sell Medigap plans in Texas.Although Medigap plans are sold by private insurers, the plans are standardized under federal rules. There are ten different plan designs (differentiated by letters, A through N), and the benefits offered by a particular plan (Plan A, Plan F, etc.) are the same from one insurer to another.Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue.
This window starts when a person is at least 65 and enrolled in Medicare Part B (you have to be enrolled in both Part A and Part B to buy a Medigap plan).Although disabled Americans under the age of 65 are eligible for Medicare, federal rules do not guarantee access to Medigap plans for people who are under 65. But the majority of the states â including Texas â have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans. Texas law requires Medigap insurers to offer at least Medigap Plan A to disabled enrollees under age 65, during the six-month period that begins when theyâre enrolled in Medicare Part B. Medigap Plan A is the least comprehensive of the Medigap plans, but it will cover the 20 percent Part B coinsurance that the enrollee would othewise have to pay out-of-pocket.Disabled Medicare beneficiaries under the age of 65 have another six-month Medigap open enrollment period when they turn 65. At that point, they have access to any of the available Medigap plans, at the standard premiums that apply to people who are enrolling in Medicare due to turning 65 (premiums are generally significantly higher for Medicare beneficiaries under age 65, since their disabilities result in more costly medical care).Medicare Advantage plans are available to anyone eligible for Medicare, except people with end-stage renal disease (starting in 2021, this limitation will no longer apply.
People with ESRD will be able to enroll in Medicare Advantage plans). So unless they have ESRD, Texas Medicare beneficiaries under the age of 65 can choose a Medicare Advantage plan instead of Medigap Plan A. Medicare Advantage plans do have a cap on out-of-pocket costs, but they also tend to have limited provider networks, which is an important consideration for people with serious health issues.Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those regulations donât apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months, if you didnât have at least six months of continuous coverage prior to your enrollment. And if you apply for a Medigap plan after your initial enrollment window closes (assuming you arenât eligible for one of the limited guaranteed-issue rights), the insurer can look back at your medical history in determining whether to accept your application, and at what premium.
Texas Medicare Part DOriginal Medicare does not cover the cost of outpatient prescription drugs. As noted above, more than half of Original Medicare beneficiaries have supplemental coverage via an employer-sponsored plan (from a current or former employer or spouseâs employer) or Medicaid, and these plans often include prescription coverage. But Medicare beneficiaries who donât have drug coverage through Medicaid or an employer-sponsored plan need to obtain Medicare Part D prescription coverage (prior to 2006, some Medigap plans included prescription coverage. People who still have those plans can keep them, but they have not been for sale since the end of 2005).Part D coverage can be purchased as a stand-alone plan, or as part of a Medicare Advantage plan that includes Part D prescription drug coverage.In Texas, there are 35 stand-alone Medicare Part D plans for sale for 2021, with premiums that range from about $7 to $155/month.As of late 2020, there were 1.65 million Medicare beneficiaries in Texas with stand-alone Medicare Part D plans. An additional 1.54 million Texas residents had Medicare Part D coverage integrated with their Medicare Advantage plans.Medicare Part D enrollment follows the same schedule as Medicare Advantage.
Beneficiaries can enroll in Medicare Part D plans when theyâre first eligible for Medicare, and thereâs also an annual enrollment window (October 15 to December 7) when people can enroll or switch to a different plan. Medicare spending in TexasIn 2018, Original Medicareâs per-beneficiary spending in Texas averaged $11,627, which was 15 percent higher than the $10,096 national average. Texas had the second-highest average per-beneficiary costs in the country. Only Louisiana had higher average costs. Thatâs based on data that were standardized to eliminate regional differences in payment rates, but it did not include costs for Medicare Advantage.How does Medicaid provide financial assistance to Medicare beneficiaries in Texas?.
Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesnât cover â such as long-term care.Our guide to financial assistance for Medicare enrollees in Texas includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.Helpful resources for Texas Medicare beneficiaries and their caregiversNeed help with your Medicare application in Texas, or have questions about Medicare eligibility in Texas?. These resources provide free assistance and information.The Health Information, Counseling, and Advocacy Program (HICAP), with any questions related to Medicare coverage in Texas. Visit the website or call 1-800-252-9240.The Texas Department of Insurance has a resources page for Texas residents with Medicare coverage.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 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..
Highlights and where can i buy ventolin nebules http://markgrigsby.org/how-to-get-a-cipro-prescription-from-your-doctor/ updates Tennessee exchange overviewTennessee is among the states that have done the least to preserve the Affordable Care Actâs gains.Tennessee has a federally run exchange, so enrollees use HealthCare.gov to sign up for exchange plans. During the first five weeks of open enrollment for 2021 coverage (through December 5, 2020), 87,930 people had made plan selections through the Tennessee marketplace. At that point, there were still 10 days remaining where can i buy ventolin nebules in the open enrollment period. Enrollment always increases towards the end of the enrollment window, and HealthCare.gov will process auto-renewals after December 15, for people with existing coverage who donât return to the exchange to pick a new plan or manually renew their coverage for 2021.Last year, total enrollment during the open enrollment period for 202 coverage (including auto-renewals) reached 200,445 people. That was down from 221,553 people who had enrolled the year before, for 2019 coverage.Tennessee continues to refuse federal funding to expand where can i buy ventolin nebules its Medicaid program to cover low-income adults in the state (13 other states have also refused to expand their Medicaid programs, although some of them will expand coverage, either fully or partially, by mid-2021).
As a result, there are an estimated 117,000 people in the coverage gap in Tennessee â ineligible for Medicaid, but also ineligible for premium subsidies in the exchange because their income is too low.Insurer participation in Tennesseeâs exchange has been fairly volatile over the years, but there are six insurers offering plans for 2021, up from five in 2020 (UnitedHealthcare joined the exchange for 2021, after previously only offering coverage in 2016. Unitedâs plans are available in much of the central and western parts of where can i buy ventolin nebules the state for 2021). Although their coverage areas donât all overlap, most Tennessee residents have a choice of insurers for 2021, as much of the state has at least three participating exchange insurers.Family and Childrenâs Service is the Tennessee Navigator organization, and brokers certified with the exchange can be found here.How are insurance premiums in Tennessee changing for 2021?. Insurers had to submit rate where can i buy ventolin nebules filings in Tennessee by July 15, 2020. Some of the rates were approved as-filed, but the Tennessee Department of Commerce and Insurance worked with some of the insurers to reduce their proposed rates for 2021, with revised rate filings submitted by some insurers in August.
By the time the rate review process was complete, the following average rate changes were approved for 2021 for the stateâs individual market insurers:Blue Cross Blue Shield of Tennessee. Average premium increase of 9.8 percent (BCBSTN had initially proposed an average rate increase where can i buy ventolin nebules of 12.9 percent). BCBSTNâs filing cover letter notes that they have about 93,000 members, although another area of the filing indicates 97,222 members. SERFF filing where can i buy ventolin nebules number. BCTN-132455585Cigna.
Average premium decrease of 6.1 percent (Cignaâs filing notes that they expect the asthma treatment ventolin where can i buy ventolin nebules to increase their costs by about 1 percent in 2021, so the rate increase would be more significant without asthma treatment as a factor). Cigna has 64,230 members. SERFF filing where can i buy ventolin nebules number. CCGH-132359549Oscar. Average premium increase of 9.9 percent (Oscar had initially proposed an average rate increase of 12.4 percent).
Oscar has where can i buy ventolin nebules 7,704 members. SERFF filing number. OHIN-132442088Bright. Average premium increase of 3 percent (Brightâs filing notes that the average rate increase would have been larger â at about 4.2 percent â without the asthma treatment ventolin. Other insurers in other states have also predicted reduced overall costs in 2021 due to asthma treatmentâs reduction in non-emergency medical services) Bright has 26,746 members.
SERFF filing number. BRHP-132308159Celtic/Ambetter. Average premium decrease of 2.5 percent (Celtic had initially proposed an average premium decrease of 0.3 percent, but the approved decrease ended up being more substantial). Celtic has 10,716 members, and has expanded into the Jackson and Tri-City areas for 2021. SERFF filing number.
CELT-132409373UnitedHealthcare. New to the market for 2021, so no applicable rate change (UHC previously offered coverage in the Tennessee exchange in 2016. The insurer is also rejoining the exchange in Maryland for 2021). UnitedHealthcare plans to offer coverage in all counties in rating areas 3, 4, 5, 6, and 8 (Figure 13 on this page shows the rating areas in map format. UHCâs plans will be available in southern/central and western Tennessee).
UHCâs filing does not include a specific rate adjustment for asthma treatment factors, but notes that they may revise this as the summer continues and more data become available. SERFF filing number. UHLC-132400597In Tennessee, each insurer filed a separate form to detail the anticipated impact of asthma treatment on 2021 claims costs. Where they had data and projections available, insurers broke it down into cost changes (either an increase or a decrease) associated with pent-up demand for elective services that were postponed this year, the cost of a asthma treatment, the cost of treating members who are diagnosed with asthma treatment, and the cost changes associated with the transition of people from the employer-sponsored market to the individual market (ie, there are expected to be more people purchasing coverage in the individual market for 2021, due to job losses amid the asthma treatment ventolin). Premiums in the Tennessee exchange started out as some of the lowest in the country in 2014, but increased rapidly in the subsequent years.
As of 2020, the average full-price premium in Tennesseeâs exchange is $641/month. Thatâs higher than the $595/month average across the 38 states that use HealthCare.gov. But 86 percent of Tennesseeâs exchange enrollees are receiving premium subsidies in 2020, and their after-subsidy premiums average $145/month â which is exactly the same as the after-subsidy average premium across those 38 states. Hereâs a summary of how full-price rates have changed in Tennesseeâs exchange over the years (keeping in mind that premium subsidies are designed to keep pace with full-price premiums, so they have grown over time as well):2014. In 2014 Tennessee had among the lowest overall average rates in the country for individual market health plans.
That was the first year that ACA-compliant plans were available, and rates were essentially educated actuarial guesses, since there was no claims experience on which to base them.2015. Average rate increase of 12.5 percent (another analysis indicated a 9 percent increase for a 40-year-old non-smoker). This included an average rate increase of 19 percent for BCBSTN, 7.5 percent for Cigna, and 14.4 percent for Humana. Tennessee was one of just eight states in a PricewaterhouseCooper analysis with double-digit average rate increases for 2015. But because Tennessee had rates so much lower than the national average in 2014, their rates were still much lower than most states in 2015, even after the rate hikes.
A Kaiser Family Foundation analysis of benchmark plan (second-lowest-cost silver plan) premium changes in major metropolitan areas in all 50 states found that the Nashville area still has the fifth-lowest average benchmark premium in the country in 2015, even after an increase of nearly 8 percent.2016. Average increase of 28.2 percent. Average premium increases ranged from just 0.4 percent for Cigna to more than 36 percent for Blue Cross Blue Shield of Tennessee (BCBSTN had 70 percent of the market share). The overall increase was substantial, but it essentially just brought Tennesseeâs lower-than-average rates more in line with rates in the rest of the country. Community Health Alliance had initially proposed a rate increase of nearly 45 percent, but the CO-OP ended up shutting down at the end of 2015, so that rate increase was not applicable.2017.
Average rate increase of 56 percent. The average rate increases ranged from 44.3 percent for Humana, to 62 percent for BCBSTN.Tennesseeâs individual market rate increase was roughly tied with Minnesotaâs for 2017, and both states trailed only Oklahoma, which had the highest weighted average increase for 2017.Cigna and Humana had originally filed average rate increases of 23 percent and 29 percent, respectively. But in early August 2016, regulators in Tennessee agreed to allow the carriers to refile new rates, after both carriers had told the state that the rates they had originally filed wouldnât be adequate to cover claims costs. Several carriers across the country made headlines in August and September with announcements that they would exit the exchanges at the end of 2016, but UnitedHealthcare was the only insurer to exit the Tennessee exchange altogether. The fact that regulators in Tennessee allowed new rates to be filed helped to keep the carriers in the market, but it also resulted in more significant premium hikes for 2017.
Carriers had asked to refile rates for 2016 during the summer of 2015, but state regulators would not allow them to do so. For 2017, regulators softened their stance in an effort to keep Cigna and Humana in the marketplace.2018. Average rate increase of 28.5 percent. BCBSTN increased average premiums by 21.4 percent. Cigna increased average premiums by 36.5 percent.
Silver plans became disproportionately expensive in 2018 in Tennessee (driving a significant chunk of the overall rate increase), as the Trump administration eliminated funding for cost-sharing reductions (CSRs). Although the official notice of the funding cut didnât come until mid-October, TDCI confirmed in September that the additional premiums necessary to cover CSR in 2018 had already been added to silver plan rates for 2018 (pre-emptively, but presciently, since the funding was cut off by the federal government a few weeks later). The higher premiums for silver plans resulted in even larger premium subsidies for 2018. So although the federal government is no longer directly reimbursing insurers for the cost of CSR, they are indirectly continuing to fund CSR, via larger premium subsidies.TDCI published a document showing average premiums for 35-year-olds and 55-year-olds in each rating area of the state, but most enrollees pay far lower premiums, as their premiums subsidies cover a large portion of the premiums.Blue Cross Blue Shield of Tennessee issued a press release in June 2017, going into great detail about their proposed rate increase for 2018. Their actuarial memo in their rate filing indicated that their average proposed rate increase was 21.4 percent, but that the majority of that was due to concerns that the Trump Administration wouldnât continue to enforce the individual mandate, and the uncertainty surrounding ongoing funding for cost-sharing reductions (CSR).The press release from Blue Cross Blue Shield of Tennessee noted that of the 21.4 percent rate increase they proposed (which was later approved by TDCI), 14 percentage points were due to the possible lack of funding for cost-sharing subsidies, and 7 percentage points were due to concerns that the individual mandate wouldnât be well enforced, resulting in a sicker risk pool (healthy people are the ones likely to drop coverage if the mandate isnât enforced.
Sick people will maintain their coverage regardless). So the rate increase for 2018 would apparently have been just 0.4 percent if it werenât for the Trump administrationâs refusal to commit to funding cost-sharing reductions and enforcing the individual mandate. Instead, BCBSTN proposed an average rate increase of 21.4 percent, and state regulators had no choice but to approve it.Cigna noted that 14.1 percentage points of their rate increase was due to the fact that the Trump Administration had not committed to funding cost-sharing subsidies.2019. Average rate decrease of 12.4 percent. But the average benchmark plan premium decreased by 26 percent in 2019, which was the largest percentage decrease in the nation.
The average, across all states, was a 1.5 percent decrease. Premium subsidies are based on the cost of the benchmark plan, so subsidies decreased by a larger margin than average premiums.In August 2018, the Tennessee Insurance Department announced approved 2019 rate changes, including rate decreases for Blue Cross Blue Shield and Cigna, which had the bulk of the stateâs individual market enrollees:Blue Cross Blue Shield of Tennessee. Average premium decrease of 14.9 percent (113,000 membes)Cigna. Average premium decrease of 12.8 percent (75,568 members)Oscar. Average increase of 7.2 percent to 10.84 percent (14,107 members)Bright.
New to the marketCeltic. New to the market 2020. Average rate decrease of about 1.1 percent. But benchmark premiums dropped by 7 percent, leading to some people paying higher after-subsidy premiums for their coverage in 2020. In 2019, when Bright and Celtic joined the marketplace in Tennessee and Cigna and Oscar expanded their coverage areas, benchmark premiums decreased much more significantly than overall average premiums, resulting in smaller premium subsidies.
So 2020 was the second year in a row that subsidy amounts dropped by more than the average premium amounts in Tennesseeâs exchange (which could partially explain the decrease in enrollment since 2018. Plans become less affordable when subsidies decrease by more than average premiums).Tennesseeâs exchange insurers implemented the following average rate changes for 2020:Blue Cross Blue Shield of Tennessee. Average premium increase of 1.4 percentCigna. Average premium decrease of 5.7 percentOscar. Average premium decrease of 8.3 percentBright.
Average premium increase of 2.93 percentCeltic. Average premium decrease of 1.6 percent Enrollment in Tennesseeâs exchange. 2014 through 2020As has been the case in the majority of states that use HealthCare.gov, enrollment in Tennesseeâs exchange peaked in 2016, and has declined each year since then.2014. The first open enrollment period, for 2014 coverage, was six months long and had an additional extension tacked onto the end. By April 19, 2014, total enrollment in the Tennessee exchange stood at 151,352 people.2015.
Enrollment grew significantly the next year, with 231,440 people enrolling through the exchange during the open enrollment period for 2015 coverage.2016. Enrollment peaked in the third year, with 268,867 people enrolling through the exchange in Tennessee.2017. President Trump took office just days before the end of the open enrollment period for 2017 coverage, and immediately cut HealthCare.govâs marketing campaign. 2017 rates were also sharply higher for people who didnât qualify for premium subsidies. So it wasnât surprising that enrollment dropped to 234,125 people.2018.
The Trump Administration reduced the marketing and outreach budget for HealthCare.gov, rates again increased sharply for people who didnât qualify for premium subsidies (due mostly to uncertainty over the future of the individual mandate and the Trump Administrationâs decision to cut off funding for cost-sharing reductions), and open enrollment was only half as long as it had been the year before (Nov 1 to Dec 15, which is the schedule thatâs currently being used). So again, it wasnât surprising that enrollment decreased, with 228,646 people buying plans during open enrollment.2019. Although rates decreased for 2019, theyâre still quite high for people who donât qualify for premium subsidies. The GOP tax bill ended the individual mandate penalty at the end of 2018, and the Trump Administration has made it easier for people to opt for coverage under short-term health plans instead of ACA-compliant plans. So enrollment dropped again during the open enrollment period for 2019 coverage, with 221,553 people buying plans.2020.
Enrollment stood at 200,445 at the end of the open enrollment period for 2020 coverage. As noted above, benchmark premiums decreased more significantly than overall average premiums in Tennesseeâs exchange, making after-subsidy premiums less affordable for many enrollees.Which insurers offer coverage in Tennessee's exchange?. There are six insurers offering coverage in Tennesseeâs exchange in 2021, up from just three in 2018. Hereâs a summary of how insurer participation in the stateâs exchange has changed over the years.2014. When the exchanges launched for 2014, plans were available in Tennesseeâs exchange from Blue Cross Blue Shield of Tennessee, Community Health Alliance (an ACA-created CO-OP), Cigna, and Humana, although only BCBSTN offered plans statewide.2015.
Time/Assurant joined the Tennessee exchange statewide in 2015, bringing the total number of participating insurers to five.2016. Four insurers offered plans. BCBSTN, Cigna, Humana, and UnitedHealthcare. UnitedHealthcare was new to the exchange for 2016, and according to Kaiser Family Foundationâs analysis, UnitedHeathcare offered at least one of the two lowest-priced silver plans in the exchange in 73 of Tennesseeâs 95 counties in 2016. But Assurant and Community Health Alliance both stopped selling plans at the end of 2015.
The CO-OPâs demise was due in part to the severe shortfall in federal risk corridor funding, although the CO-OP had stopped selling 2015 plans as of January 15, 2015, noting that they had already met their enrollment goal for the year. Community Health Alliance had planned to begin selling plans again during the 2016 open enrollment, but instead they ceased operations altogether at the end of 2015, leaving 27,000 enrollees who needed to select new coverage for 2016 from a different carrier.2017. Plans were available from Humana, Cigna, and BCBSTN. Like Assurantâs brief stint in the exchange, UnitedHealthcareâs participation was also short-lived, as they exited the entire individual market in Tennessee at the end of 2016. The Department of Commerce and Insurance confirmed that the exit applied to both the exchange (UnitedHealthcare Insurance Company) and off-exchange (UnitedHealthcare Life Insurance Company).
The state reported that 40,879 people needed to secure new coverage for 2017 as a result of Unitedâs exit (the large majority of these enrollees had their United coverage through the exchange). 2017 was also the first year that BCBSTN opted not to offer statewide coverage. As of 2017, BCBSTN stopped offering coverage in the metro areas of Knoxville, Nashville, and Memphis, which are the three largest metropolitan areas in the state.Blue Cross Blue Shield of Tennessee had the lionâs share of the Tennessee exchange market in 2016, covering almost 69 percent of the enrollees. Because of BCBSTâs exit from the three metropolitan areas, approximately 52,000 people in Nashville, 31,000 people in Knoxville, and 29,000 in Memphis had to switch to a different plan for 2017. So although there were three insurers offering plans in Tennesseeâs exchange for 2017, residents in 73 of the stateâs 95 counties had only one carrier option in the exchange.
Cigna offered coverage in the Memphis and Nashville areas. Humana offered coverage in the Memphis, Nashville, and Knoxville areas, and BCBSTN offered coverage in the rest of the state.2018. There was quite a bit of upheaval in the Tennessee exchange for 2018, in terms of insurer participation. Humana stopped offering individual market coverage in any states at the end of 2017. Humanaâs exit meant that residents in the Knoxville area were facing the possibility of having no exchange insurers at all in 2018.
Humana insured about 40,000 people in the Knoxville area, and about 79,000 people across all three metropolitan areas in the state. State regulators scrambled to reach a solution, and succeeded. In May 2017, Blue Cross Blue Shield of Tennessee agreed to once again offer coverage in 2018 in the Knoxville area in order to ensure that all areas of the state would have insurance plans available in the exchange.While it initially appeared that there would only be two insurers in the Tennessee exchange for 2019, Oscar Healthâs entry to the market meant that three insurers offered plans:Cignaâs plans were available in a total of 22 counties in Memphis, Nashville, and the Tri-City area (the eight eastern-most counties in the state), just as they were in 2017.BCBS of Tennessee had plans available everywhere except Memphis and Nashville. They continued to offer coverage in the non-metro areas of the state where they offered plans in 2017, and expanded back into the Knoxville area.Oscar Health has plans available in nine counties in the Nashville area.Nashville and the Tri-City areas were the only parts of the state where enrollees had a choice between two insurers, with both BCBSTN and Cigna offering plans in the Tri-City area, and Oscar and Cigna offering plans in the Nashville area.Tennessee Insurance Commissioner, Julie Mix McPeak, expressed satisfaction that all areas of the state would have at least one insurer offering coverage in the exchange in 2018, but she reiterated how the uncertainty caused by the Trump Administration and Congress was damaging the individual health insurance market, noting that âthe uncertainty about the future of the exchange, cost-sharing reduction payments, and enforcement of the individual mandate will likely increase carrier rate requests by 15 to 20 percent above what they would have otherwise filed. I share consumersâ frustrations about federal uncertainty and how that is impacting their ability to afford insurance.â2019.
Bright Health joined the Tennessee exchange for 2019, offering coverage in 16 counties in the Knoxville area, nine counties in the Nashville area, and five counties in the Memphis area.Celtic (Centene) also joined the Tennessee exchange for 2019, with plans available in Memphis and Chattanooga. Much of the state had multiple carrier options for 2019 coverage:Nashville. Oscar, Cigna, BrightKnoxville. BCBSTN, Bright, and CignaMemphis. Bright, Oscar, Cigna, and CelticTri-City area.
BCBSTN and CignaChattanooga area. Celtic and BCBSTN2020. Tennessee continues to have five exchange insurers in 2020, but three have larger coverage areas. Blue Cross Blue Shield of Tennessee came back to the Memphis and Nashville areas for 2020. Celtic expanded into the Nashville and Knoxville areas, and Cigna expanded into the Chattanooga and Jackson areas.2021.
UnitedHealthcare rejoined the exchange in Tennessee for 2021, after leaving at the end of 2016. That brings the state to six insurers. UnitedHealthcareâs plans are available in all counties in rating areas 3, 4, 5, 6, and 8 (southern/central and western Tennessee). Tennessee Insurance Commissionerâs reform proposalsJulie Mix McPeak was the Insurance Commissioner for Tennessee from 2011 through mid-2019, and also served as the President of the National Association of Insurance Commissioners. In February 2017, Mix McPeak spoke before the Senate Committee on Health, Education, Labor, &.
Pensions, presenting her recommendations for health care reform. Among her proposals were:Allowing states to define essential health benefits, rather than requiring all plans sold in every state to conform to the ACAâs essential health benefits (this has been part of most of the GOP proposals to repeal or change the ACA, although it has not been implemented. As of 2019, essential health benefits are still defined at the federal level).Relaxing the age band ratio from the 3:1 level set by the ACA, to a 5:1 or 6:1 cap. The ACA limits premiums for older enrollees to no more than three times those of younger enrollees. Mix McPeak suggested that insurers should be able to charge older enrollees five or six times as much as younger enrollees, in an effort to reduce premiums for younger enrollees and incentivize them to enroll (this is another provision that was included in most of the GOP efforts to repeal or change the ACA in 2017, but none of those efforts were successful.
Itâs worth noting that adjusting the age rating bands would result in lower premiums for younger people, but markedly higher premiums for older people. For those who receive premium subsidies, the subsidies would grow to offset the increase. But for those who donât get subsidies, coverage could become unaffordable).Tighter restrictions and increased verification of eligibility for special enrollment periods (HHS finalized a market stabilization rule in April 2017 that included increased eligibility verification, and restrictions such as limiting enrolleesâ ability to use a special enrollment period to switch to a plan at a different metal level).Reducing the current 90-day grace period for people with premium subsidies down to a 30-day grace period (the market stabilization rule kept the 90-day grace period, but allows insurers to apply new enrollment premiums to past-due balances from the previous 12 months if the person seeks to re-enroll after losing coverage for non-payment of premium).Senator Alexander. 2017 legislation to protect bare counties, and a plea for CSR fundingIn 2017, the U.S. Senators from Tennessee, Lamar Alexander and Bob Corker, both Republicans, introduced legislation (S.761, the Health Care Options Act of 2017) that would allow people in counties without any participating exchange insurers to use ACA subsidies for off-exchange plans.
That scenario has never come to pass, but there were concerns at that point that some areas of the country, including the Knoxville, Tennessee area, might not have had any ACA-compliant plans available.Senator Alexander also, notably, stated in early 2017 that Congress or the Trump administration should commit to funding cost-sharing reductions (CSRs) through 2019, in an effort to stabilize the individual health insurance market. CSRs lower out-of-pocket costs for low-income exchange enrollees who pick silver plans, and 57 percent of Tennessee exchange enrollees have plans that include CSRs in 2017.CSR funding was ultimately eliminated by the Trump administration in October 2017, but the uncertainty (during the rate filing season of spring/summer 2017) around whether or not the funding would continue resulted in premium proposals for 2018 that were higher than they would otherwise have been. Without a federal commitment to fund CSR, Tennessee Insurance Commissioner, Julie Mix McPeak estimated that premiums in Tennessee would be 15 to 20 percent higher than they would otherwise have been in 2018.Senator Alexander joined forces with Senator Patty Murray (D, Washington) in an effort to pass bipartisan legislation aimed at stabilizing the individual insurance markets nationwide, with a proposal that included CSR funding. However, Republican leadership in the Senate opted to push forward on their efforts to repeal the ACA (via the Graham-Cassidy legislation) and pulled the plug on Alexander and Murrayâs bipartisan approach in September 2017.In the announcement about the approved rates for 2018, Mix McPeak said âIâm disappointed by yesterdayâs announcement out of Washington [about Alexander and Murrayâs bipartisan approach being abandoned by Senate leadership]. While Tennessee is supportive of long-term strategies such as the Graham-Cassidy Amendment introduced in Congress, I appreciate the diligent efforts of Senators Lamar Alexander and Patty Murray to find common ground in providing more immediate stabilization in the marketplace.
Instead, it appears more likely that Tennesseans must prepare themselves for a round of actuarially justified rates for 2018 that are far higher than could be necessary as a result of uncertainty in Washington.â Farm Bureau plans arenât compliance with the ACA, but theyâre still allowed to be sold in TennesseeAs of 2017, there were about 73,000 people in Tennessee who were covered under Farm Bureau plans that arenât ACA-compliant. About 50,000 of those were grandfathered plans, but the rest are medically underwritten âtraditionalâ plans that are still available for purchase. Medical underwriting means that the insurer uses the applicantâs medical history to determine whether to offer coverage and at what price. That practice is no longer allowed under the ACA â on or off-exchange â for any plans that are considered individual major medical health insurance.But in Tennessee, the state doesnât consider Farm Bureau to be a licensed health insurer. Thatâs been the case for more than two decades â Farm Bureau plans operate outside of the regulatory structure imposed by the state (and the ACA) on health insurers.
As a result, Farm Bureauâs âtraditionalâ plans, which are less expensive than regular health insurance but only available to healthy people, are being sold to healthy people in Tennessee, effectively removing them from the ACA-compliant risk pool.People who enroll in Farm Bureauâs âtraditionalâ plans are not in compliance with the ACAâs individual mandate, so from 2014 through 2018, they were assessed a penalty for being uninsured unless they were exempt from the individual mandate (this is the same as the rule that required people with short-term health insurance to pay the individual mandate penalty. Just like the Tennessee Farm Bureau âtraditionalâ plans, short-term health insurance is not regulated by the ACA). But the individual mandate penalty no longer applies in 2019 and future years, so there is no longer a penalty for relying on a Farm Bureau plan.Farm Bureauâs plans are not as robust as regular health insurance, and arenât helpful for people with pre-existing conditions. But the fact that Tennessee has allowed them to continue to be sold outside the scope of the stateâs insurance regulations could be part of the reason the state has a risk pool in the ACA-compliant market thatâs sicker than most states.Iowa has decided to follow Tennesseeâs lead, enacting legislation in 2018 that allows Farm Bureau to partner with Wellmark to offer non-ACA-compliant plans in Iowa.BCBSTN losses pre-2017 and rate hike request â some backgroundDuring open enrollment for 2016 coverage, 166,425 exchange enrollees (62 percent of the total) signed up with Blue Cross Blue Shield of Tennessee for 2016. This was an increase of 16 percent over BCBSTNâs exchange enrollment in 2015, despite the fact that the carrier raised its premiums by an average of 36 percent for 2016.
The remaining 38 percent of the exchange enrollees selected plans from Humana, Cigna, and United Healthcare.Blue Cross Blue Shield of Tennessee had the lowest priced plans in the Tennessee exchange â and the nation â in 2014. Although BCBSTNâs average rate increase was 19 percent for 2015 and 36 percent for 2016 (and their competitors had significantly smaller rate hikes), they still had among the lowest premiums in many areas of Tennessee in 2016. In the Memphis area, a search on Healthcare.gov indicated that the five least expensive bronze plans and the four least expensive silver plans were all offered by BCBSTN in 2016. Their lower premiums and brand-name recognition likely played a role in their outsized market share. But because enrollees have been sicker than expected, the carrier lost $300 million during 2014 and 2015, and projected total losses to reach $500 million by the end of 2016.
Losses of that magnitude are not sustainable.In order to continue working towards long-term sustainability in the ACA-compliant individual market, BCBSTN had indicated earlier in 2016 that they were expecting to propose significant rate increases for 2017, although the expectation in early 2016 was that the proposed rate increases for 2017 would be comparable to the 36 percent average increase that the carrier implemented for 2016. Ultimately, BCBSTN requested a much higher average increase â 62 percent â for 2017, and regulators approved it in order to keep the insurer in the marketplace.Joe Sullivan of The Knoxville Mercury tracked down some 2016 data that adds perspective to the rate changes for 2017, particularly in the Memphis and Nashville metropolitan areas, where Humana, Cigna, and BCBS all offered plans in the exchange in 2016:BCBS had two networks, and offered 10 silver PPO plans in Nashville and in Memphis in 2016. The plans included out-of-network coverage. BCBST did not offer plans in either area in 2017.Humana had one silver PPO plan in Nashville and in Memphis.Cigna had three silver EPO plans in Nashville (no out-of-network coverage) and three silver PPO plans in Memphis.In Memphis, all three carriers offered silver PPO plans, and BCBS had the lowest prices (BCBST stopped offering coverage in Memphis in 2017).In Nashville, Cignaâs silver prices were lower than BCBS, but the Cigna plans were EPOs, without coverage for out-of-network care (BCBST stopped offering plans in Nashville in 2017).Grandmothered/Transitional health plansTennessee has allowed transitional (grandmothered) plans to remain in force, but the Tennessee Department of Commerce and Insurance confirmed in 2017 that they no longer had any grandmothered plans remaining in the individual market, as insurers had opted to end those plans and replace them with ACA-compliant plans instead.History of the Tennessee exchangeIn December 2012, then-Gov. Bill Haslam announced Tennessee would not develop its own health insurance exchange, citing a lack of information from the federal government.Prior to his 2012 announcement, Haslam had leaned toward a state-run exchange.
He believed local state control was preferable and that the state could run the exchange more cost-effectively that the federal government.However, Republican legislators opposed the exchange, Tea Party supporters staged repeated protests, and Tennessee eventually ended up with an exchange run by HHS.Tennessee health insurance exchange linksHealthCare.gov800-318-2596State Exchange Profile. TennesseeThe Henry J. Kaiser Family Foundation overview of Tennesseeâs progress toward creating a state health insurance exchange.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 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.Key takeawaysNearly 4.3 million people in Texas have Medicare plans, but thatâs only a little more than 14 percent of the stateâs population.Nearly 43% Texas Medicare beneficiaries had Medicare Advantage plans (or other private Medicare plans, including Medicare Cost plans) as of 2020.
Medicare Advantage plan availability ranges from eight plans to 60 plans, depending on the county.In Texas, 70 insurers offer Medigap plans and more than 873,000 Texas residents are enrolled in Medigap plans. Medigap insurers in Texas are required to offer at least Medigap Plan A to disabled beneficiaries under the age of 65.Premiums for stand-alone Part D prescription plans in Texas range from about $7 to $155 per month for 2021 coverage. 1.65 million Texas Medicare beneficiaries have stand-alone Part D plans, plus 1.54 million with Part D integrated with Medicare Advantage.Per-enrollee Original Medicare spending in Texas is the second-highest in the nation (Louisiana is the only state where average per-beneficiary spending is higher).Extended enrollment opportunity for Texas residents affected by 2020 tropical stormsThe regular annual open enrollment period for 2021 Medicare Advantage and Part D plans ended on December 7. But Texas residents who live in counties affected by tropical storms Marco and Laura have additional time to enroll in a Part D or Advantage plan for 2021. This window in Texas continues until December 31, 2020 (four calendar months after the tropical storm disaster incident in Texas).This extended enrollment opportunity applies to people who live in the counties in eastern Texas where FEMA declared a disaster, as well as those who live elsewhere but rely on a friend or family member for assistance with the enrollment process, and that person lives in one of the affected counties.
If youâre eligible for the enrollment period extension and you sign up for a Part D or Medicare Advantage plan by December 31, your new coverage will take effect January 1, the same as it would have if youâd enrolled by December 7. Medicare enrollment in TexasThe number of Medicare beneficiaries in Texas stood at 4,292,236 as of October 2020. Only Florida and California have more residents enrolled in Medicare.CMS has extended Medicare open enrollment through December 31 in 54 Texas counties in response to the natural disasters in 2020.But only a little more than 14 percent of Texas residents are enrolled in Medicare, compared with almost 19 percent of the United States population enrolled in Medicare. Texas has among the youngest populations in the country, and since most people become eligible for Medicare enrollment when they turn 65, the stateâs lower median age results in a smaller percentage of its residents filing for Medicare benefits.Although most people become eligible for Medicare coverage enrollment when they turn 65, Medicare also provides coverage for people under age 65. Those who have been receiving disability benefits for 24 months, have ALS, or have end-stage renal disease are eligible for Medicare.
Fifteen percent of all Medicare beneficiaries in Texas â and nationwide â are under the age of 65.Medicare health insurance optionsIn most areas of the country, Medicare beneficiaries can choose Original Medicare or a Medicare Advantage plan.Original Medicare is provided directly by the federal government and includes Medicare Parts A and B. Medicare Part A, also called hospital insurance, helps to pay for inpatient stays at a hospital, skilled nursing facility, or hospice center. Part B, also called medical insurance, helps pay for outpatient care like physician services, kidney dialysis, preventive care, durable medical equipment, etc.Medicare Advantage plans are administered by private insurance companies that have contracts with the federal government. Medicare Advantage plans include all of the benefits of Original Medicare (albeit with different cost-sharing, as the plans set their own deductibles, coinsurance, and copays, within the limits established by the federal government), and they typically have additional benefits, such coverage for prescription drugs, dental, and vision. But provider networks are often limited with Medicare Advantage plans, and out-of-pocket costs are typically higher than a person would have if they opted for Original Medicare plus a Medigap plan.
In short, there are pros and cons either way, and no one-size-fits-all solution. Medicare Advantage in TexasMedicare Advantage plans are available in all 254 counties in Texas in 2021, but plan availability ranges from as few as nine plans some of the stateâs service areas to as many as 90 plans for sale in Harris County.A little more than a third of Texas Medicare beneficiares â just slightly more than the national average â were enrolled in private Medicare plans in 2018. These were mostly Medicare Advantage plans, but some residents in Texas have Medicare Cost plans, which are another form of private coverage. By late 2020, however, the share of Texas Medicare beneficiaries enrolled in private plans had grown to more than 43 percent. The other 57 percent of Medicare beneficiaries in Texas were enrolled in Original Medicare instead.Medicare beneficiaries can switch between Medicare Advantage enrollment and Original Medicare (and can add or drop a Medicare Part D prescription plan) during the Medicare annual election period, which runs from October 15 to December 7 each year.
Medicare Advantage enrollees also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.Medigap in TexasMore than half of Original Medicare beneficiaries have supplemental coverage provided by an employer-sponsored plan or Medicaid. But for those who donât, Medigap plans (also known as Medicare supplement plans) are designed to pay some or all of the out-of-pocket costs (deductibles and coinsurance) that enrollees would otherwise have to pay themselves. Since Original Medicare does not include a cap on out-of-pocket costs, most enrollees maintain some form of supplemental coverage, and Medigap plans are one way to do this.According to an AHIP analysis, there were 873,514 Texas Medicare beneficiaries with Medigap coverage as of 2018.There are 70 insurers licensed to sell Medigap plans in Texas.Although Medigap plans are sold by private insurers, the plans are standardized under federal rules. There are ten different plan designs (differentiated by letters, A through N), and the benefits offered by a particular plan (Plan A, Plan F, etc.) are the same from one insurer to another.Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue.
This window starts when a person is at least 65 and enrolled in Medicare Part B (you have to be enrolled in both Part A and Part B to buy a Medigap plan).Although disabled Americans under the age of 65 are eligible for Medicare, federal rules do not guarantee access to Medigap plans for people who are under 65. But the majority of the states â including Texas â have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans. Texas law requires Medigap insurers to offer at least Medigap Plan A to disabled enrollees under age 65, during the six-month period that begins when theyâre enrolled in Medicare Part B. Medigap Plan A is the least comprehensive of the Medigap plans, but it will cover the 20 percent Part B coinsurance that the enrollee would othewise have to pay out-of-pocket.Disabled Medicare beneficiaries under the age of 65 have another six-month Medigap open enrollment period when they turn 65. At that point, they have access to any of the available Medigap plans, at the standard premiums that apply to people who are enrolling in Medicare due to turning 65 (premiums are generally significantly higher for Medicare beneficiaries under age 65, since their disabilities result in more costly medical care).Medicare Advantage plans are available to anyone eligible for Medicare, except people with end-stage renal disease (starting in 2021, this limitation will no longer apply.
People with ESRD will be able to enroll in Medicare Advantage plans). So unless they have ESRD, Texas Medicare beneficiaries under the age of 65 can choose a Medicare Advantage plan instead of Medigap Plan A. Medicare Advantage plans do have a cap on out-of-pocket costs, but they also tend to have limited provider networks, which is an important consideration for people with serious health issues.Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those regulations donât apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months, if you didnât have at least six months of continuous coverage prior to your enrollment. And if you apply for a Medigap plan after your initial enrollment window closes (assuming you arenât eligible for one of the limited guaranteed-issue rights), the insurer can look back at your medical history in determining whether to accept your application, and at what premium.
Texas Medicare Part DOriginal Medicare does not cover the cost of outpatient prescription drugs. As noted above, more than half of Original Medicare beneficiaries have supplemental coverage via an employer-sponsored plan (from a current or former employer or spouseâs employer) or Medicaid, and these plans often include prescription coverage. But Medicare beneficiaries who donât have drug coverage through Medicaid or an employer-sponsored plan need to obtain Medicare Part D prescription coverage (prior to 2006, some Medigap plans included prescription coverage. People who still have those plans can keep them, but they have not been for sale since the end of 2005).Part D coverage can be purchased as a stand-alone plan, or as part of a Medicare Advantage plan that includes Part D prescription drug coverage.In Texas, there are 35 stand-alone Medicare Part D plans for sale for 2021, with premiums that range from about $7 to $155/month.As of late 2020, there were 1.65 million Medicare beneficiaries in Texas with stand-alone Medicare Part D plans. An additional 1.54 million Texas residents had Medicare Part D coverage integrated with their Medicare Advantage plans.Medicare Part D enrollment follows the same schedule as Medicare Advantage.
Beneficiaries can enroll in Medicare Part D plans when theyâre first eligible for Medicare, and thereâs also an annual enrollment window (October 15 to December 7) when people can enroll or switch to a different plan. Medicare spending in TexasIn 2018, Original Medicareâs per-beneficiary spending in Texas averaged $11,627, which was 15 percent higher than the $10,096 national average. Texas had the second-highest average per-beneficiary costs in the country. Only Louisiana had higher average costs. Thatâs based on data that were standardized to eliminate regional differences in payment rates, but it did not include costs for Medicare Advantage.How does Medicaid provide financial assistance to Medicare beneficiaries in Texas?.
Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesnât cover â such as long-term care.Our guide to financial assistance for Medicare enrollees in Texas includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.Helpful resources for Texas Medicare beneficiaries and their caregiversNeed help with your Medicare application in Texas, or have questions about Medicare eligibility in Texas?. These resources provide free assistance and information.The Health Information, Counseling, and Advocacy Program (HICAP), with any questions related to Medicare coverage in Texas. Visit the website or call 1-800-252-9240.The Texas Department of Insurance has a resources page for Texas residents with Medicare coverage.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 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..
What should I tell my health care providers before I take Ventolin?
They need to know if you have any of the following conditions:
- diabetes
- heart disease or irregular heartbeat
- high blood pressure
- pheochromocytoma
- seizures
- thyroid disease
- an unusual or allergic reaction to albuterol, levalbuterol, sulfites, other medicines, foods, dyes, or preservatives
- pregnant or trying to get pregnant
- breast-feeding
Ventolin generic price
The transpopulation represents a vulnerable population segment both socially and medically, with a higher incidence of mental health issues ventolin generic price How do you get seroquel. During the asthma treatment outbreak, transgender persons have faced additional social, psychological and physical difficulties.1 2 In Italy and in several other countries access to healthcare has been difficult or impossible thereby ventolin generic price hindering the start or continuation of hormonal and psychological treatments. Furthermore, several planned gender-affirming surgeries ventolin generic price have been postponed. These obstacles ventolin generic price may have caused an additional psychological burden given the positive effects of medical and surgical treatments on well-being, directly and indirectly, reducing stressors such as workplace discrimination and social inequalities.3 Some organisational aspects should also be considered. Binary gender policies may worsen ventolin generic price inequalities and marginalisation of transgender subjects potentially increasing the risk of morbidity and mortality.As with the general population, during the lockdown, the Internet and social media were useful in reducing isolation and, in this particular population, were also relevant for keeping in touch with associations and healthcare facilities with the support of telemedicine services.4 Addressing the role of the telemedicine in the transpopulation, between May and June 2020 we conducted an anonymous web-based survey among transgenders living in Italy (ClinicalTrials.gov Identifier NCT04448418).
Among the 108 respondents, with a mean age of 34.3±11.7 years, 73.1% were transmen and 26.9% transwomen and 88.9% were undergoing gender-affirming hormonal treatment (GAHT). One in four ventolin generic price subjects (24.1%) presented a moderate-to-severe impact of the ventolin event (Impact of Event Scale score â¥26). The availability of telematic endocrinological visit was associated with better Mental Health Scores in the 12-items Short Form Health Survey(SF-12) (p=0.030) and better IES (p=0.006).Our survey suggests a positive effect of telemedicine as the availability of telematic endocrinological consultations may have relieved the distress caused by the ventolin by offering the opportunity ventolin generic price to avoid halting GAHT. In fact, deprivation of GAHT may result in several negative effects such as the increase in short-term self-medication and in depression and suicidal behaviour not only for those waiting for the start of treatment but also for those already using hormones.5 In ventolin generic price conclusion, particular attention should be paid to vulnerable groups like the transpopulation who may pay a higher price during the ventolin. The use ventolin generic price of telemedicine for continuation and monitoring of GAHT may be an effective tool for mitigating the negative effects of the ventolin.AcknowledgmentsThe authors thank Julie Norbury for English copy editing.The British Medical Association recently published their report on the impact of asthma treatment on mental health in England, highlighting the urgent need for investment in mental health services and further recruitment of mental health staff.1 Like many others, they have predicted a substantial increase in demand on mental health services in the coming months.
Their recommendations include a call for ventolin generic price detailed workforce planning at local, national and system levels. This coincides with the publication of the âNHS People Planâ which also emphasised the need to maximise staff potential.2 ventolin generic price The message from both is clear, it is time for Trusts to revise and improve how they use their multidisciplinary workforce, including non-medical prescribers (NMPs).Pharmacists have been able to register as independent prescribers since 20063 and as such, can work autonomously to prescribe any medicine for any medical condition within their areas of competency.4 There has been a slow uptake of pharmacists into this role5 and while a recent General Pharmaceutical Council survey found only a small increase between the number of active prescribers from 2013 (1.094) to 2019 (1.590), almost a quarter of prescribers included mental health within their prescribing practice.6 More recently, we have started to see increasing reports of the value of pharmacist independent prescribers in mental health services.7 8Pharmacists bring a unique perspective to patient consultation. Their expertise in pharmacology and medicine use means they are ideally placed to help patients optimise their medicines treatment4 and to ensure that patients are involved in decisions about their medicines, taking into account individual views and preferences. This approach is consistent with the guidance on medicines optimisation from the National Institute for Health and Care Excellence9 and the Royal Pharmaceutical Society,10 and the Department of Healthâs drive to involve patients actively in clinical decisions.11 ventolin generic price An increased focus on precision psychiatry in urging clinicians to tailor medicines to patients according to evidence about individualised risks and benefits.12 13 However, it takes time to discuss medicine choices and to explore individual beliefs about medicines. This is especially relevant ventolin generic price in Psychiatry, where a large group of medicines (eg, antipsychotics) may have a wide range of potential side effects.
Prescribing pharmacists could provide leadership and support in tailoring medicines for patients, as part of the wider multidisciplinary team.10The recent news that Priadel, the most commonly used brand of lithium in the UK, is planned to be discontinued14 is another example where a new and unexpected burden on psychiatric services could be eased by sharing the workload with ventolin generic price prescribing pharmacists. The Medicines and Healthcare Products Regulatory Agency recommends that patients should have an individualised ventolin generic price medication review in order to switch from one brand of lithium to another.14 This is work that can be done by prescribing pharmacists who have an in-depth knowledge of the pharmacokinetics of lithium formulations.Importantly, this is a role that can be delivered using telepsychiatry and enhanced by the use of digital tools. Patients can meet pharmacists from the comfort of their own ventolin generic price home using video conferencing. Pharmacists can upload and share medicines information on the screen while discussing the benefits, risks and individual medication needs with each client. Increasingly organisations are using technology whereby prescriptions can be prepared electronically and sent securely to patients or their medicines providers.15We know from systematic reviews that NMPs in general are considered to provide a responsive, efficient and convenient service5 and to deliver similar prescribing outcomes as ventolin generic price doctors.16 Medical professionals who have worked with NMPs have found that this support permits them to concentrate on clinical issues that require medical expertise.5 A patient survey carried out in 2013 indicated that independent nonâmedical prescribing was valued highly by patients and that generally there were few perceived differences in the care received from respondentsâ NMP and their usual doctor.17 The literature also suggests that an NMPâs role is more likely to flourish when linked to a strategic vision of NMPs within an National Health Service (NHS) Trust, along with a well-defined area of practice.18Mental health trusts are being asked to prepare for a surge in referrals and as part of this planning, they will need to ensure that they get the most out of their highly skilled workforce.
There are active pharmacist prescribers in many trusts, however, this role is not yet commonplace.19 Health Education England has already identified that this is an important area of transformation for pharmacy and has called on mental health pharmacy teams to develop and share innovative ways of working.19 The âNHS People Planâ outlines a commitment to train 50 community-based specialist mental health pharmacists within the next 2âyears, along with ventolin generic price a plan to extend the pharmacy foundation training to create a sustainable supply of prescribing pharmacists in future years.2We suggest that Mental Health Trusts should urgently develop prescribing roles for specialist mental health pharmacists, which are integrated within mental health teams. In these roles, prescribing pharmacists can actively support their multidisciplinary ventolin generic price colleagues in case discussion meetings. Furthermore, they should host regular medication review clinics, where patients can be referred to discuss ventolin generic price their medicine options and, as advancements in precision therapeutics continue, have their treatment individually tailored to their needs. This is the way forward for a modern and patient-oriented NHS in the UK..
The transpopulation represents a vulnerable population segment both socially and find more info medically, with where can i buy ventolin nebules a higher incidence of mental health issues. During the asthma treatment outbreak, transgender persons have faced additional social, psychological and physical difficulties.1 2 In Italy and in where can i buy ventolin nebules several other countries access to healthcare has been difficult or impossible thereby hindering the start or continuation of hormonal and psychological treatments. Furthermore, several planned where can i buy ventolin nebules gender-affirming surgeries have been postponed. These obstacles may have caused an additional psychological where can i buy ventolin nebules burden given the positive effects of medical and surgical treatments on well-being, directly and indirectly, reducing stressors such as workplace discrimination and social inequalities.3 Some organisational aspects should also be considered.
Binary gender policies may worsen inequalities and marginalisation of transgender subjects potentially increasing the risk of morbidity and mortality.As with the general population, during the lockdown, the Internet and social media were useful in reducing isolation and, in this particular population, were also relevant for keeping in touch with associations where can i buy ventolin nebules and healthcare facilities with the support of telemedicine services.4 Addressing the role of the telemedicine in the transpopulation, between May and June 2020 we conducted an anonymous web-based survey among transgenders living in Italy (ClinicalTrials.gov Identifier NCT04448418). Among the 108 respondents, with a mean age of 34.3±11.7 years, 73.1% were transmen and 26.9% transwomen and 88.9% were undergoing gender-affirming hormonal treatment (GAHT). One in four subjects (24.1%) presented a moderate-to-severe impact of the ventolin event (Impact of Event where can i buy ventolin nebules Scale score â¥26). The availability of telematic endocrinological visit was associated with better Mental Health Scores in the 12-items Short Form Health Survey(SF-12) (p=0.030) and better where can i buy ventolin nebules IES (p=0.006).Our survey suggests a positive effect of telemedicine as the availability of telematic endocrinological consultations may have relieved the distress caused by the ventolin by offering the opportunity to avoid halting GAHT.
In fact, deprivation of where can i buy ventolin nebules GAHT may result in several negative effects such as the increase in short-term self-medication and in depression and suicidal behaviour not only for those waiting for the start of treatment but also for those already using hormones.5 In conclusion, particular attention should be paid to vulnerable groups like the transpopulation who may pay a higher price during the ventolin. The use of telemedicine for continuation and monitoring of GAHT may be an effective tool for mitigating the negative effects of the ventolin.AcknowledgmentsThe authors thank Julie Norbury for English copy editing.The British where can i buy ventolin nebules Medical Association recently published their report on the impact of asthma treatment on mental health in England, highlighting the urgent need for investment in mental health services and further recruitment of mental health staff.1 Like many others, they have predicted a substantial increase in demand on mental health services in the coming months. Their recommendations include a call for detailed workforce planning at local, national and system where can i buy ventolin nebules levels. This coincides with the publication of the âNHS People Planâ which also emphasised the need to maximise staff potential.2 The message from both is clear, it is time for Trusts to revise and improve how they use their multidisciplinary workforce, including non-medical prescribers (NMPs).Pharmacists have been able to register as independent prescribers since 20063 and as such, can work autonomously to prescribe any medicine for any where can i buy ventolin nebules medical condition within their areas of competency.4 There has been a slow uptake of pharmacists into this role5 and while a recent General Pharmaceutical Council survey found only a small increase between the number of active prescribers from 2013 (1.094) to 2019 (1.590), almost a quarter of prescribers included mental health within their prescribing practice.6 More recently, we have started to see increasing reports of the value of pharmacist independent prescribers in mental health services.7 8Pharmacists bring a unique perspective to patient consultation.
Their expertise in pharmacology and medicine use means they are ideally placed to help patients optimise their medicines treatment4 and to ensure that patients are involved in decisions about their medicines, taking into account individual views and preferences. This approach is consistent with the guidance on medicines optimisation from the National Institute for Health and Care Excellence9 and the Royal Pharmaceutical Society,10 and the Department of Healthâs drive to involve patients actively in clinical decisions.11 An increased focus on precision psychiatry in urging clinicians to tailor medicines to patients according to where can i buy ventolin nebules evidence about individualised risks and benefits.12 13 However, it takes time to discuss medicine choices and to explore individual beliefs about medicines. This is especially relevant in Psychiatry, where a large group of medicines (eg, antipsychotics) may have a wide range of potential side where can i buy ventolin nebules effects. Prescribing pharmacists could provide leadership and support in tailoring medicines for patients, as part of the wider multidisciplinary team.10The recent news that Priadel, the most commonly where can i buy ventolin nebules used brand of lithium in the UK, is planned to be discontinued14 is another example where a new and unexpected burden on psychiatric services could be eased by sharing the workload with prescribing pharmacists.
The Medicines and Healthcare Products Regulatory Agency recommends that patients should have an individualised where can i buy ventolin nebules medication review in order to switch from one brand of lithium to another.14 This is work that can be done by prescribing pharmacists who have an in-depth knowledge of the pharmacokinetics of lithium formulations.Importantly, this is a role that can be delivered using telepsychiatry and enhanced by the use of digital tools. Patients can meet pharmacists from the comfort of their own home where can i buy ventolin nebules using video conferencing. Pharmacists can upload and share medicines information on the screen while discussing the benefits, risks and individual medication needs with each client. Increasingly organisations are using technology whereby prescriptions can be where can i buy ventolin nebules prepared electronically and sent securely to patients or their medicines providers.15We know from systematic reviews that NMPs in general are considered to provide a responsive, efficient and convenient service5 and to deliver similar prescribing outcomes as doctors.16 Medical professionals who have worked with NMPs have found that this support permits them to concentrate on clinical issues that require medical expertise.5 A patient survey carried out in 2013 indicated that independent nonâmedical prescribing was valued highly by patients and that generally there were few perceived differences in the care received from respondentsâ NMP and their usual doctor.17 The literature also suggests that an NMPâs role is more likely to flourish when linked to a strategic vision of NMPs within an National Health Service (NHS) Trust, along with a well-defined area of practice.18Mental health trusts are being asked to prepare for a surge in referrals and as part of this planning, they will need to ensure that they get the most out of their highly skilled workforce.
There are active pharmacist prescribers in many trusts, however, this role is not yet commonplace.19 Health Education England has already identified that this is an important area of transformation for pharmacy and has called on mental health pharmacy teams to develop and share innovative ways of working.19 The âNHS People Planâ outlines a commitment to train 50 community-based specialist mental health pharmacists within the next 2âyears, along with a plan to extend the pharmacy foundation training to create a where can i buy ventolin nebules sustainable supply of prescribing pharmacists in future years.2We suggest that Mental Health Trusts should urgently develop prescribing roles for specialist mental health pharmacists, which are integrated within mental health teams. In these roles, prescribing where can i buy ventolin nebules pharmacists can actively support their multidisciplinary colleagues in case discussion meetings. Furthermore, they should host regular medication review clinics, where patients can be referred to discuss their medicine options and, as advancements in precision therapeutics continue, have their treatment individually tailored where can i buy ventolin nebules to their needs. This is the way forward for a modern and patient-oriented NHS in the UK..
Ventolin for 1 year old
California spent nearly $200 million to set up, operate and staff alternate care sites that ultimately provided little help when the state's worst asthma surge spiraled out of control last winter, forcing exhausted hospital workers to treat patients in tents and low price ventolin cafeterias.It was a costly way to learn California's hospital system is ventolin for 1 year old far more elastic than was thought at the start of the ventolin. Through desperation and innovation, the system was able to expand enough to accommodate patients even during the dire surge ventolin for 1 year old that saw hospitalizations top 20,000 and nearly 700 people die weekly."Definitely some hospitals, particularly in the Los Angeles area, were at the breaking point, but we did not see that much use of the alternate care sites relative to what was contemplated," said Janet Coffman, a health policy professor at University of California, San Francisco. "As dire as the situation was in the winter, it ventolin for 1 year old could have been even worse."In the early weeks of the ventolin, Democratic Gov.
Gavin Newsom ordered alternate care sites be set up in a ventolin for 1 year old former professional basketball arena, two state centers that usually treat people with developmental and intellectual disabilities, and other facilities.It was part of an early plan to add an extra 66,000 hospital beds as California prepared for a projected crushing load of asthma treatment patients, one of many steps taken by the governor as he imposed the nation's first statewide lockdown.Ultimately, the state spent $43 million to set up eight sites, $48 million to hire contract employees and $96 million to operate them under a scaled-back plan, according to tallies that The Associated Press requested from the departments of Finance and General Services and the Health and Human Services Agency.The sites treated a combined 3,582 patients, records show, but half were during the first three months of the ventolin when the number of s was still low and, as it turned out, the traditional hospital system could have handled them on its own. The sites reopened in early December, treating fewer patients during the next three months even though many hospitals were overflowing.The traditional hospital system squeaked through the worst of the ventolin with little overflow into the alternate care sites because the state temporarily eased nurse-to-patient staffing ratios â designed to protect the sick and their caretakers â and because of a scramble to bring in temporary outside workers, said Stephanie Roberson, government relations director of the California Nurses Association.Brian Ferguson, a spokesman for the state Office of Emergency Services, said officials learned that it is better to align the state's efforts with existing health care facilities than to set up makeshift, standalone hospitals.For instance, two vacant ventolin for 1 year old hospitals reopened during a surge last summer, one each in Northern and Southern California, as the most populous state overtook New York for the most cases in the nation. But it didn't use ventolin for 1 year old them again during the winter surge, choosing instead to work more closely with existing hospitals.Similarly, Newsom in early April 2020 announced Sleep Train Arena, the former home of the NBA's Sacramento Kings, would be turned into a 400-bed hospital.
It wound up treating just nine patients over 10 weeks because existing hospitals in the region handled other cases.The state never reopened that main arena when the ventolin surged again around Thanksgiving but instead treated 232 patients in the much smaller adjacent practice facility."If you look in hindsight, you could say, 'Well, we could have used the money that we spent to rent Sleep Train and we could have put it back into the hospital system or we could have put it into procuring PPE (personal protective equipment) or any number of things,'" Roberson said. "But these are lessons learned."She added ventolin for 1 year old. "As we move forward, we have to take a look at all of these missteps and do ventolin for 1 year old better."Officials learned to be more flexible in opening and shutting the facilities and to "quickly pivot the site to have additional value or purpose" if it wasn't needed for patients, Ferguson said.For example, the surge centers all shut down by March as the worst wave abated.
But two were shifted to other ventolin-related ventolin for 1 year old duties â one was used for asthma testing and the other was used for antibody infusion treatments.Similarly, contracts for traveling medical workers early in the ventolin required that they work at the alternate care sites even if they were not often needed. But the contracts during the winter surge were rewritten so that "in instances where they were no longer needed, you could quickly move them to a hospital" or to other duties like administering vaccinations, Ferguson said.State officials had planned to rely more on the newly ventolin for 1 year old formed California Health Corps of medical professionals, particularly after 95,000 people initially answered Newsom's call for volunteers.But only a fraction actually qualified or signed up."When the health corps didn't pan out as was hoped, travelers were the next best alternative," said Coffman, who studies the health care workforce. "Yes, contract travelers are expensive, but at least you ventolin for 1 year old have confidence this is somebody we can count on to take good care of patients, to have the skills that are needed."California spent $612 million for contract medical employees and $2.2 million for the health corps, most of which it hopes to recoup from the federal government or the facilities where they worked.The state budgeted $74.5 million for the fiscal year that started this month to cover late-arriving bills or if there is another surge that requires the state to ramp up again."If things were to take a turn for the worse â mainly delta variant ...
We still want to be able to move quickly," said H.D. Palmer, spokesman for the California Department of Finance.A Missouri hospital reached a "sad new record" on Sunday when the number of asthma patients in its care rose to 187, an administrator said.CoxHealth CEO Steve Edwards urged residents via Twitter to get vaccinated "to protect ventolin for 1 year old others, to protect children, to protect our community."On Saturday, Edwards wrote on social media that the hospital had 180 infected inpatients, which at the time was a new record, according to the Kansas City Star. The number was as low as 28 patients about eight weeks ago, he said."I can't understand the motivations of people disparaging healthcare providers and diminishing the reality of this ventolin," Edwards said on Twitter, as health officials continue to urge ventolin for 1 year old Missourians to get vaccinated as the more aggressive delta variant added to recent spikes in s and deaths.In Greene County, where Springfield is located, 42.5% of the population has initiated vaccination and 36.2% has completed the vaccination process.
Statewide, 48.1% can you buy ventolin over the counter australia of the population has initiated the treatment and 41.3% has completed it, according to the Missouri Department of Health and Senior Services.In the ventolin for 1 year old past week, 887 more people tested positive for asthma treatment-29 in Greene County, according to state data. Increasingly, hospitals are admitting children with the ventolin.On Thursday, more than 300 people were hospitalized for asthma treatment across the two health systems in Springfield, including three patients ventolin for 1 year old under age 10.That day, there were 145 asthma treatment patients at Mercy Springfield, said chief administrative officer Erik Frederick. Five of those patients ventolin for 1 year old were under the age of 20 and three were under age 10.Ninety-three percent of the patients were unvaccinated.Meanwhile, officials in St.
Louis asked people who attended a Tuesday city council meeting to quarantine, including five council members, the county executive and director of the county health department, according to the St. Louis Post-Dispatch.Most of those at the meeting came to protest the joint city and county ventolin for 1 year old mask mandate and were not wearing face coverings. A city resident who attended the meeting began experiencing symptoms the following day and underwent a test for asthma treatment on Thursday, ventolin for 1 year old according Dr.
Fredrick Echols, acting director of health for the city.The city health department received notification of the positive result on Saturday, sparking the advisory asking that everyone who attended the meeting ventolin for 1 year old â even those who are fully vaccinated â to quarantine for the next nine days to complete the 14-day quarantine period.The restrictions have drawn a fierce response. St. Louis County Health Director Faisal Khan said he was assaulted and bombarded with racial slurs after defending a new mask mandate.
One county councilman questioned whether Khan was telling the truth.Khan spoke at the St. Louis County Council meeting on Tuesday, when the council voted 5-2 to end a mask mandate imposed by Democratic County Executive Sam Page. The resurgent asthma began its summer assault in under-vaccinated rural areas of Missouri, but has increasingly led to new cases and hospitalizations in St.
Louis.Maine's independent senator is asking CMS to follow his state's lead in making sure patients aren't subjected to surprise medical bills.Sen. Angus King has made the case to CMS Administrator Chiquita Brooks-LaSure. He cited the fact Maine patients have been able to compare prices for some healthcare services since October 2015.King said the federal government should work with advocates and hospitals to eliminate surprise billing.
That would put the country in line with the No Surprises Act that was implemented in December 2020, he said.King said he looks forward to a "seamless implementation of this important law to make sure consumers are able to make the best decisions for their families.".
California spent nearly $200 million to set up, operate and where can i buy ventolin nebules staff alternate care sites that ultimately provided little help when the state's worst asthma surge spiraled out of control last winter, forcing exhausted hospital workers to treat patients http://www.mstopjobandfriends.net/?p=205 in tents and cafeterias.It was a costly way to learn California's hospital system is far more elastic than was thought at the start of the ventolin. Through desperation and innovation, the system was able to expand enough to accommodate patients even during the dire surge that where can i buy ventolin nebules saw hospitalizations top 20,000 and nearly 700 people die weekly."Definitely some hospitals, particularly in the Los Angeles area, were at the breaking point, but we did not see that much use of the alternate care sites relative to what was contemplated," said Janet Coffman, a health policy professor at University of California, San Francisco. "As dire as the where can i buy ventolin nebules situation was in the winter, it could have been even worse."In the early weeks of the ventolin, Democratic Gov. Gavin Newsom ordered alternate care sites be set up in a former professional basketball arena, two state centers that usually treat people with developmental and intellectual disabilities, and other facilities.It was part of an early plan to add an extra 66,000 hospital beds as California prepared for a projected crushing load of asthma treatment patients, one of many steps taken by the governor as he imposed the nation's first statewide lockdown.Ultimately, the state spent $43 million to set up eight sites, $48 million to hire contract employees and $96 million to operate them under a scaled-back plan, according to tallies where can i buy ventolin nebules that The Associated Press requested from the departments of Finance and General Services and the Health and Human Services Agency.The sites treated a combined 3,582 patients, records show, but half were during the first three months of the ventolin when the number of s was still low and, as it turned out, the traditional hospital system could have handled them on its own. The sites reopened in early December, treating fewer patients during the next three months even though many hospitals were overflowing.The traditional hospital system squeaked through the worst of the ventolin with little overflow into the alternate care sites because where can i buy ventolin nebules the state temporarily eased nurse-to-patient staffing ratios â designed to protect the sick and their caretakers â and because of a scramble to bring in temporary outside workers, said Stephanie Roberson, government relations director of the California Nurses Association.Brian Ferguson, a spokesman for the state Office of Emergency Services, said officials learned that it is better to align the state's efforts with existing health care facilities than to set up makeshift, standalone hospitals.For instance, two vacant hospitals reopened during a surge last summer, one each in Northern and Southern California, as the most populous state overtook New York for the most cases in the nation.
But it didn't use them again during the winter surge, choosing instead to work more closely with existing hospitals.Similarly, Newsom in early where can i buy ventolin nebules April 2020 announced Sleep Train Arena, the former home of the NBA's Sacramento Kings, would be turned into a 400-bed hospital. It wound up treating just nine patients over 10 weeks because existing hospitals in the region handled other cases.The state never reopened that main arena when the ventolin surged again around Thanksgiving but instead treated 232 patients in the much smaller adjacent practice facility."If you look in hindsight, you could say, 'Well, we could have used the money that we spent to rent Sleep Train and we could have put it back into the hospital system or we could have put it into procuring PPE (personal protective equipment) or any number of things,'" Roberson said. "But these where can i buy ventolin nebules are lessons learned."She added. "As we move forward, we have to take a look at all of these missteps and do better."Officials learned to be more flexible in opening and shutting the facilities and to "quickly pivot the site to have additional value or purpose" if it wasn't needed for patients, Ferguson where can i buy ventolin nebules said.For example, the surge centers all shut down by March as the worst wave abated. But two were shifted to other ventolin-related duties â one was used for asthma testing and the other was used for antibody infusion where can i buy ventolin nebules treatments.Similarly, contracts for traveling medical workers early in the ventolin required that they work at the alternate care sites even if they were not often needed.
But the contracts during the winter surge were rewritten so that "in instances where they were no longer needed, you could quickly move them to a hospital" or to other duties like administering vaccinations, Ferguson said.State officials had planned to rely more on the where can i buy ventolin nebules newly formed California Health Corps of medical professionals, particularly after 95,000 people initially answered Newsom's call for volunteers.But only a fraction actually qualified or signed up."When the health corps didn't pan out as was hoped, travelers were the next best alternative," said Coffman, who studies the health care workforce. "Yes, contract travelers are expensive, but at least you have confidence this is somebody we can count on to take good care of patients, to have the skills that where can i buy ventolin nebules are needed."California spent $612 million for contract medical employees and $2.2 million for the health corps, most of which it hopes to recoup from the federal government or the facilities where they worked.The state budgeted $74.5 million for the fiscal year that started this month to cover late-arriving bills or if there is another surge that requires the state to ramp up again."If things were to take a turn for the worse â mainly delta variant ... We still want to be able to move quickly," said H.D. Palmer, spokesman for the California Department of Finance.A Missouri hospital reached a "sad new record" on Sunday when the number of asthma patients in its care rose to 187, an administrator said.CoxHealth CEO Steve Edwards urged residents via Twitter to get vaccinated "to protect others, to protect children, to protect our community."On Saturday, Edwards wrote on where can i buy ventolin nebules social media that the hospital had 180 infected inpatients, which at the time was a new record, according to the Kansas City Star. The number was as low as 28 patients about eight weeks ago, he said."I can't understand the motivations of people disparaging healthcare providers and diminishing the reality of this ventolin," Edwards said on Twitter, as health officials continue to urge Missourians to get vaccinated as the more aggressive delta variant added to recent spikes in s and deaths.In Greene County, where Springfield is located, 42.5% of the population has initiated vaccination and 36.2% has completed the where can i buy ventolin nebules vaccination process.
Statewide, 48.1% of the population has initiated the ventolin price without insurance treatment and 41.3% has completed it, according to the Missouri Department of where can i buy ventolin nebules Health and Senior Services.In the past week, 887 more people tested positive for asthma treatment-29 in Greene County, according to state data. Increasingly, hospitals are admitting children with the ventolin.On Thursday, more than 300 people were hospitalized for asthma treatment across the two health systems in Springfield, including three patients under age 10.That day, there were 145 asthma treatment patients at Mercy Springfield, where can i buy ventolin nebules said chief administrative officer Erik Frederick. Five of those patients were under where can i buy ventolin nebules the age of 20 and three were under age 10.Ninety-three percent of the patients were unvaccinated.Meanwhile, officials in St. Louis asked people who attended a Tuesday city council meeting to quarantine, including five council members, the county executive and director of the county health department, according to the St. Louis Post-Dispatch.Most of those at the meeting came to protest the joint city and county mask mandate and were not wearing face where can i buy ventolin nebules coverings.
A city resident who attended the meeting began experiencing symptoms the where can i buy ventolin nebules following day and underwent a test for asthma treatment on Thursday, according Dr. Fredrick Echols, acting director of health for the city.The city health department received notification of the positive result on Saturday, sparking the advisory where can i buy ventolin nebules asking that everyone who attended the meeting â even those who are fully vaccinated â to quarantine for the next nine days to complete the 14-day quarantine period.The restrictions have drawn a fierce response. St. Louis County Health Director Faisal Khan said he was assaulted and bombarded with racial slurs after defending a new mask mandate. One county councilman questioned whether Khan was telling the truth.Khan spoke at the St.
Louis County Council meeting on Tuesday, when the council voted 5-2 to end a mask mandate imposed by Democratic County Executive Sam Page. The resurgent asthma began its summer assault in under-vaccinated rural areas of Missouri, but has increasingly led to new cases and hospitalizations in St. Louis.Maine's independent senator is asking CMS to follow his state's lead in making sure patients aren't subjected to surprise medical bills.Sen. Angus King has made the case to CMS Administrator Chiquita Brooks-LaSure. He cited the fact Maine patients have been able to compare prices for some healthcare services since October 2015.King said the federal government should work with advocates and hospitals to eliminate surprise billing.
That would put the country in line with the No Surprises Act that was implemented in December 2020, he said.King said he looks forward to a "seamless implementation of this important law to make sure consumers are able to make the best decisions for their families.".
Ventolin coupon 2020
Follow the ventolin coupon 2020 instructions for submitting ventolin online canada comments. Mail. Jeffrey M.
Zirger, Information Collection Review Office, Centers for Disease Control and Prevention, 1600 Clifton Road NE, ventolin coupon 2020 MS-D74, Atlanta, Georgia 30329. Instructions. All submissions received must include the agency name and Docket Number.
CDC will post, without ventolin coupon 2020 change, all relevant comments to Regulations.gov. Please note. Submit all comments through the Federal eRulemaking portal regulations.gov) or by U.S.
Mail to the address listed above ventolin coupon 2020. Start Further Info To request more information on the proposed project or to obtain a copy of the information collection plan and instruments, contact Jeffrey M. Zirger, Information Collection Review Office, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-D74, Atlanta, Georgia 30329.
Omb@cdc.gov. End Further Info End Preamble Start Supplemental Information Under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3501-3520), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor.
In addition, the PRA also requires Federal agencies to provide a 60-day notice in the Federal Register concerning each proposed collection of information, including each new proposed collection, each proposed extension of existing collection of information, and each reinstatement of previously approved information collection before submitting the collection to the OMB for approval. To comply with this requirement, we are publishing this notice of a proposed data collection as described below. The OMB is particularly interested in comments that will help.
1. Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility. 2.
Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used. 3. Enhance the quality, utility, and clarity of the information to be collected.
4. Minimize the burden of the collection of information on those who are to respond, including using appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submissions of responses. And 5.
Assess information collection costs. Proposed Project Assessments to Inform Program Refinement for HIV, other STD, and Pregnancy Prevention among Middle and High-School Aged Youth (OMB Control No. 0920-1235, Exp.
05/31/2022)âExtensionâNational Center for HIV/AIDS, Viral Hepatitis, STD, TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC). Background and Brief Description The Centers for Disease Control and Prevention (CDC) requests three-year OMB approval for the extension of a Generic information collection package (OMB Control No. #0920-1235, Exp http://sawyerlawllc.com/blog/.
05/31/2022) that supports collection of quantitative and qualitative information from adolescents (ages 11-19) and their parents/caregivers for the purpose of needs assessment and program refinement for programs and services to prevent HIV, other sexually transmitted diseases (STDs), and pregnancy among middle and high school aged adolescents. NCHHSTP conducts behavioral and health service assessments and research projects as part of its response to the domestic HIV/AIDS epidemic, STD prevention, TB elimination and viral hepatitis control with national, state, and local partners. Adolescents are a population with specific developmental, health and social, and resource needs, and their health risk factors and access to health care are addressed as a primary mission by the Division of Adolescent and School Health (DASH), and adolescents are a population of interest for several other NCHHSTP divisions.
The assessment and research conducted by NCHHSTP is one pillar upon which recommendations and guidelines are revised and updated. Recommendations and guidelines for adolescent sexual risk reduction require that foundation of scientific evidence. Assessment of programmatic practices for adolescents helps to assure effective and evidence-based sexual risk reduction practices and efficient use of resources.
Such assessments also help to improve programs through better identification of strategies relevant to adolescents as a population as well as specific sub-groups of adolescents at highest risk for HIV and other STDs so that programs can be better tailored for them. The information collection requests under this generic package are intended to allow for data collection with two types of respondents. Adolescents (11-19 years old) of middle and high school age.
And Parents and/or caregivers of adolescents of middle and high school age. For the purposes of this generic package, parents/caregivers include the adult primary caregiver(s) for a child's basic needs (e.g., food, shelter, and safety). This includes biological parents.
Other biological relatives such as grandparents, aunts, uncles, or siblings. Start Printed Page 41475and non-biological parents such as adoptive, foster, or stepparents. The types of information collection activities included in this generic package are.
(1) Quantitative data collection through electronic, telephone, or paper questionnaires to gather information about programmatic and service activities related to the prevention of HIV and other STDs among adolescents of middle- and high-school age. (2) Qualitative data collection through electronic, telephone, or paper means to gather information about programmatic and service activities related to the prevention of HIV and other STDs among adolescents of middle- and high-school age. Qualitative data collection may involve focus groups and in-depth interviewing through group interviews, and cognitive interviewing.
For adolescents, data collection instruments will include questions on demographic characteristics. Experiences with programs and services to reduce the risk of HIV and other STD transmission. And knowledge, attitudes, behaviors, and skills related to sexual risk and protective factors on the individual, interpersonal, and community levels.
For parents and caregivers, data collection instruments will include questions on demographic characteristics as well as parents'/caregivers' (1) perceptions about programs and services provided to adolescents. (2) knowledge, attitudes, and perceptions about their adolescents' health risk and protective behaviors. And (3) parenting knowledge, attitudes, behaviors, and skills.
Any data collection request put forward under this generic clearance will identify the programs and/or services to be informed or refined, and will include a cross-walk of data elements to the aspects of the program the project team seeks to inform or refine. Because this request includes a wide range of possible data collection instruments, specific requests will include items of information to be collected and copies of data collection instruments. It is expected that all data collection instruments will be pilot-tested, and will be culturally, developmentally, and age appropriate for the adolescent populations included.
Similarly, parent data collection instruments will be pilot-tested, and the data collection instruments will reflect the culture, developmental stage, and age of the parents' adolescent children. All data collection procedures will receive review and approval by an Institutional Review Board for the Protection of Human Subjects and follow appropriate consent and assent procedures as outlined in the IRB-approved protocols. These will be described in the individual information collection requests put forward under this Generic package.
The table below provides the estimated annualized response burden for up to 15 individual data collections per year under this generic clearance at 57,584 hours. Participation of respondents is voluntary. There is no cost to participants other than their time.
Estimated Annualized Burden HoursType of respondentsForm nameNumber of respondentsNumber of responses per respondentAverage burden per response (in hours)Total burden (in hours)Middle and High School Age AdolescentsYouth Questionnaire20,000150/6016,667Middle and High School Age AdolescentsPre/Post youth questionnaire10,000250/6016,667Middle and High School Age AdolescentsYouth interview/focus group guide3,000290/609,000Parents/caregivers of adolescentsParent/Caregiver questionnaire7,500225/606,250Parents/caregivers of adolescentsParent/Caregiver interview/focus group guide3,000290/609,000Total57,584 Start Signature Jeffrey M. Zirger, Lead, Information Collection Review Office, Office of Scientific Integrity, Office of Science, Centers for Disease Control and Prevention.
CDC-2021-0076 by any of the check this following where can i buy ventolin nebules methods. Federal eRulemaking Portal. Regulations.gov. Follow the instructions for submitting where can i buy ventolin nebules comments. Mail.
Jeffrey M. Zirger, Information Collection Review Office, Centers for Disease Control where can i buy ventolin nebules and Prevention, 1600 Clifton Road NE, MS-D74, Atlanta, Georgia 30329. Instructions. All submissions received must include the agency name and Docket Number. CDC will post, without change, all relevant comments to Regulations.gov where can i buy ventolin nebules.
Please note. Submit all comments through the Federal eRulemaking portal regulations.gov) or by U.S. Mail to the where can i buy ventolin nebules address listed above. Start Further Info To request more information on the proposed project or to obtain a copy of the information collection plan and instruments, contact Jeffrey M. Zirger, Information Collection Review Office, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-D74, Atlanta, Georgia 30329.
Phone. 404-639-7118. Email. Omb@cdc.gov. End Further Info End Preamble Start Supplemental Information Under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C.
3501-3520), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. In addition, the PRA also requires Federal agencies to provide a 60-day notice in the Federal Register concerning each proposed collection of information, including each new proposed collection, each proposed extension of existing collection of information, and each reinstatement of previously approved information collection before submitting the collection to the OMB for approval. To comply with this requirement, we are publishing this notice of a proposed data collection as described below. The OMB is particularly interested in comments that will help. 1.
Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility. 2. Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used. 3. Enhance the quality, utility, and clarity of the information to be collected.
4. Minimize the burden of the collection of information on those who are to respond, including using appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submissions of responses. And 5. Assess information collection costs. Proposed Project Assessments to Inform Program Refinement for HIV, other STD, and Pregnancy Prevention among Middle and High-School Aged Youth (OMB Control No.
0920-1235, Exp http://www.ec-rodolphe-reuss-strasbourg.ac-strasbourg.fr/wp/?p=946. 05/31/2022)âExtensionâNational Center for HIV/AIDS, Viral Hepatitis, STD, TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC). Background and Brief Description The Centers for Disease Control and Prevention (CDC) requests three-year OMB approval for the extension of a Generic information collection package (OMB Control No. #0920-1235, Exp. 05/31/2022) that supports collection of quantitative and qualitative information from adolescents (ages 11-19) and their parents/caregivers for the purpose of needs assessment and program refinement for programs and services to prevent HIV, other sexually transmitted diseases (STDs), and pregnancy among middle and high school aged adolescents.
NCHHSTP conducts behavioral and health service assessments and research projects as part of its response to the domestic HIV/AIDS epidemic, STD prevention, TB elimination and viral hepatitis control with national, state, and local partners. Adolescents are a population with specific developmental, health and social, and resource needs, and their health risk factors and access to health care are addressed as a primary mission by the Division of Adolescent and School Health (DASH), and adolescents are a population of interest for several other NCHHSTP divisions. The assessment and research conducted by NCHHSTP is one pillar upon which recommendations and guidelines are revised and updated. Recommendations and guidelines for adolescent sexual risk reduction require that foundation of scientific evidence. Assessment of programmatic practices for adolescents helps to assure effective and evidence-based sexual risk reduction practices and efficient use of resources.
Such assessments also help to improve programs through better identification of strategies relevant to adolescents as a population as well as specific sub-groups of adolescents at highest risk for HIV and other STDs so that programs can be better tailored for them. The information collection requests under this generic package are intended to allow for data collection with two types of respondents. Adolescents (11-19 years old) of middle and high school age. And Parents and/or caregivers of adolescents of middle and high school age. For the purposes of this generic package, parents/caregivers include the adult primary caregiver(s) for a child's basic needs (e.g., food, shelter, and safety).
This includes biological parents. Other biological relatives such as grandparents, aunts, uncles, or siblings. Start Printed Page 41475and non-biological parents such as adoptive, foster, or stepparents. The types of information collection activities included in this generic package are. (1) Quantitative data collection through electronic, telephone, or paper questionnaires to gather information about programmatic and service activities related to the prevention of HIV and other STDs among adolescents of middle- and high-school age.
(2) Qualitative data collection through electronic, telephone, or paper means to gather information about programmatic and service activities related to the prevention of HIV and other STDs among adolescents of middle- and high-school age. Qualitative data collection may involve focus groups and in-depth interviewing through group interviews, and cognitive interviewing. For adolescents, data collection instruments will include questions on demographic characteristics. Experiences with programs and services to reduce the risk of HIV and other STD transmission. And knowledge, attitudes, behaviors, and skills related to sexual risk and protective factors on the individual, interpersonal, and community levels.
For parents and caregivers, data collection instruments will include questions on demographic characteristics as well as parents'/caregivers' (1) perceptions about programs and services provided to adolescents. (2) knowledge, attitudes, and perceptions about their adolescents' health risk and protective behaviors. And (3) parenting knowledge, attitudes, behaviors, and skills. Any data collection request put forward under this generic clearance will identify the programs and/or services to be informed or refined, and will include a cross-walk of data elements to the aspects of the program the project team seeks to inform or refine. Because this request includes a wide range of possible data collection instruments, specific requests will include items of information to be collected and copies of data collection instruments.
It is expected that all data collection instruments will be pilot-tested, and will be culturally, developmentally, and age appropriate for the adolescent populations included. Similarly, parent data collection instruments will be pilot-tested, and the data collection instruments will reflect the culture, developmental stage, and age of the parents' adolescent children. All data collection procedures will receive review and approval by an Institutional Review Board for the Protection of Human Subjects and follow appropriate consent and assent procedures as outlined in the IRB-approved protocols. These will be described in the individual information collection requests put forward under this Generic package. The table below provides the estimated annualized response burden for up to 15 individual data collections per year under this generic clearance at 57,584 hours.