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Start Preamble Centers for cialis price 10mg Medicare buy cialis without prescription &. Medicaid Services (CMS), HHS. Extension of timeline buy cialis without prescription for publication of final rule. This notice announces an extension of the timeline for publication of a Medicare final rule in accordance with the Social Security Act, which allows us to extend the timeline for publication of the final rule. As of August 26, 2020, the timeline for publication of the final rule to finalize the provisions buy cialis without prescription of the October 17, 2019 proposed rule (84 FR 55766) is extended until August 31, 2021.

Start Further Info Lisa O. Wilson, (410) 786-8852. End Further Info End Preamble Start Supplemental Information In the October 17, 2019 Federal Register buy cialis without prescription (84 FR 55766), we published a proposed rule that addressed undue regulatory impact and burden of the physician self-referral law. The proposed rule was issued in conjunction with the Centers for Medicare &. Medicaid Services' (CMS) Patients over Paperwork initiative and the Department of Health and Human Services' buy cialis without prescription (the Department or HHS) Regulatory Sprint to Coordinated Care.

In the proposed rule, we proposed exceptions to the physician self-referral law for certain value-based compensation arrangements between or among physicians, providers, and suppliers. A new exception for certain arrangements under which a physician receives limited remuneration for items or services actually provided by the physician. A new exception for buy cialis without prescription donations of cybersecurity technology and related services. And amendments to the existing exception for electronic health records (EHR) items and services. The proposed rule also provides critically necessary guidance for physicians and health care providers and suppliers whose financial relationships are governed by the physician self-referral statute buy cialis without prescription and regulations.

This notice announces an extension of the timeline for publication of the final rule and the continuation of effectiveness of the proposed rule. Section 1871(a)(3)(A) of the Social Security Act (the Act) requires us to establish and publish a regular timeline for the publication of final regulations based on the previous publication of a proposed regulation. In accordance with section 1871(a)(3)(B) of the Act, the timeline may vary among buy cialis without prescription different regulations based on differences in the complexity of the regulation, the number and scope of comments received, and other relevant factors, but may not be longer than 3 years except under exceptional circumstances. In addition, in accordance with section 1871(a)(3)(B) of the Act, the Secretary may extend the initial targeted publication date of the final regulation if the Secretary, no later than the regulation's previously established proposed publication date, publishes a notice with the new target date, and such notice includes a brief explanation of the justification for the variation. We announced in the Spring 2020 Unified Agenda (June 30, 2020, www.reginfo.gov) that buy cialis without prescription we would issue the final rule in August 2020.

However, we are still working through the Start Printed Page 52941complexity of the issues raised by comments received on the proposed rule and therefore we are not able to meet the announced publication target date. This notice extends the timeline for publication of buy cialis without prescription the final rule until August 31, 2021. Start Signature Dated. August 24, 2020. Wilma M buy cialis without prescription.

Robinson, Deputy Executive Secretary to the Department, Department of Health and Human Services. End Signature End Supplemental Information buy cialis without prescription [FR Doc. 2020-18867 Filed 8-26-20. 8:45 am]BILLING CODE 4120-01-PStart Preamble Notice of amendment. The Secretary issues this amendment pursuant to section 319F-3 of the Public Health Service Act to add additional categories of Qualified buy cialis without prescription Persons and amend the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures.

This amendment to the Declaration published on March 17, 2020 (85 FR 15198) is effective as of August 24, 2020. Start Further buy cialis without prescription Info Robert P. Kadlec, MD, MTM&H, MS, Assistant Secretary for Preparedness and Response, Office of the Secretary, Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201. Telephone. 202-205-2882.

End Further Info End Preamble Start Supplemental Information The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the Secretary of Health and Human Services (the Secretary) to issue a Declaration to provide liability immunity to certain individuals and entities (Covered Persons) against any claim of loss caused by, arising out of, relating to, or resulting from the manufacture, distribution, administration, or use of medical countermeasures (Covered Countermeasures), except for claims involving “willful misconduct” as defined in the PREP Act. Under the PREP Act, a Declaration may be amended as circumstances warrant. The PREP Act was enacted on December 30, 2005, as Public Law 109-148, Division C, § 2. It amended the Public Health Service (PHS) Act, adding section 319F-3, which addresses liability immunity, and section 319F-4, which creates a compensation program. These sections are codified at 42 U.S.C.

247d-6d and 42 U.S.C. 247d-6e, respectively. Section 319F-3 of the PHS Act has been amended by the cialis and All-Hazards Preparedness Reauthorization Act (PAHPRA), Public Law 113-5, enacted on March 13, 2013 and the erectile dysfunction Aid, Relief, and Economic Security (CARES) Act, Public Law 116-136, enacted on March 27, Start Printed Page 521372020, to expand Covered Countermeasures under the PREP Act. On January 31, 2020, the Secretary declared a public health emergency pursuant to section 319 of the PHS Act, 42 U.S.C. 247d, effective January 27, 2020, for the entire United States to aid in the response of the nation's health care community to the erectile dysfunction treatment outbreak.

Pursuant to section 319 of the PHS Act, the Secretary renewed that declaration on April 26, 2020, and July 25, 2020. On March 10, 2020, the Secretary issued a Declaration under the PREP Act for medical countermeasures against erectile dysfunction treatment (85 FR 15198, Mar. 17, 2020) (the Declaration). On April 10, the Secretary amended the Declaration under the PREP Act to extend liability immunity to covered countermeasures authorized under the CARES Act (85 FR 21012, Apr. 15, 2020).

On June 4, the Secretary amended the Declaration to clarify that covered countermeasures under the Declaration include qualified countermeasures that limit the harm erectile dysfunction treatment might otherwise cause. The Secretary now amends section V of the Declaration to identify as qualified persons covered under the PREP Act, and thus authorizes, certain State-licensed pharmacists to order and administer, and pharmacy interns (who are licensed or registered by their State board of pharmacy and acting under the supervision of a State-licensed pharmacist) to administer, any treatment that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule (ACIP-recommended treatments).[] The Secretary also amends section VIII of the Declaration to clarify that the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures includes not only erectile dysfunction treatment caused by erectile dysfunction or a cialis mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by erectile dysfunction treatment, erectile dysfunction, or a cialis mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Description of This Amendment by Section Section V. Covered Persons Under the PREP Act and the Declaration, a “qualified person” is a “covered person.” Subject to certain limitations, a covered person is immune from suit and liability under Federal and State law with respect to all claims for loss caused by, arising out of, relating to, or resulting from the administration or use of a covered countermeasure if a declaration under subsection (b) has been issued with respect to such countermeasure. €œQualified person” includes (A) a licensed health professional or other individual who is authorized to prescribe, administer, or dispense such countermeasures under the law of the State in which the countermeasure was prescribed, administered, or dispensed.

Or (B) “a person within a category of persons so identified in a declaration by the Secretary” under subsection (b) of the PREP Act. 42 U.S.C. 247d-6d(i)(8).[] By this amendment to the Declaration, the Secretary identifies an additional category of persons who are qualified persons under section 247d-6d(i)(8)(B).[] On May 8, 2020, CDC reported, “The identified declines in routine pediatric treatment ordering and doses administered might indicate that U.S. Children and their communities face increased risks for outbreaks of treatment-preventable diseases,” and suggested that a decrease in rates of routine childhood vaccinations were due to changes in healthcare access, social distancing, and other erectile dysfunction treatment mitigation strategies.[] The report also stated that “[p]arental concerns about potentially exposing their children to erectile dysfunction treatment during well child visits might contribute to the declines observed.” [] On July 10, 2020, CDC reported its findings of a May survey it conducted to assess the capacity of pediatric health care practices to provide immunization services to children during the erectile dysfunction treatment cialis. The survey, which was limited to practices participating in the treatments for Children program, found that, as of mid-May, 15 percent of Northeast pediatric practices were closed, 12.5 percent of Midwest practices were closed, 6.2 percent of practices in the South were closed, and 10 percent of practices in the West were closed.

Most practices had reduced office hours for in-person visits. When asked whether their practices would likely be able to accommodate new patients for immunization services through August, 418 practices (21.3 percent) either responded that this was not likely or the practice was permanently closed or not resuming immunization services for all patients, and 380 (19.6 percent) responded that they were unsure. Urban practices and those in the Northeast were less likely to be able to accommodate new patients compared with rural practices and those in the South, Midwest, or West.[] In response to these troubling developments, CDC and the American Academy of Pediatrics have stressed, “Well-child visits and vaccinations are essential services and help make sure children are protected.” [] The Secretary re-emphasizes that important recommendation to parents and legal guardians here. If your child is due for a well-child visit, contact your pediatrician's or other primary-care provider's office and ask about ways that the office safely offers well-child visits and vaccinations. Many medical offices are taking extra steps to make sure that well-child visits can occur safely during the erectile dysfunction treatment cialis, including.

Scheduling sick visits and well-child visits during different times of the Start Printed Page 52138day or days of the week, or at different locations. Asking patients to remain outside until it is time for their appointments to reduce the number of people in waiting rooms. Adhering to recommended social (physical) distancing and other -control practices, such as the use of masks. The decrease in childhood-vaccination rates is a public health threat and a collateral harm caused by erectile dysfunction treatment. Together, the United States must turn to available medical professionals to limit the harm and public health threats that may result from decreased immunization rates.

We must quickly do so to avoid preventable s in children, additional strains on our healthcare system, and any further increase in avoidable adverse health consequences—particularly if such complications coincide with additional resurgence of erectile dysfunction treatment. Together with pediatricians and other healthcare professionals, pharmacists are positioned to expand access to childhood vaccinations. Many States already allow pharmacists to administer treatments to children of any age.[] Other States permit pharmacists to administer treatments to children depending on the age—for example, 2, 3, 5, 6, 7, 9, 10, 11, or 12 years of age and older.[] Few States restrict pharmacist-administered vaccinations to only adults.[] Many States also allow properly trained individuals under the supervision of a trained pharmacist to administer those treatments.[] Pharmacists are well positioned to increase access to vaccinations, particularly in certain areas or for certain populations that have too few pediatricians and other primary-care providers, or that are otherwise medically underserved.[] As of 2018, nearly 90 percent of Americans lived within five miles of a community pharmacy.[] Pharmacies often offer extended hours and added convenience. What is more, pharmacists are trusted healthcare professionals with established relationships with their patients. Pharmacists also have strong relationships with local medical providers and hospitals to refer patients as appropriate.

For example, pharmacists already play a significant role in annual influenza vaccination. In the early 2018-19 season, they administered the influenza treatment to nearly a third of all adults who received the treatment.[] Given the potential danger of serious influenza and continuing erectile dysfunction treatment outbreaks this autumn and the impact that such concurrent outbreaks may have on our population, our healthcare system, and our whole-of-nation response to the erectile dysfunction treatment cialis, we must quickly expand access to influenza vaccinations. Allowing more qualified pharmacists to administer the influenza treatment to children will make vaccinations more accessible. Therefore, the Secretary amends the Declaration to identify State-licensed pharmacists (and pharmacy interns acting under their supervision if the pharmacy intern is licensed or registered by his or her State board of pharmacy) as qualified persons under section 247d-6d(i)(8)(B) when the pharmacist orders and either the pharmacist or the supervised pharmacy intern administers treatments to individuals ages three through 18 pursuant to the following requirements. The treatment must be FDA-authorized or FDA-approved.

The vaccination must be ordered and administered according to ACIP's standard immunization schedule.[] The licensed pharmacist must complete a practical training program of at least 20 hours that is approved by the Accreditation Council for Pharmacy Education (ACPE). This training Start Printed Page 52139program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments.[] The licensed or registered pharmacy intern must complete a practical training program that is approved by the ACPE. This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments.[] The licensed pharmacist and licensed or registered pharmacy intern must have a current certificate in basic cardiopulmonary resuscitation.[] The licensed pharmacist must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during each State licensing period.[] The licensed pharmacist must comply with recordkeeping and reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (treatment registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a treatment must review the treatment registry or other vaccination records prior to administering a treatment.[] The licensed pharmacist must inform his or her childhood-vaccination patients and the adult caregivers accompanying the children of the importance of a well-child visit with a pediatrician or other licensed primary-care provider and refer patients as appropriate.[] These requirements are consistent with those in many States that permit licensed pharmacists to order and administer treatments to children and permit licensed or registered pharmacy interns acting under their supervision to administer treatments to children.[] Administering vaccinations to children age three and older is less complicated and requires less training and resources than administering vaccinations to younger children. That is because ACIP generally recommends administering intramuscular injections in the deltoid muscle for individuals age three and older.[] For individuals less than three years of age, ACIP generally recommends administering intramuscular injections in the anterolateral aspect of the thigh muscle.[] Administering injections in the thigh muscle often presents additional complexities and requires additional training and resources including additional personnel to safely position the child while another healthcare professional injects the treatment.[] Moreover, as of 2018, 40% of three-year-olds were enrolled in preprimary programs (i.e. Preschool or kindergarten programs).[] Preprimary programs are beginning in the coming weeks or months, so the Secretary has concluded that it is particularly important for individuals ages three through 18 to receive ACIP-recommended treatments according to ACIP's standard immunization schedule.

All States require children to be vaccinated against certain communicable diseases as a condition of school attendance. These laws often apply to both public and private schools with identical immunization and exemption provisions.[] As nurseries, preschools, kindergartens, and schools reopen, increased access to childhood vaccinations is essential to ensuring children can return. Notwithstanding any State or local scope-of-practice legal requirements, (1) qualified licensed pharmacists are identified as qualified persons to order and administer ACIP-recommended treatments and (2) qualified State-licensed or registered pharmacy interns are identified as qualified persons to administer the ACIP-recommended treatments ordered by their supervising qualified licensed pharmacist.[] Both the PREP Act and the June 4, 2020 Second Amendment to the Declaration define “covered countermeasures” to include qualified cialis and epidemic products that “limit the harm such cialis or epidemic might otherwise cause.” [] The troubling decrease in ACIP-recommended childhood vaccinations and the resulting increased risk of associated diseases, adverse health conditions, and other threats are categories of harms otherwise caused by Start Printed Page 52140erectile dysfunction treatment as set forth in Sections VI and VIII of this Declaration.[] Hence, such vaccinations are “covered countermeasures” under the PREP Act and the June 4, 2020 Second Amendment to the Declaration. Nothing in this Declaration shall be construed to affect the National treatment Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National treatment Injury Compensation Program authorized under 42 U.S.C.

300aa-10 et seq. Are covered under this Declaration for the purposes of liability immunity and injury compensation only to the extent that injury compensation is not provided under that Program. All other terms and conditions of the Declaration apply to such covered countermeasures. Section VIII. Category of Disease, Health Condition, or Threat As discussed, the troubling decrease in ACIP-recommended childhood vaccinations and the resulting increased risk of associated diseases, adverse health conditions, and other threats are categories of harms otherwise caused by erectile dysfunction treatment.

The Secretary therefore amends section VIII, which describes the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures, to clarify that the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures is not only erectile dysfunction treatment caused by erectile dysfunction or a cialis mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by erectile dysfunction treatment, erectile dysfunction, or a cialis mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Amendments to Declaration Amended Declaration for Public Readiness and Emergency Preparedness Act Coverage for medical countermeasures against erectile dysfunction treatment. Sections V and VIII of the March 10, 2020 Declaration under the PREP Act for medical countermeasures against erectile dysfunction treatment, as amended April 10, 2020 and June 4, 2020, are further amended pursuant to section 319F-3(b)(4) of the PHS Act as described below. All other sections of the Declaration remain in effect as published at 85 FR 15198 (Mar. 17, 2020) and amended at 85 FR 21012 (Apr.

15, 2020) and 85 FR 35100 (June 8, 2020). 1. Covered Persons, section V, delete in full and replace with. V. Covered Persons 42 U.S.C.

247d-6d(i)(2), (3), (4), (6), (8)(A) and (B) Covered Persons who are afforded liability immunity under this Declaration are “manufacturers,” “distributors,” “program planners,” “qualified persons,” and their officials, agents, and employees, as those terms are defined in the PREP Act, and the United States. In addition, I have determined that the following additional persons are qualified persons. (a) Any person authorized in accordance with the public health and medical emergency response of the Authority Having Jurisdiction, as described in Section VII below, to prescribe, administer, deliver, distribute or dispense the Covered Countermeasures, and their officials, agents, employees, contractors and volunteers, following a Declaration of an emergency. (b) any person authorized to prescribe, administer, or dispense the Covered Countermeasures or who is otherwise authorized to perform an activity under an Emergency Use Authorization in accordance with Section 564 of the FD&C Act. (c) any person authorized to prescribe, administer, or dispense Covered Countermeasures in accordance with Section 564A of the FD&C Act.

And (d) a State-licensed pharmacist who orders and administers, and pharmacy interns who administer (if the pharmacy intern acts under the supervision of such pharmacist and the pharmacy intern is licensed or registered by his or her State board of pharmacy), treatments that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule. Such State-licensed pharmacists and the State-licensed or registered interns under their supervision are qualified persons only if the following requirements are met. The treatment must be FDA-authorized or FDA-approved. The vaccination must be ordered and administered according to ACIP's standard immunization schedule. The licensed pharmacist must complete a practical training program of at least 20 hours that is approved by the Accreditation Council for Pharmacy Education (ACPE).

This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments. The licensed or registered pharmacy intern must complete a practical training program that is approved by the ACPE. This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments. The licensed pharmacist and licensed or registered pharmacy intern must have a current certificate in basic cardiopulmonary resuscitation. The licensed pharmacist must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during each State licensing period.

The licensed pharmacist must comply with recordkeeping and reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (treatment registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a treatment must review the treatment registry or other vaccination records prior to administering a treatment. The licensed pharmacist must inform his or her childhood-vaccination patients and the adult caregiver accompanying the child of the importance of a well-child visit with a pediatrician or other licensed primary-care provider and refer patients as appropriate. Nothing in this Declaration shall be construed to affect the National treatment Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National treatment Injury Compensation Program authorized under 42 U.S.C. 300aa-10 et seq.

Are covered under this Declaration for the purposes of liability immunity and injury compensation only to the extent that injury compensation is not provided under that Program. All other Start Printed Page 52141terms and conditions of the Declaration apply to such covered countermeasures. 2. Category of Disease, Health Condition, or Threat, section VIII, delete in full and replace with. VIII.

Category of Disease, Health Condition, or Threat 42 U.S.C. 247d-6d(b)(2)(A) The category of disease, health condition, or threat for which I recommend the administration or use of the Covered Countermeasures is not only erectile dysfunction treatment caused by erectile dysfunction or a cialis mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by erectile dysfunction treatment, erectile dysfunction, or a cialis mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Start Authority 42 U.S.C. 247d-6d. End Authority Start Signature Dated.

August 19, 2020. Alex M. Azar II, Secretary of Health and Human Services. End Signature End Supplemental Information [FR Doc. 2020-18542 Filed 8-20-20.

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Explore full-page version of the map New erectile dysfunction treatment s average cost cialis increased slightly in rural America last week, the first rise in new cases in nearly my blog two months. The number of erectile dysfunction treatment-related deaths in rural (or nonmetropolitan) counties fell modestly during the same period. The number of new rural average cost cialis s grew by about 6% last week, to 16,741.

Despite the increase, new cases remained at their lowest rate in a year. New s are down by more than 90% in rural America since the peak of the winter surge in January. erectile dysfunction treatment-related deaths average cost cialis in rural counties dropped by about 3%, from 538 two weeks ago to 524 last week.

Since March 2020, 93,624 erectile dysfunction treatment-related deaths have been reported in rural counties. In metropolitan counties, new s fell for the ninth consecutive average cost cialis week, dropping by 11% to 72,071. erectile dysfunction treatment-related deaths in metropolitan counties fell by 16%, from 2,478 two weeks ago to 2,058 last week.

Only 13 states saw an increase in rural s last week. A handful of states more average cost cialis than account for the higher rural numbers. This week’s Daily Yonder report on erectile dysfunction treatment in rural America covers Sunday, June 6, through Saturday, June 12.

Unless otherwise noted, data is from the nonprofit USA average cost cialis Facts. Tennessee Sees Big Increase in Rural Cases Like this story?. Sign up for our newsletter.

At the top of nation for rural s is Tennessee, where rural erectile dysfunction treatment cases grew seven-fold last week, giving the state the highest rural rate in the nation, at 135.7 per 100,000 residents average cost cialis. Missouri is a distant second, with a rural rate of 73.8 per 100,000.Tennessee’s new s in rural counties grew from 277 two weeks ago to 2,068 last week. The number of erectile dysfunction treatment tests conducted in Tennessee last week dropped slightly from the week before, average cost cialis according to Tennessee Department of Health data, meaning last week’s high case rate was not artificially inflated by additional testing.

Tennessee’s vaccination rate was sixth from the bottom in the Daily Yonder’s most recent vaccination analysis.Tennessee was also at the top of the growth in “red-zone” counties – localities where the rate of new s for the week exceeded 100 per 100,000 residents. The White House has advised counties that exceed that threshold to take additional steps to contain the cialis. Tennessee had no red-zone counties two weeks ago average cost cialis but had 26 last week.

About half of the state’s 53 nonmetropolitan counties are in the red zone, the highest proportion in the U.S. Other States Missouri added 12 counties to the red-zone list.Fifteen states decreased the number of rural counties on the red-zone list, led by Louisiana, which decreased its red-zone list by six rural counties.The biggest improvement last week in rural s was in Pennsylvania (348 fewer cases last week than two weeks ago), Michigan (down 245), and Texas average cost cialis (down 202). Changes in erectile dysfunction treatment Data This week’s rural erectile dysfunction treatment report was delayed by the slow release of state data to USA Facts, the nonprofit organization that has been the source of data for the Daily Yonder’s erectile dysfunction treatment analysis.

In an email this week, USA Facts’ data manager said most states have discontinued one or more days of reporting on the weekend. Florida, Oklahoma, average cost cialis and Rhode Island report data only weekly. And Nebraska is no longer providing erectile dysfunction treatment data at the county level, meaning we cannot provide a rural/urban analysis for the state.

We will keep you posted on data changes and how they might affect the Daily Yonder’s weekly reports. You Might Also LikeAs part of President Biden’s continued efforts to ensure the cialis response reaches all people and all communities, the Biden Administration is average cost cialis announcing an investment of $1.8 billion to combat erectile dysfunction treatment in Indian Country. This is in addition to an investment of more than $4 billion that was announced in April 2021.

€œThis investment from the American Rescue Plan will strengthen the public health workforce in Indian Country, support mental health and substance abuse prevention and treatment, continue efforts to detect average cost cialis and treat erectile dysfunction treatment, and meet facility and equipment needs related to the erectile dysfunction treatment cialis,” said Elizabeth Fowler, IHS acting director. €œInvesting in our workforce and providing our team with the facilities, equipment, supplies, and funds they need is absolutely critical to ensuring our ability to fulfill the IHS mission of raising the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level. Today’s allocations include.

$240 million for Public Health Workforce Activities Thanks to the American Rescue Plan, IHS will invest $240 million for public health workforce activities, to recruit and retain additional public health average cost cialis professionals at IHS, tribal health programs, and urban Indian organization health programs. IHS will also use these funds to create a new IHS career opportunities web site and improve the loan repayment application process. $420 million for Mental Health average cost cialis and Substance Abuse Prevention and Treatment IHS will invest $420 million to expand mental health and substance abuse prevention and treatment services, at IHS, tribal health programs, and urban Indian organization health programs and to support nationwide mental health and substance abuse prevention support activities.

$500 million to Detect, Diagnose, Trace, Monitor, and Mitigate erectile dysfunction treatment s The IHS will invest an additional $500 million to directly support detection, diagnosis, treatment, monitoring, and mitigation of erectile dysfunction treatment. $220 million will be distributed to IHS facilities, tribal health programs, and urban Indian organization health programs. $280 million will be allocated to the IHS National Supply Service Center to purchase average cost cialis testing supplies, personal protective equipment, and related erectile dysfunction treatment supply needs to be provided to IHS, tribal, and urban Indian health programs at no cost.

In addition, these funds will expand the National Supply Service Center warehouse footprint and stockpiling capacity for these critically needed materials. $610 million for erectile dysfunction treatment-Related Facilities Activities The IHS will invest average cost cialis $610 million for erectile dysfunction treatment related facilities activities. $381 million to IHS, tribal, and urban Indian health programs for the lease, purchase, construction, alteration, renovation, and maintenance and improvement of facilities.

$167 million to IHS and tribal health programs for erectile dysfunction treatment related sanitation facilities construction projects. $23 million to IHS and tribal health programs for erectile dysfunction treatment average cost cialis equipment needs. $29 million to support the appropriate management and oversight of facilities-related expenditures and to expand erectile dysfunction treatment related environmental health activities.

$10 average cost cialis million for potable water delivery to IHS and tribal health programs on a case-by-case basis. The IHS continues to work closely with our tribal and urban Indian organization partners, as well as state and local public health officials, to coordinate a comprehensive public health response to the ongoing erectile dysfunction treatment cialis. For more on the federal response in Indian Country, visit https://www.ihs.gov/erectile dysfunction/.

The IHS, an agency in the U.S. Department of Health and Human Services , provides a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized tribes in 37 states. Follow the agency via social media on Facebook , Twitter , and LinkedIn ..

Explore full-page version of the map New erectile dysfunction treatment s increased slightly in rural America last week, the buy cialis without prescription first rise link in new cases in nearly two months. The number of erectile dysfunction treatment-related deaths in rural (or nonmetropolitan) counties fell modestly during the same period. The number buy cialis without prescription of new rural s grew by about 6% last week, to 16,741. Despite the increase, new cases remained at their lowest rate in a year. New s are down by more than 90% in rural America since the peak of the winter surge in January.

erectile dysfunction treatment-related deaths in rural buy cialis without prescription counties dropped by about 3%, from 538 two weeks ago to 524 last week. Since March 2020, 93,624 erectile dysfunction treatment-related deaths have been reported in rural counties. In metropolitan counties, new s fell for the ninth consecutive week, buy cialis without prescription dropping by 11% to 72,071. erectile dysfunction treatment-related deaths in metropolitan counties fell by 16%, from 2,478 two weeks ago to 2,058 last week. Only 13 states saw an increase in rural s last week.

A handful of states more than account for the higher rural numbers buy cialis without prescription. This week’s Daily Yonder report on erectile dysfunction treatment in rural America covers Sunday, June 6, through Saturday, June 12. Unless otherwise noted, buy cialis without prescription data is from the nonprofit USA Facts. Tennessee Sees Big Increase in Rural Cases Like this story?. Sign up for our newsletter.

At the top of nation for rural s is Tennessee, where rural erectile dysfunction treatment cases grew seven-fold last week, giving buy cialis without prescription the state the highest rural rate in the nation, at 135.7 per 100,000 residents. Missouri is a distant second, with a rural rate of 73.8 per 100,000.Tennessee’s new s in rural counties grew from 277 two weeks ago to 2,068 last week. The number of erectile dysfunction treatment tests conducted in Tennessee last week dropped slightly from the week before, according to Tennessee Department of Health data, meaning last week’s high buy cialis without prescription case rate was not artificially inflated by additional testing. Tennessee’s vaccination rate was sixth from the bottom in the Daily Yonder’s most recent vaccination analysis.Tennessee was also at the top of the growth in “red-zone” counties – localities where the rate of new s for the week exceeded 100 per 100,000 residents. The White House has advised counties that exceed that threshold to take additional steps to contain the cialis.

Tennessee had no red-zone counties two weeks ago but had 26 buy cialis without prescription last week. About half of the state’s 53 nonmetropolitan counties are in the red zone, the highest proportion in the U.S. Other States Missouri added 12 counties to the red-zone list.Fifteen states decreased the buy cialis without prescription number of rural counties on the red-zone list, led by Louisiana, which decreased its red-zone list by six rural counties.The biggest improvement last week in rural s was in Pennsylvania (348 fewer cases last week than two weeks ago), Michigan (down 245), and Texas (down 202). Changes in erectile dysfunction treatment Data This week’s rural erectile dysfunction treatment report was delayed by the slow release of state data to USA Facts, the nonprofit organization that has been the source of data for the Daily Yonder’s erectile dysfunction treatment analysis. In an email this week, USA Facts’ data manager said most states have discontinued one or more days of reporting on the weekend.

Florida, Oklahoma, and Rhode Island report data only buy cialis without prescription weekly. And Nebraska is no longer providing erectile dysfunction treatment data at the county level, meaning we cannot provide a rural/urban analysis for the state. We will keep you posted on data changes and how they might affect the Daily Yonder’s weekly reports. You Might Also LikeAs part of President Biden’s continued efforts to ensure the cialis response reaches all people and all communities, the Biden Administration is announcing an investment buy cialis without prescription of $1.8 billion to combat erectile dysfunction treatment in Indian Country. This is in addition to an investment of more than $4 billion that was announced in April 2021.

€œThis investment from the American Rescue Plan will strengthen the public health workforce in Indian Country, support mental health and substance abuse prevention and treatment, continue efforts buy cialis without prescription to detect and treat erectile dysfunction treatment, and meet facility and equipment needs related to the erectile dysfunction treatment cialis,” said Elizabeth Fowler, IHS acting director. €œInvesting in our workforce and providing our team with the facilities, equipment, supplies, and funds they need is absolutely critical to ensuring our ability to fulfill the IHS mission of raising the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level. Today’s allocations include. $240 million for Public Health Workforce Activities Thanks to the American Rescue Plan, IHS will invest $240 million for public health workforce activities, to recruit and retain buy cialis without prescription additional public health professionals at IHS, tribal health programs, and urban Indian organization health programs. IHS will also use these funds to create a new IHS career opportunities web site and improve the loan repayment application process.

$420 million for Mental Health and Substance Abuse Prevention and Treatment IHS will buy cialis without prescription invest $420 million to expand mental health and substance abuse prevention and treatment services, at IHS, tribal health programs, and urban Indian organization health programs and to support nationwide mental health and substance abuse prevention support activities. $500 million to Detect, Diagnose, Trace, Monitor, and Mitigate erectile dysfunction treatment s The IHS will invest an additional $500 million to directly support detection, diagnosis, treatment, monitoring, and mitigation of erectile dysfunction treatment. $220 million will be distributed to IHS facilities, tribal health programs, and urban Indian organization health programs. $280 million will be allocated to the IHS National Supply Service Center buy cialis without prescription to purchase testing supplies, personal protective equipment, and related erectile dysfunction treatment supply needs to be provided to IHS, tribal, and urban Indian health programs at no cost. In addition, these funds will expand the National Supply Service Center warehouse footprint and stockpiling capacity for these critically needed materials.

$610 million for erectile dysfunction treatment-Related Facilities Activities buy cialis without prescription The IHS will invest $610 million for erectile dysfunction treatment related facilities activities. $381 million to IHS, tribal, and urban Indian health programs for the lease, purchase, construction, alteration, renovation, and maintenance and improvement of facilities. $167 million to IHS and tribal health programs for erectile dysfunction treatment related sanitation facilities construction projects. $23 million to IHS and tribal health programs for buy cialis without prescription erectile dysfunction treatment equipment needs. $29 million to support the appropriate management and oversight of facilities-related expenditures and to expand erectile dysfunction treatment related environmental health activities.

$10 million buy cialis without prescription for potable water delivery to IHS and tribal health programs on a case-by-case basis. The IHS continues to work closely with our tribal and urban Indian organization partners, as well as state and local public health officials, to coordinate a comprehensive public health response to the ongoing erectile dysfunction treatment cialis. For more on the federal response in Indian Country, visit https://www.ihs.gov/erectile dysfunction/. The IHS, an agency in the U.S. Department of Health and Human Services , provides a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized tribes in 37 states.

Follow the agency via social media on Facebook , Twitter , and LinkedIn ..

What may interact with Cialis?

Do not take Cialis with any of the following medications:

  • nitrates like amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin

Cialis may also interact with the following medications:

  • certain drugs for high blood pressure
  • certain drugs for the treatment of HIV or AIDS
  • certain drugs used for fungal or yeast s, like fluconazole, itraconazole, ketoconazole, and voriconazole
  • certain drugs used for seizures like carbamazepine, phenytoin, and phenobarbital
  • grapefruit juice
  • macrolide antibiotics like clarithromycin, erythromycin, troleandomycin
  • medicines for prostate problems
  • rifabutin, rifampin or rifapentine

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

Cialis side effects forum

Here is an weblink example cialis side effects forum. Sam is age 50 and has Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME cialis side effects forum - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335.

Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 cialis side effects forum (2021) but she can still qualify for MIPP. 2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would cialis side effects forum otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time.

This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is cialis side effects forum under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3.

New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case cialis side effects forum is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved cialis side effects forum by the LDSS. The consumer is entitled to MIPP payments for at least three months during the transition.

Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY cialis side effects forum Social Services Law 366, subd. 4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during erectile dysfunction treatment emergency their case may remain with NYSoH for more than 12 months cialis side effects forum.

See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note cialis side effects forum. During the erectile dysfunction treatment emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments.

See GIS cialis side effects forum 20 MA/04 or this article on erectile dysfunction treatment eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or cialis side effects forum blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN.

See this article. Consumers may have income higher than MSP limits, but cialis side effects forum keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums. See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to cialis side effects forum MSP.

If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C cialis side effects forum (pg 8). Pickle &. 1619B.

5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019.

Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B.

It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &.

Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP.

If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program. The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS).

Unfortunately, the notice is not consumer-friendly and may be confusing. See attached sample for what to look for. Health Insurance Premium Payment Program (HIPP) HIPP is a sister program to MIPP and will reimburse consumers for private third party health insurance when deemed “cost effective.” Directives:Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in QMB receive additional subsidies for Medicare costs.

See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y. Soc. Serv. L.

§ 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging Note. Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP. See this article for more info. TOPICS COVERED IN THIS ARTICLE 1.

No Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?.

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

6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP.

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

Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA 027.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan.

GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

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

People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare.

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

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

Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply.

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

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

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

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

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

$400 - buy cialis without prescription $65 = http://drinks.theflapper.co.uk/product/the-man/ $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP. 2 buy cialis without prescription. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries.

Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of buy cialis without prescription the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income buy cialis without prescription is above 120% FPL, then they can enroll in MIPP.

(See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3. New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should buy cialis without prescription be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS.

The consumer is entitled to MIPP payments for at least three months during the transition buy cialis without prescription. Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS.

NOTE during erectile dysfunction treatment emergency their case may remain with NYSoH for more than 12 months. See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note. During the erectile dysfunction treatment emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS.

They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on erectile dysfunction treatment eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit.

If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums. See page 96 of the Medicaid Reference Guide (Categorical Factors).

If their income is lower than the MSP SLIMB threshold, they can be added to MSP. If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &.

1619B. 5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium.

See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check.

MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7).

Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777.

Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program.

The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS). Unfortunately, the notice is not consumer-friendly and may be confusing. See attached sample for what to look for. Health Insurance Premium Payment Program (HIPP) HIPP is a sister program to MIPP and will reimburse consumers for private third party health insurance when deemed “cost effective.” Directives:Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below.

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

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

TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A. Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3.

The Three MSP Programs - What are they and how are they Different?. 4. FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &.

Applications for People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!.

Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2021) Single Couple Single Couple Single Couple $1,094 $1,472 $1,308 $1,762 $1,469 $1,980 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &.

B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application).

See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down.

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

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

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

(a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc.

For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE.

The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE.

Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO.

DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP.

In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link. (Updated 4/14/2021.)) 3.

The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations.

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

Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1).

For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid.

They cannot be in both. It is their choice. DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB.

4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments.

Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy.

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

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

Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A.

See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits.

Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP.

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

The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods.

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

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

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

Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing.

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

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

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

One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program.

In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification.

NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test.

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

08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability).

Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan.

See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown.

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

This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements.

SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7.

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

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

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

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Cialis soft review

How to cialis soft review cite this article:Singh OP Generic amoxil cost. Comprehensive Mental Health Action Plan 2013–2030. We must rise to the cialis soft review challenge.

Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health Assembly accepted the updates cialis soft review to the action plan, including updates to the target options for indicators and implementation. This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1.

Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there cialis soft review is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is an cialis soft review opportunity for us to expand psychiatry by being involved in general medical care and reduce stigma.

We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization. Mental Health cialis soft review Action Plan 2013-2020. Geneva.

World Health Organization cialis soft review. 2013. 2.World cialis soft review Health Organization.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization.

2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal. AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background.

Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation.

Assessment based on cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods.

This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation.

Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA. Correlation was done using Pearson's correlation test.Results.

Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages.

Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions. Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses.

Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 20];63:418-23. Available from.

Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking.

It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls.

Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases.

Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department).

Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA).

The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.

We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY.

IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables. Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate.

The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.

Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married.

Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence.

[Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses.

Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09).

About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent. Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI.

2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71).

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11).

Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <.

0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2.

Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls.

This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this.

Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment.

Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement.

Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics.

CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE.

Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed.

We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation. As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE.

Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected.

Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy.

The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.

Alcohol dependence. A public health perspective. Addiction 2002;97:633-45.

2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.

3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model.

J Addict Nurs 2005;16:5-12. 4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers.

J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ. An attributional analysis of Alcoholics Anonymous.

J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment.

Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment.

A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP.

Motivation to withdraw from heroin. A factor-analytic study. Br J Addict 1992;87:245-50.

9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain.

How, when and why?. Trends Cogn Sci 2006;10:435-41. 11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA.

The QCAE. A questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84-95.

12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61.

13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3.

14.Krebs D. Empathy and auism. J Pers Soc Psychol 1975;32:1134-46.

15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale. J Adolesc 2006;29:589-611.

16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles.

Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy.

A preliminary analysis. Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS.

Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32.

19.Uekermann J, Daum I. Social cognition in alcoholism. A link to prefrontal cortex dysfunction?.

Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism.

Addiction 2007;102:232-40. 21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy.

Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N.

The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W.

The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study. Br J Addict 1990;85:635-7.

24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78.

25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448-70.

26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21.

28.Decety J, Jackson PL. A social-neuroscience perspective on empathy. Curr Dir Psychol Sci 2006;15:54-8.

29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism. Alcohol Clin Exp Res 1988;12:471-80.

30.Moyers TB, Miller WR. Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84.

31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70.

32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling.

J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

How to cite this buy cialis without prescription article:Singh OP. Comprehensive Mental Health Action Plan 2013–2030. We must buy cialis without prescription rise to the challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health Assembly accepted the updates to the action plan, including updates buy cialis without prescription to the target options for indicators and implementation.

This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health buy cialis without prescription Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is buy cialis without prescription an opportunity for us to expand psychiatry by being involved in general medical care and reduce stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization.

Mental Health buy cialis without prescription Action Plan 2013-2020. Geneva. World Health Organization buy cialis without prescription. 2013. 2.World Health buy cialis without prescription Organization.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization. 2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence.

However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods.

This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA.

Correlation was done using Pearson's correlation test.Results. Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 20];63:418-23.

Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence.

This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males.

Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used.

The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant. Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis.

The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016).

This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71).

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2].

However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation.

Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking.

Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial.

It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE.

Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management.

Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.

Alcohol dependence. A public health perspective. Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence.

Alcohol Res Health 2010;33:55-63. 3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ. An attributional analysis of Alcoholics Anonymous.

J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment. Int J Psychoanal 1972;53:51-9. 7.Miller WR.

Motivation for treatment. A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin.

A factor-analytic study. Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?. Trends Cogn Sci 2006;10:435-41.

11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L.

Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61. 13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3.

14.Krebs D. Empathy and auism. J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles. Psychol Psychother 1983;20:368-75.

17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis. Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS.

Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism.

A link to prefrontal cortex dysfunction?. Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40.

21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N.

The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W. The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study.

Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B.

Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL. A social-neuroscience perspective on empathy.

Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism. Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR.

Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84. 31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70.

32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

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Medically known as dysmenorrhea, period pain affects around 71 percent of females and can interfere with daily activities, such as work, for around 20 percent.It can cause nausea, fatigue, back pain, cramps, and extreme pain could be an indicator of endometriosis.In a study by Western Sydney University, examining the results of 38 studies of, more than 21,000 comparison between viagra cialis and levitra young women worldwide, period pain was linked to poor academic performance and missed days of school.Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.Another researcher commented severe dysmenorrhea can cause pain “almost as bad as having a heart attack”, yet it’s historically been written off as ‘women’s hysteria’ by society and our employers.In a new survey conducted by Womanizer of 470 menstruators from 26 countries, more than half deemed it not socially acceptable to request a sick day due to period pain, while 47 percent said their employers wouldn’t deem period pain as a legitimate reason for calling in sick.“Many experience debilitating pain and discomfort, and feel they have to push through it”, says Georgia Grace, sex coach and sexual health expert for Womanizer.CEO at the HR consultancy ASPL Group Kris Grant says it’s important companies consult with their HR departments to find out what their employees need, like flexible working hours, or a number of days allocated to menstrual leave per year. But it shouldn’t be seen as special treatment.“It’s simply comparison between viagra cialis and levitra destigmatising menstruation and showing compassion to common issues women face”, she says, adding the downside is that it could make employees uncomfortable.“If an employee takes sick leave, they don’t need to tell their employer what it’s for,” she explains.“When you create specific leave types, it forces an employee to put up their hand and say, ‘I’m on my period today. I can’t work.’ They might not be comfortable doing that, so being wary of employee privacy is a huge consideration.”Georgia Grace adds. €œIt's vital that this leave is presented to employees without judgment, comparison between viagra cialis and levitra shame or blame.

Menstruators must feel safe to take leave and prioritise their health.”.

We speak to the wine makers buy cialis without prescription at Tempus Two on how to make a *still delicious* lower alcohol, lower calorie wine.With Dry July in full swing and a lot of us reconsidering how much and how often alcohol we drink, low-alcohol and no alcohol wines have never been more popular or present on shelves. With huge advances in technology and wines now on the market with all the flavour but with up to 40 per cent less calories, have we reached the holy grail of booze?. So how is low alcohol wine made? buy cialis without prescription. If you’re counting cals, which variety of wine is has the least?. And is it possible to make a low-alcohol wine that really buy cialis without prescription tastes just as good?.

We enlisted Tempus Two Winemaker Andrew Duff to answer all the important questions.Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.Is it possible to make buy cialis without prescription a low-calorie wine with a standard alcohol concentration?. The two major potential contributors to the calorie count in wine is alcohol and sugar. Because we convert the majority of the sugar into alcohol, alcohol is therefore the major contributor to calorie content.Alcohol also contributes more calories per gram than other contributors in buy cialis without prescription wine, almost double that per gram of sugar. Therefore, any significant lowering of calories will occur because of the lower alcohol level.How is low-calorie wine achieved?.

To achieve our buy cialis without prescription low alcohol and therefore reduced calorie wine we take full strength wine and use spinning cone technology to gently remove some of the alcohol while retaining the delicate varietal flavours and aromas.This technology is key in ensuring the end product is premium quality wine just with less alcohol and therefore calories that has not compromised on flavour.Is there a taste difference between low-alcohol and regular alcohol wine?. Alcohol is critically important in providing structure, taste and sensation to wine. However using our technology and buy cialis without prescription years of winemaking skill and knowledge in the category we are able to blend and produce lower alcohol wines yet maintain a taste profile as close to full strength alcohol wine as possible.Assuring the end consumer’s enjoyment, the idea is you enjoy the wine the same way you do a full strength wine, with no compromise on taste profile but the added benefit of lower alcohol.What is the approximate calorie difference between a standard glass and a glass of low calorie wine?. A glass of Lighten Up Pinot Noir, for example, has 40% less calories than there is in a standard bottle from the Tempus Two Varietal Series.There are 88 calories in a 100ml glass of Tempus Two Varietal Pinot Noir whereas there are only 53 calories in a 100ml glass of Tempus Two Lighten Up Pinot Noir.Do the lower calories come from lower sugar or lower alcohol or are they the same thing?. The only sugars contained in the wines is from the buy cialis without prescription grapes.

No refined sugar is added. The lower calories mainly buy cialis without prescription come from the low alcohol content. In theory, all the calories do come from the natural grape sugars, however it takes roughly 18g of sugar to produce 1 degree of alcohol, so the result is more calories are therefore found in the alcohol after fermentation rather than the residual sugar itself.As mentioned previously, with Lighten Up, we gently remove the alcohol which in turn removes the higher portion of calories.Is there much of a calorie difference between red, white, rose and sparkling wines?. If buy cialis without prescription so which has the most?. Which has the least?.

The calorie content of wine is less about the buy cialis without prescription varietal and more about the harvesting and fermentation conditions. Some varieties or styles may consequently carry higher calorie counts because they are generally higher in alcohol. And the buy cialis without prescription opposite is seen with varieties and styles generally lower in alcohol.Some varietals and styles may carry higher calorie counts because they are sweeter and due to the fermentation conditions they undergo. Therefore it is very hard to pigeon hole varieties to lower and higher calorie categories.What we can say with confidence is. Lighten Up Prosecco is 30% less in calories and 40% less in alcohol than the Tempus Two Varietal Prosecco The Rosé is 30% less in calories and 37% less in alcohol than the Tempus Two buy cialis without prescription Varietal Rosé The Pinot Noir is 40% less calories and 51% less in alcohol than the full-strength versionAll of which are not compromised on style or flavour.Why do people assume that lower alcohol wines lack depth?.

There can be a stigma attached to lower alcohol wine due to the category offerings in the past missing the mark, the consumer expects a lower alcohol wine to taste like the full strength equivalent just with less alcohol.For example, the alcohol in wine is mostly directly related to the ripeness of the grape berries when harvested. Without the assistance of the right technology or experience in the category, one way to achieve a consequently lower alcohol wine is to harvest fruit prior to full sugar ripeness and therefore most likely prior to flavour ripeness creating buy cialis without prescription a wine with less depth and/or potential unripe greener characteristics unlike a full strength fully ripe equivalent.Alternatively, grapes can be picked at ideal ripeness and fermentation halted at the intended alcohol level which leaves unfermented sugars creating a wine sweeter than expected.As a result, many products in the past in this category may not have the taste profile that has been expected. What we have been able to achieve with Lighten Up is a product with all the key attributes expected in a full strength equivalent at a lower alcohol level and therefore we are confident this can change consumers perception of lower alcohol wines.Period pain has historically been brushed off as ‘women’s hysteria’, even though it can be as bad as a heart attack for some. So why isn’t it buy cialis without prescription acceptable to ask for a sick day off work?. Some kind of discomfort associated with your menstrual cycle is very common, but for some, it can be debilitating.

Medically known as dysmenorrhea, period pain affects around 71 percent of females and can interfere with daily buy cialis without prescription activities, such as work, for around 20 percent.It can cause nausea, fatigue, back pain, cramps, and extreme pain could be an indicator of endometriosis.In a study by Western Sydney University, examining the results of 38 studies of, more than 21,000 young women worldwide, period pain was linked to poor academic performance and missed days of school.Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.Another researcher commented severe dysmenorrhea can cause pain “almost as bad as having a heart attack”, yet it’s historically been written off as ‘women’s hysteria’ by society and our employers.In a new survey conducted by Womanizer of 470 menstruators from 26 countries, more than half deemed it not socially acceptable to request a sick day due to period pain, while 47 percent said their employers wouldn’t deem period pain as a legitimate reason for calling in sick.“Many experience debilitating pain and discomfort, and feel they have to push through it”, says Georgia Grace, sex coach and sexual health expert for Womanizer.CEO at the HR consultancy ASPL Group Kris Grant says it’s important companies consult with their HR departments to find out what their employees need, like flexible working hours, or a number of days allocated to menstrual leave per year. But it shouldn’t be seen as special treatment.“It’s simply destigmatising menstruation and showing compassion to common issues women face”, she says, adding the downside is that it could make employees uncomfortable.“If an employee takes sick leave, they don’t need to tell their employer what it’s for,” she explains.“When you create specific leave types, buy cialis without prescription it forces an employee to put up their hand and say, ‘I’m on my period today. I can’t work.’ They might not be comfortable doing that, so being wary of employee privacy is a huge consideration.”Georgia Grace adds. €œIt's vital that this leave is presented to employees without judgment, shame or buy cialis without prescription blame.

Menstruators must feel safe to take leave and prioritise their health.”.