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Starting tomorrow, the Indonesian government will deliver free telemedicine services for erectile dysfunction treatment patients with mild symptoms across the country in a bid to ease hospital pressure as cases hit record highs.These services will be delivered in partnership with digital health platforms Alodokter and Halodoc, who will provide free teleconsultations and medication delivery, said Health Minister Budi Gunadi Sadikinat at a press conference.A report noted that 75% of all hospital beds in the country were occupied as of 2 July, with the island of Java reporting levitra online shop over 90% capacity.The country's health spending has also been raised to $13.39 billion for erectile dysfunction treatment, testing, tracing, drugs, treatments and protective gear.THE LARGER CONTEXTerectile dysfunction treatment cases in Indonesia continues to hit record highs over the past two weeks, largely due to the Delta variant first discovered in India. This has added nearly 300,000 cases since 21 June to a total of 2.28 million as of late, based on data from Johns Hopkins University's erectile dysfunction treatment levitra online shop Dashboard. The daily count has also stayed over 20,000 since 26 June.Last week, President Joko Widodo announced community restrictions from 3-20 July in the islands of Java and Bali.ON THE RECORD"Positive erectile dysfunction treatment patients can get medical services on time without waiting in line at hospitals, levitra online shop so that hospitals can be prioritised for patients with medium, heavy, and critical symptoms," Minister Sadikin said..

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So, what is it buy levitra pills online about the heart, that peculiar, emotive and sensorially charged organ, that continues to be associated with some essence of the self?. After all, in medical terms, it is a mere pump.Except that the heart-as-pump is beginning to lose favour. Not in teaching or mainstream popular dialogue, where the pump metaphor has become ubiquitous, to explain the movement of the heart, and as a way of connecting to the ‘spare parts’ model of the body.

Viewing the body as a series of spare buy levitra pills online parts is critical to the principles and practice of organ donation. That is not to say that the process must be an unemotional one. Organ donation rests principally on the idea of the ‘gift’, of an altruistic exchange from one person to another.

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History, Medicine, Emotion (Bound Alberti, 2010), http://smilingprince.com/bow-tie-series-ladies-man/ I posited that the heart of culture and the heart of science became disconnected in the nineteenth century levitra online shop. That the heart which had for centuries been the centre of life, emotions and personhood lost out to the brain as the organ par excellence of selfhood. This process was not clear-cut or definitive. There had been interest in craniocentric versions of the self in the ancient world, and there is continued emphasis in the emotional heart in the levitra online shop present day, as Josh Hordern’s article explores through such examples as the organ scandal at Alder Hey Children’s Hospital in Liverpool.

So, what is it about the heart, that peculiar, emotive and sensorially charged organ, that continues to be associated with some essence of the self?. After all, in medical terms, it is a mere pump.Except that the heart-as-pump is beginning to lose favour. Not in teaching or mainstream popular dialogue, where the pump metaphor has become ubiquitous, to explain the movement of the heart, and as a way of connecting to levitra online shop the ‘spare parts’ model of the body. Viewing the body as a series of spare parts is critical to the principles and practice of organ donation.

That is not to say that the process must be an unemotional one. Organ donation rests principally on the idea of the levitra online shop ‘gift’, of an learn this here now altruistic exchange from one person to another. It also raises questions about bodily ownership, however, especially given the development of presumed consent via the ‘opt-out’ system of transplantation in the UK as in many other countries.It is difficult to align popular perceptions about the heart as a site …AbstractIn ‘Chronic fatigue syndrome and an illness-focused approach to care. Controversy, morality and paradox’, authors Michael Sharpe and Monica Greco begin by characterising myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as illness-without-disease.

On that basis they ask why patients reject treatments for illness-without-disease, and they answer with a levitra online shop philosophical idea. Whitehead’s ‘bifurcation of nature’, they suggest, still dominates public and professional thinking, and that conceptual confusion leads patients to reject the treatment they need. A great deal has occurred, however, since Whitehead characterised his culture’s confusions 100 years ago. In our time, I suggest, experience is no longer construed as an invalid second cousin of bodily states in philosophy, in medicine or in levitra online shop the culture at large.

More importantly, we must evaluate medical explanations before we reach for philosophical alternatives. The National Institutes of Health and the Institute of Medicine have concluded that ME/CFS is, in fact, a biomedical disease, and all US governmental health organisations now agree. Although it would be productive for Sharpe and Greco to state and support their disagreement with the other side of the disease debate, it is no longer tenable, or safe, to ignore the possibility of disease in patients with ME/CFS, or to recommend that clinicians should do so.

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Q. Under the ACA, my insurance premium subsidy is dependent on adjusted gross income (AGI). But, for a self-employed person, AGI is dependent on the insurance premium, since premiums are deductible for the self-employed.For example, my husband and I have an AGI of $77,000 before accounting for health insurance. That’s too high for a subsidy for a household of two in 2021, so our tax-deductible self-employed health insurance premiums (line 16 of the Schedule 1 for the 1040) would be $10,952, which is the full cost of our health plan. Subtracting $10,952 from $77,000, our new AGI is at $66,048.

Now, since our AGI would be less than $68,960 (for 2021 coverage, that’s the upper limit for subsidy eligibility for two people), we qualify for the subsidy. So our after-subsidy annual premium for the benchmark plan would be $6,493 (9.83 percent of our MAGI, which applies in 2021 for households with income beween 300 and 400 percent of the poverty level). But if $6,493 is what we should put in line 16 of the Schedule 1, our AGI (and ACA-specific MAGI) would be $70,507 (that’s $77,000 minus $6,493). And since that’s higher than $68,980, we would no longer be eligible for the subsidy!. Help!.

!. A. This can be a complex situation, and our answer is intended to serve as an overview of how the subsidy calculation works. Always seek help from a qualified tax professional if you have questions about your specific situation.[Note that in the example above, we’ve included subsidy thresholds and income percentages for 2021. These numbers change from one year to the next, and poverty level numbers will be from the year before the year in question (eg.

2020 poverty level numbers are used to determine subsidy amounts for 2021 coverage).]In July 2014, the IRS released 26 CFR 601.105, in which they acknowledged the circular relationship between self-employed health insurance premium deductions, AGI, and premium tax credits:“… the amount of the [self-employed health insurance premium] deduction is based on the amount of the … premium tax credit, and the amount of the credit is based on the amount of the deduction – a circular relationship. Consequently, a taxpayer eligible for both a … deduction for premiums paid for qualified health plans and a … premium tax credit may have difficulty determining the amounts of those items.”In the regulation, the IRS provides two methods that self-employed taxpayers can use to calculate their deduction and their subsidy. The iterative calculation will result in a more exact answer, but it is a little more time-consuming to compute. The alternative calculation is less exact (and appears to favor the IRS just slightly), but less time-consuming and easier to calculate. You have your choice of which one you want to use, and tax software should have the calculations built in, which would make them both simple to use.In a nutshell, both methods have you do the calculations repeatedly, getting ever-closer to the correct answer (that’s what iteration means).

But while the iterative calculation has you keep going until the difference between successive answers is less than $1, the alternative calculation lets you stop sooner.The easiest way to understand how the two calculations work is to start on page 9 of the regulation and work through the examples the IRS has provided. When they mention the “limitation on additional tax,” they’re just referencing the caps on how much you have to pay back when you file your taxes if it turns out that your advance subsidy (the amount sent to your health insurance company each month) was overpaid because your income ended up being higher than projected. So in example 1 on page 9, the IRS uses $2,500 as the limitation on additional tax, because the family’s household income is between 300 and 400 percent of poverty (these limits vary by year. For the 2020 tax year, it’s grown to $2,700).[Note that the caps on repayment of excess subsidies are listed in Table 5 on the IRS instructions for Form 8962 (the form that’s used to claim or reconcile the ACA’s premium tax credit), and they depend on your income. The more you earn, the more you potentially have to pay back if your premium subsidy was overpaid during the year, and if you end up with income over 400 percent of the poverty level and are thus not eligible for the subsidy at all, you have to pay it all back.]In addressing the question of the circular relationship between AGI and premium subsidies for self-employed people, the examples the IRS provides cover scenarios where the filers took advance premium tax credits as well as scenarios where they did not, since you can pay your own premiums in full each month and then claim your total credit for the year when you file your taxes.

The examples make the calculations relatively straightforward, although the standard advice applies. If in doubt at all, contact a tax professional for assistance.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Key takeaways Open enrollment extended through December 31, 2020Open enrollment for 2021 health plans has been extended through December 31, 2020 in Idaho. People who enroll by that date will have coverage effective January 1, 2021.

This is the first time Your Health Idaho (the state-run exchange) has ever issued a significant extension to the open enrollment period, but in announcing the extension, the exchange noted that “an unprecedented year calls for unprecedented measures.” (Open enrollment normally ends on December 15 in Idaho.) Once open enrollment ends, residents will only be able to enroll or make changes to their coverage if they experience a qualifying event.Idaho exchange overviewIdaho has a state-run exchange, Your Health Idaho. The state used HealthCare.gov’s enrollment platform during the first open enrollment period, but transitioned to its own enrollment platform in time for the second open enrollment period, and have been successfully using it ever since.Your Health Idaho is the only fully state-run exchange that did not open a erectile dysfunction treatment special enrollment period for people without health insurance (and without a qualifying event). The state explained that this is because “enhanced” short-term plans are available year-round in Idaho, but it’s important to note that those plans can have pre-existing condition waiting periods.While the majority of exchanges across the country had at least one carrier exiting at the end of 2016, all of Idaho’s exchange carriers continued to participate in the exchange in 2017. Unlike many states, there were more plan options (including dental) for consumers in 2017 than there were in 2016 in the Idaho exchange. As of 2018, BridgeSpan left the exchange in Idaho, but Your Health Idaho remained one of the more robust exchanges in the country in terms of carrier participation, with four insurers offering plans in 2019 and 2020.

And for 2021, Regence BlueShield of Idaho has joined the exchange — after previously offering off-exchange coverage — bringing the total number of participating individual market insurers to five.Governor Otter signed S.1288 in March 2018, allowing out-of-state insurers to sell health insurance policies in Idaho as long as they’re licensed and in good standing in the state in which they are domiciled, provide coverage for Idaho’s state-mandated benefits, and pay Idaho’s premium tax and high-risk pool fees. The legislation allows Idaho to enter into compacts with other states to allow for interstate insurance sales. Several other states have passed similar legislation in recent years, including Oklahoma, Georgia, Kentucky, and Maine, but individual market insurers have shown little interest in selling policies across state lines, in part because the insurers don’t tend to have interstate provider networks.2021 rates and plans. 1% average rate increase, plus Regence joined the exchangeFor 2021, Regence BlueShield of Idaho opted to begin offering coverage through Your Health Idaho, after previously offering plans outside the exchange. The Idaho Department of Insurance announced approved average rate changes in early October 2020, and Your Health Idaho enabled plan browsing at the start of October (plan selections can begin November 1).The following average rate changes were approved for individual market plans for 2021, amounting to an overall average rate increase of about 1 percent:Blue Cross of Idaho.

4 percent decreaseMountain Health CO-OP (an ACA-created CO-OP). 2% increase [In neighboring Montana, the same CO-OP, which goes by Montana Health CO-OP in that state, is increasing premiums by an average of just 0.68% for 2021.]SelectHealth. 5 percent increasePacificSource. 7 percent decreaseRegence BlueShield of Idaho. 1 percent decrease.

A look at previous rate changes in Idaho’s exchangeThe Idaho Department of Insurance does not have the authority to prevent health insurers from implementing rates that are deemed unjustified. But they do have a review and negotiation process during which they analyze the rates that have been filed for the coming year and work with carriers to ensure that proposed rates are actuarially justified, and it’s common for final rates in Idaho to be considerably different from what the insurers initially propose.Here’s a look at how premiums have changed in Idaho over the years. Note that these rate changes are calculated before subsidies are applied. For people who receive premium subsidies, the subsidies grow to keep pace with the benchmark plan in each area, largely offsetting changes in premiums.2016. An estimated average rate increase of 20 percent, ranging from an 8 percent decrease for PacificSource, to a 26 percent increase for Montana Health CO-OP.Kaiser Family Foundation analyzed data on benchmark plan (second-lowest-cost Silver plan) premium changes from 2015 to 2016 in metropolitan areas across the country.

In Boise, they found that the average benchmark plan for a 40-year-old non-smoker would be increasing from $210/month to $273/month – a 30 percent increase, which is three times the average they found nationwide. But that’s before premium subsidies were applied. Most enrollees receive subsidies, and the subsidies change to keep pace with the cost of the benchmark plan.2017. Average increase of 24 percent, ranging from 15 percent for PacificSource, to 29 percent for SelectHealth.2018. Average rate increase of 27 percent, but much of that was due to the termination of federal funding for cost-sharing reductions (CSR).

The average approved rate increases for silver plans in Idaho (for on-exchange insurers) were much higher than the overall averages, at 44 percent (the average rate increase for bronze and gold plans was 11 percent and 9 percent, respectively).2019. Average increase of 5 percent, ranging from a 1 percent decrease for SelectHealth, to a 10 percent increase for Blue Cross of Idaho and PacificSource. The cost of cost-sharing reductions continues to be added to silver plan rates in 2019.Although the federal government is no longer requiring meaningful differences in the plans that a carrier offers in the exchange, Idaho is continuing to require each insurer to have meaningful differences among their various plan offerings (this is detailed on page 15 of the state’s letter to issuers).2020. Overall, the average rate increase for 2020 was about 6 percent, versus the proposed overall average increase of 7 percent that insurers had initially proposed. Average rate changes ranged from a 1 percent increase for Regence (off-exchange only in 2020) to an 8 percent increase for SelectHealth.Medicaid expansion took effect in 2020.

More than 90,000 people covered by October 2020A significant change in Idaho for 2020 was the expansion of Medicaid under the terms of a ballot initiative that voters passed in the 2018 election. Medicaid expansion took effect in many states in 2014, and Idaho joined them as of 2020. Through 2019, premium subsidies were available through Your Health Idaho for people with income from 100 to 400 percent of the poverty level. But as of 2020, people with income between 100 and 138 percent of the poverty level are instead eligible for expanded Medicaid.This has been a hotly contested point in Idaho. The state submitted a waiver proposal to the federal government, seeking permission to give these individuals a choice between Medicaid and subsidized plans in the exchange, but CMS rejected that proposal in August 2019.

The agency indicated that the waiver proposal wasn’t complete, but that the concept wouldn’t be approvable even with revisions. Governor Little and Idaho’s legislative leaders expressed surprise and disappointment that the waiver proposal was rejected, and said that they would continue to work towards federal approval for their “coverage choice” concept. [As described below, this is not the first time that CMS has rejected a proposal from Idaho.]However, the legislation that initiated the state’s efforts to modify the expansion of Medicaid (with the “coverage choice” proposal and a Medicaid work requirement that will also need federal approval) did clarify that full expansion would be implemented if the state was unable to obtain federal approval for a modified approach. So people with income between 100 and 138 percent of the poverty level became eligible for Medicaid as of January 2020, instead of premium subsidies in the exchange.Enrollment in expanded Medicaid in Idaho began November 1—the same day that open enrollment started for qualified health plans in the exchange—and coverage took effect starting January 1, 2020. More than 90,000 people had enrolled as of October 2020.Your Health Idaho enrollment.

2014 – 2020Here’s a look at how enrollment in private individual market plans (during open enrollment) through Your Health Idaho has changed each year. Your Health Idaho’s enrollment reports (examples here and here) tend to have higher numbers than the CMS reports, because they include people who enrolled only in dental coverage, as well as those who signed up for medical plans (the CMS reports only count medical plans).Nationwide, enrollment in the exchanges peaked in 2016 and has declined since then, for a variety of reasons. Some—like the Trump administration’s budget cuts for HealthCare.gov—don’t affect state-run exchanges like Your Health Idaho. But others, such as the elimination of the individual mandate penalty and the new federal rules that expand access to short-term health plans, have affected enrollment in Idaho. Premium increases have also played a role.

Although they’re mitigated by larger subsidies for people who are subsidy-eligible, people who don’t get premium subsidies must shoulder the full burden of rate hikes, and coverage has become unaffordable for some.And for 2020, it was expected that enrollment in private plans through the exchange would decline significantly as a result of Medicaid expansion. People with income between 100 and 138 percent of the poverty level are now eligible for Medicaid in Utah instead of premium subsidies in the exchange. The “enhanced” short-term health plans that became available in Idaho as of 2020 may have also contributed to the decline in exchange enrollment.Insurer participation. 2014 – 2021A new insurer was approved by the Idaho Department of Insurance for 2015. Mountain Health CO-OP, which is the Idaho branch of Montana Health CO-OP.

The CO-OP joined Blue Cross of Idaho, BridgeSpan Health Company, PacificSource Health Plans, and SelectHealth, all of which returned to the exchange for 2015.The same five carriers offered coverage in 2016 and 2017. But BridgeSpan exited the market at the end of 2017 (they initially planned to offer off-exchange plans in 2018, but ultimately left the individual market altogether), and SelectHealth reduced their coverage area for 2018.Compared with the rest of the country, however, Idaho remained among the states with the most robust exchanges in terms of insurer participation for 2018. Most counties in the state had four insurers offering plans in the exchange, and 12 counties had three. There were only a handful of other states where most counties had four or more insurers offering exchange plans for 2018.Your Health Idaho confirmed by email in December 2017 that while BridgeSpan enrollees and eastern Idaho enrollees with select Select Health plans were being mapped to comparable plans (assuming they didn’t pick their own new plan by December 15), there was no special enrollment period for BridgeSpan or SelectHealth members who had coverage through Your Health Idaho.The exchange noted that the comparable plans selected on behalf of these enrollees were the least expensive plan at the same metal level as the consumer’s 2017 plan, and that this was based on guidance from the Idaho Department of Insurance. Enrollees with terminating BridgeSpan and Select Health coverage were notified of the impending plan cancellation and the plan that the exchange intended to map them to, and they were able to pick their own plan instead between November 1 and December 15.

But there was not a special enrollment period for people who were mapped to a new plan by the exchange (this is in contrast to people in similar situations in states that use HealthCare.gov, where the special enrollment period is available, even after the exchange picks a replacement plan).Other than BridgeSpan’s exit, Idaho’s exchange has had very consistent insurer participation over the years. Blue Cross of Idaho, Mountain Health CO-OP, SelectHealth, and PacificSource all continued to offer plans in the exchange for 2019, and again in 2020.Starting in 2016, there were not any Platinum plans available in the Idaho exchange. Only about 2 percent of Idaho exchange enrollees selected platinum plans in 2015, and the carriers opted not to offer those plans starting in 2016, as they aren’t required by the ACA and clearly were not a popular choice among enrollees.For 2021, Regence BlueShield of Idaho is joining the exchange, after previously offering off-exchange plans. So there are five on-exchange insurers as of 2021. Regence, Blue Cross of Idaho, Mountain Health CO-OP, PacificSource, and SelectHealth Idaho’s approach to the CSR funding uncertainty and eventual terminationThe Idaho Department of Insurance clarified that for 2018, “the proposed rate increases for silver-level plans on the exchange are significantly higher this year because cost-sharing reduction subsidies are assumed to not be funded by the federal government.” This assumption was correct, as the Trump Administration cut off CSR funding in October 2017, just before the start of open enrollment for 2018 coverage.According to the Idaho Department of Insurance, insurers didn’t have leeway to create new, similar-but-not-identical off-exchange plans at the silver level for 2018 (that’s the approach that California used).

Since on-exchange carriers that offer the same plan off-exchange are required to charge the same price on and off-exchange, the additional premium to cover the cost of CSRs was spread across the on and off-exchange silver plans in Idaho, unless the plan is offered only outside the exchange (this would be the case with all of Regence Blue Shield’s silver plans, since Regence doesn’t offer plans in the exchange).Instead, insurers in Idaho created new “extended bronze” plans, using the new de minimum range (-4/+5) that applies to bronze plan actuarial value starting in 2018 (this extended actuarial value range was part of the market stabilization rule that HHS finalized in April 2017). So insurers in Idaho began offering bronze plans with 65 percent actuarial value as of 2018. Compared with prior years’ actuarial value rules, this is in between a silver and a bronze plan, which have typically had actuarial values of roughly 70 and 60 percent, respectively.For silver plan enrollees in the exchange who are receiving premium subsidies, the additional CSR-related premium load on silver plans is covered or mostly covered by commensurately larger premiums subsidies. And for enrollees in other metal levels who are receiving premium subsidies, net premiums are more affordable than they were in 2017, as the larger premium subsidies (to account for the CSR load on silver plans) can be applied to plans at other metal levels that don’t have the CSR load added to their pre-subsidy premiums.For non-silver plan enrollees who aren’t receiving premium subsidies, the cost of coverage has increased in line with normal annual rate increases, but the CSR load isn’t a factor, since it’s only being added to silver plans.For silver plan enrollees who aren’t receiving premiums subsidies, however, the full weight of the higher rates (driven in large part by the cost of CSR) began to apply in 2018. These enrollees could keep their silver plans, but many have found the new “extended bronze” plans, on or off-exchange, to be a better — and much less expensive — fit.

Extended bronze plans continue to be an option in Idaho in 2019.Premium subsidies (which are different from cost-sharing reduction subsidies) are based on the cost of silver plans in the exchange. So an approach like Idaho is taking (ie, applying the higher rates that come with a lack of CSR funding to silver on-exchange plans and the same silver plans offered off-exchange, rather than spreading them out across all plans) results in larger premium subsidies, as the subsidies grow to keep pace with the increasing silver plan premiums. Bronze and gold plans become an even better value for people who receive subsidies, as the larger subsidies are applicable to those plans too, despite the fact that the additional premiums to account for the lack of CSR funding is only added to silver plans.The subsidies are actually just tax credits, which means the Trump administration is taking from one hand to give to the other (ie, not funding CSRs, but having to pay out more in premium subsidies). The people who end up bearing the brunt of the rate increases are those who don’t qualify for premium subsidies. That includes a few different categories of people.

And as noted above, the people who bear the brunt of the additional premiums are only those who purchase silver plans (on-exchange, or the same qualified health plan sold off-exchange) and don’t receive premium subsidies.Idaho Insurance Director Dean Cameron has made it clear in past statements that he supports GOP efforts to repeal and replace the ACA. Cameron also supports a provision like the Cruz Amendment to the Better Care Reconciliation Act, which would have allowed non-ACA-compliant plans to be sold off-exchange. These plans would certainly be less expensive, so if your only priority is lower premiums, this seems like a valid solution. But they would serve to destabilize the individual insurance market. Healthy people would opt for the less-robust plans (particularly if insurers were allowed to use medical underwriting to offer lower premiums to healthy people, as would have been the case under the Cruz Amendment), leaving sicker people on the ACA-compliant plans, which causes higher premiums, which drives more healthy people towards the non-compliant plans, and so on, until you end up with a death spiral.Cameron has also called for federal reinsurance, which is a valid solution.

The ACA included a reinsurance program, but it was temporary and only lasted through 2016. Reinstating it on a permanent basis would certainly serve to stabilize the insurance markets and minimize premium increases. As an alternative, several states have implemented their own reinsurance programs, although Idaho is not yet among them. CMS rejected Idaho’s plan to allow insurers to sell state-based plans that aren’t compliant with the ACA, so Idaho has created “enhanced” short-term plans insteadSince President Trump took office, there has been considerable discussion about legislative and regulatory changes at the federal level that would allow individual and small group plans to be sold without complying with the full suite of ACA regulations. None of the legislative changes were enacted, although some of the regulatory changes were implemented (for example, expanded access to association health plans, and the relaxed rules for short-term health plans).States also have the option to submit 1332 waivers that (if approved) would allow them to get around some of the ACA’s requirements.

But Idaho’s Department of Insurance opted to simply take the bull by the horns and issue a regulatory bulletin in 2018, outlining a new protocol for allowing insurers in Idaho to sell “state-based health benefit plans” that would avoid many of the ACA’s regulations. The bulletin came three weeks after Governor Butch Otter issued an executive order calling on regulators to devise methods for “restoring choice in health insurance for Idahoans.University of Michigan law professor, Nicholas Bagley, called Idaho’s bulletin “crazypants illegal” and health policy experts expressed varying degrees of skepticism over the chances that the state’s new regulations would stand up to legal scrutiny. In March, after weeks of speculation over whether the federal government would step in to uphold federal law in Idaho, CMS sent a letter to Governor Otter and Idaho Insurance Commissioner, Dean Cameron, explaining that the “state-based” plans would run afoul of the ACA, and if Idaho were to proceed with implementing them, CMS would have to step in and enforce the ACA on behalf of the state. But CMS went out of their way to clarify that they don’t think the ACA is serving the people of Idaho well, and that they appreciate the state’s efforts to essentially circumvent the law. Idaho’s “state-based” plans were simply too much a stretch.CMS clarified that if Idaho failed to enforce the ACA and CMS had to begin enforcing the law instead, the agency would issue cease and desist letters to any insurer offering “state-based” plans in Idaho (Blue Cross of Idaho had previously stated their intent to begin offering “state-based” plans under the terms of Idaho’s regulatory bulletin).

If the insurer continued to offer the plans, it would be subject to financial penalties of up to $100 per day, per individual enrolled in the non-compliant plans.But CMS went on to state that the agency believes that “with certain modifications,” Idaho’s “state-based” plans could instead be offered as short-term plans, which are exempt from the ACA’s regulations. The federal government has since finalized new regulations that allow for much longer short-term plans, unless a state imposes its own restrictions. Idaho allows short-term plans to have initial terms of up to a year, and although the state previously banned renewal of short-term plans, legislation was enacted in Idaho in 2019 to allow for “enhanced” short-term plans, which will be renewable if the policyholder chooses that option.Blue Cross of Idaho is the first insurer to create “enhanced” short-term plans (although SelectHealth appears poised to do so as well). The BCBSID Access Plans will be available for purchase as of December 2019. According to the plan filings for the new Access Plans (SERFF filing number BCOI-132140320), the policies will be guaranteed-issue, but with premiums based on medical history.

They’ll be renewable for up to 36 months of coverage, and although they’ll have a 12-month waiting period for pre-existing condition coverage, the waiting period can be reduced or eliminated if you had creditable prior coverage (this is how pre-existing condition waiting periods worked on employer-sponsored plans before the ACA eliminated them altogether). The new Access Plans have some features that resemble ACA-compliant plans, such as premiums only being charged for up to three children under the age of 21 on a family’s plan, and free preventive care. And they cover maternity care, mental health care, and prescription drugs, all of which are benefits that are often excluded on traditional short-term plans. But the Access Plans have out-of-pocket caps that can be as high as $50,000, and as mentioned above, they also base premiums on medical history, which isn’t allowed on ACA-compliant plans. What was Idaho proposing?.

At Health Affairs, Katie Keith has an excellent overview of what Idaho’s bulletin would have allowed and the implications of what would have happened if insurers had started offering these “state-based” plans. In summary, the bulletin includes the following regulations:An insurer would only be allowed to offer a state-based plan in a given area if the insurer also offers at least one ACA-compliant plan in that area.Enrollment would be available year-round (ie, no open enrollment period).Coverage in state-based plans would be guaranteed-issue (ie, applications could not be rejected based on medical history), but applicants could be charged higher premiums (up to 50 percent above the plan index rate) based on their medical history.Pre-existing conditions could be subject to a waiting period before coverage applies, but that waiting period would be waived if the consumer had proof of continuous prior coverage.Most of the ACA’s essential health benefits would have to be offered, but there are some exceptions. Pediatric dental and pediatric vision coverage would not be required, and insurers would be able to offer state-based plans without maternity coverage as long as they offer at least one state-based plan with maternity coverage (and at least one ACA-compliant plan with maternity coverage, since that’s a requirement for insurers to be able to participate in the state-based coverage program). Blue Cross of Idaho has proposed five state-based plans—one of them does not include maternity coverage, and none of them include pediatric dental or vision coverage.Out-of-pocket costs would still have to be capped, but notably, insurers would be able to apply separate out-of-pocket maximums for various services, such as prescriptions versus other medical care.State-based plans could impose benefit caps of $1 million or more, but would have to assist consumers in switching seamlessly to their ACA-compliant plans if the consumer were to reach the state-based plan’s benefit cap.Insurers could use a 5:1 age rating ratio for state-based plans, as opposed to the ACA’s 3:1 age rating ratio. Under the ACA, older applicants cannot be charged more than three times as much as younger applicants, but Idaho’s bulletin would allow insurers to offer state-based plans with premiums for older applicants that are up to five times as much as the premiums for younger applicants.Insurers would be required to place the state-based and ACA-compliant plans into a single risk pool, but Kaiser Family Foundation’s Larry Levitt notes that may be hard to enforce, especially given that the state-based plans would not participate in the ACA’s risk adjustment program.Clearly, some of those provisions would align well with the concept of short-term plans, which is the option CMS encouraged Idaho to pursue in order to implement their proposal within the parameters of the ACA (since the ACA doesn’t apply to short-term plans).In February, before CMS rejected Idaho’s proposal, Blue Cross of Idaho submitted five state-based plans to the Department of Insurance for review.

The proposed BC of Idaho plans would have had $1 million annual benefit caps, would not have covered pediatric dental or vision, and one of the plans would not have included maternity coverage.The plans would have had premiums that would have varied considerably depending on medical history. The Wall Street Journal reported that a healthy 45-year-old would pay about $194.67 a month in premiums, but a 45-year-old with a poorer medical history might be charged as much as $525.69/month in premiums (no premium subsidies would be available). For comparison, an ACA-compliant bronze plan from Blue Cross of Idaho would have pre-subsidy premiums of about $343.09/month for a 45-year-old, and those premiums don’t vary based on medical history (under the ACA, healthy people pay the same rates as sick people). For people who buy the ACA-compliant plans via Your Health Idaho, and who are eligible for premium subsidies, the subsidies offset a significant portion of the premium costs.The state-based plans would no doubt have appealed to younger, healthier applicants, particularly those who don’t qualify for premium subsidies in the exchange (most exchange enrollees do qualify for premium subsidies, but everyone who buys individual market coverage off-exchange is paying full price, with no available subsidies). A healthy person would be drawn to the cheaper premiums, while a person with medical conditions will be better off keeping their ACA-compliant plan.

This, in turn, would leave the ACA-compliant market with sicker, older enrollees, and higher premiums.Under Idaho’s new rules, an insurer’s state-based and ACA-compliant risk pools would have to have been merged, but it’s unclear how well that provision would have been enforced. But since the state would have required insurers to offer ACA-compliant plans in order to offer state-based plans, and since premium subsidies via Your Health Idaho continue to be available (and grow to keep pace with premiums), the ACA-compliant market would have continued to exist alongside the “state-based” plans, albeit likely with fewer enrollees than it has to today. Assuming the people who would have remained in the ACA-compliant market are primarily those who are older, sicker, and/or receiving premium subsidies, the total federal outlay for premium subsidies would likely have grown, placing an additional burden on taxpayers.Consumers who purchase state-based plans would ostensibly have been somewhat protected by the provision that requires insurers to transfer members to one of the insurer’s ACA-compliant plans if the member hits the state-based plan’s benefit cap. But rescission could have become a major issue in scenarios in which members do hit the benefit cap. Since these plans would have been medically underwritten, a person who ended up hitting the benefit cap (ie, a million dollars worth of claims during the year) could have been subject to significant post-claims underwriting.Basically, the insurer would have been able to go back through the person’s medical records with a fine-toothed comb, checking to make sure that the person had been 100 percent honest when completing the initial medical underwriting questions.

If the insurer found anything that the person hadn’t disclosed on the application, they would have potentially been able to rescind the policy for fraud or misrepresentation (this is still allowed under the ACA, but is much less of an issue on plans that don’t ask enrollees about their medical history). At that point, not only would the person retroactively lose their coverage, they also wouldn’t be eligible to switch to an ACA-compliant plan until the next open enrollment period.It’s also unclear whether the out-of-pocket costs that the consumer had already paid would have been counted towards the ACA-compliant plan’s out-of-pocket exposure, or if the consumer would have been starting from zero mid-year in that scenario, assuming they were indeed able to transition to an ACA-compliant plan.And it’s also important to note that consumers who select a state-based plan and then find out that it doesn’t cover as much as they thought it did would not have been able to switch to an ACA-compliant plan until open enrollment, unless they have a qualifying event. For example, the consumer might not notice that a particular state-based plan doesn’t cover maternity, especially since people have become accustomed to the concept of all plans covering maternity. In that case, she might only find out about the lack of maternity coverage if and when she becomes pregnant, and she would not be able to switch to an ACA-compliant plan until open enrollment.This is an issue with short-term plans as well. A person who enrolls in a short-term plan and subsequently finds out that it doesn’t cover his or her medical needs cannot switch to an ACA-compliant plan until the next open enrollment.

And since short-term plans are not considered minimum essential coverage, the termination of a short-term plan does not count as a qualifying event to trigger a special enrollment period for ACA-compliant plans.Cameron and Otter expressed optimism in the face of the letter from CMS, noting that “we consider the letter an invitation from CMS to continue discussing the specifics of what can and cannot be included in state-based plans. We will consider all possible options and then continue discussions with CMS and HHS on how best to achieve our shared goals of reducing the costs of coverage and stabilizing our health insurance market.” As noted above, the state has largely shifted focus to enhanced short-term plans, but Cameron noted in late 2019 that Idaho “still may pursue the state-based plans.”Assessment fee increased to 1.99% — still far lower than Healthcare.gov feeYour Health Idaho was previously funded with a 1.5 percent assessment fee on all health insurance plans sold through the exchange (unlike many other states, the fee is not collected for plans sold outside the exchange). The fee increased to 1.99 percent in 2016, which is still considerably lower than the 3.5 percent assessment that Healthcare.gov collects in states that use the federally-facilitated marketplace (HealthCare.gov’s fee is dropping to 3 percent as of 2020).The exchange does not receive any state funding, and had spent most of their initial federal start-up funding by 2016. The exchange must be self-sustaining going forward, which is why the assessment was increased.A Leavitt Partners study found Your Health Idaho to be an excellent example of an exchange that is operating well on a much smaller-than-average budget. Your Health Idaho mostly uses in-house support for its systems, and only contracts with vendors for highly specialized services, like marketing.

Many other state-run exchanges contract with vendors for much of their day-to-day operations, while Your Health Idaho staff handles most of the day-to-day operations of the exchange. This is part of the reason they’re able to operate at a lower cost than the rest of the state-run exchanges.But at the same time, Your Health Idaho has limited itself to only essential functions. The exchange leaves plan oversight and rate review entirely to the Idaho Department of Insurance, and the Idaho Department of Health and Welfare does all of the subsidy and Medicaid eligibility determination for exchange enrollees. The exchange does not have to spend time or money being involved in these processes, or creating systems that would essentially duplicate the functionality of the DOI or DHW.SHOP exchange – direct enrollmentAs part of their cost-saving plan, Your Health Idaho opted not to build a SHOP (small business) exchange enrollment platform, and instead relies on direct enrollment through health insurance carriers (with agents and brokers providing enrollment assistance) when businesses want to enroll in SHOP plans.Your Health Idaho has a paper application that small businesses can complete, with contact information that the exchange can use to get in touch with the business and help them move forward with the enrollment process. But in general, Your Health Idaho recommends that small businesses reach out to a broker or agent for assistance with SHOP enrollment.This approach saves the exchange from having to administer and fund a SHOP platform, and in hindsight, is probably a wise decision—SHOP enrollments nationwide have been relatively lackluster, and Idaho’s decision means that the exchange is not having to fund and maintain a low-use enrollment platform.History of Idaho’s marketplace developmentRepublican Gov.

Butch Otter announced in December 2012 that Idaho would implement a state-run health insurance exchange, and HHS gave conditional approval of the state’s plan in early January 2013.The state-run option was resisted by both the governor and many Republican legislators. Like those in other “red” states, Idaho leaders hoped the U.S. Supreme Court would find the Affordable Care Act (ACA) unconstitutional. However, after the Court upheld most elements of the ACA and a state task force in October 2012 strongly recommended a state-run exchange, Otter began leaning toward that option as preferable to a federally run exchange.After Otter’s announcement in December 2012, legislators began considering legislation, and both chambers passed bills authorizing a state-run in exchange in the first quarter of 2013. However, that left scant time to set up the exchange.

Idaho used the federal site for the first open enrollment period, but transitioned to its state-run platform in time for the 2015 open enrollment period.In December 2015, a Leavitt Partners study called Your Health Idaho a “model for state based adoption [of an exchange]” and noted that the exchange has a budget well below average, a “lean organizational structure” and “strong financial controls.” The Leavitt study also indicates that Your Health Idaho benefited from the fact that they used Healthcare.gov during the first open enrollment, and waited until the second open enrollment period to debut their own enrollment platform. That allowed them to obtain lower-cost, better-developed software solutions, with the benefit of hindsight in terms of seeing what worked and what didn’t for the other state-run exchanges during year one.Idaho is the only state that opted to build its own marketplace, but rejected Medicaid expansion. Medicaid is being expanded as of 2020, however, thanks to a voter-backed ballot initiative that passed in 2018.Idaho health insurance exchange linksYour Health Idaho855-YHIdaho (855-944-3246)State Exchange Profile. IdahoThe Henry J. Kaiser Family Foundation overview of Idaho’s progress toward creating a state health insurance exchange.Idaho Department of InsuranceAnswers questions about insurance bought on the individual market and insurance provided by an employer who only does business in Idaho.(208) 334-4250 / toll-free (800) 721-3272Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

Q http://bacma.co.uk/uncategorized/hello-world/ levitra online shop. Under the ACA, my insurance premium subsidy is dependent on adjusted gross income (AGI). But, for a self-employed person, AGI is dependent on the insurance premium, since premiums are deductible for the self-employed.For example, my husband and I have an levitra online shop AGI of $77,000 before accounting for health insurance.

That’s too high for a subsidy for a household of two in 2021, so our tax-deductible self-employed health insurance premiums (line 16 of the Schedule 1 for the 1040) would be $10,952, which is the full cost of our health plan. Subtracting $10,952 from levitra online shop $77,000, our new AGI is at $66,048. Now, since our AGI would be less than $68,960 (for 2021 coverage, that’s the upper limit for subsidy eligibility for two people), we qualify for the subsidy.

So our after-subsidy annual premium for the benchmark plan would be $6,493 levitra online shop (9.83 percent of our MAGI, which applies in 2021 for households with income beween 300 and 400 percent of the poverty level). But if $6,493 is what we should put in line 16 of the Schedule 1, our AGI (and ACA-specific MAGI) would be $70,507 (that’s $77,000 minus $6,493). And since that’s higher than $68,980, we levitra online shop would no longer be eligible for the subsidy!.

This can be a complex situation, and our answer is intended to serve as an overview of how the subsidy calculation works. Always seek help from a qualified tax professional if you have questions about your specific situation.[Note that in the example above, we’ve included subsidy thresholds and income percentages for 2021. These numbers change from one year to the next, and poverty level numbers will be from the year before the year in question (eg.

2020 poverty level numbers are used to determine subsidy amounts for 2021 coverage).]In July 2014, the IRS released 26 CFR 601.105, in which they acknowledged the circular relationship between self-employed health insurance premium deductions, AGI, and premium tax credits:“… the amount of the [self-employed health insurance premium] deduction is based on the amount of the … premium tax credit, and the amount of the credit is based on the amount of the deduction – a circular relationship. Consequently, a taxpayer eligible for both a … deduction for premiums paid for qualified health plans and a … premium tax credit may have difficulty determining the amounts of those items.”In the regulation, the IRS provides two methods that self-employed taxpayers can use to calculate their deduction and their subsidy. The iterative calculation will result in a more exact answer, but it is a little more time-consuming to compute.

The alternative calculation is less exact (and appears to favor the IRS just slightly), but less time-consuming and easier to calculate. You have your choice of which one you want to use, and tax software should have the calculations built in, which would make them both simple to use.In a nutshell, both methods have you do the calculations repeatedly, getting ever-closer to the correct answer (that’s what iteration means). But while the iterative calculation has you keep going until the difference between successive answers is less than $1, the alternative calculation lets you stop sooner.The easiest way to understand how the two calculations work is to start on page 9 of the regulation and work through the examples the IRS has provided.

When they mention the “limitation on additional tax,” they’re just referencing the caps on how much you have to pay back when you file your taxes if it turns out that your advance subsidy (the amount sent to your health insurance company each month) was overpaid because your income ended up being higher than projected. So in example 1 on page 9, the IRS uses $2,500 as the limitation on additional tax, because the family’s household income is between 300 and 400 percent of poverty (these limits vary by year. For the 2020 tax year, it’s grown to $2,700).[Note that the caps on repayment of excess subsidies are listed in Table 5 on the IRS instructions for Form 8962 (the form that’s used to claim or reconcile the ACA’s premium tax credit), and they depend on your income.

The more you earn, the more you potentially have to pay back if your premium subsidy was overpaid during the year, and if you end up with income over 400 percent of the poverty level and are thus not eligible for the subsidy at all, you have to pay it all back.]In addressing the question of the circular relationship between AGI and premium subsidies for self-employed people, the examples the IRS provides cover scenarios where the filers took advance premium tax credits as well as scenarios where they did not, since you can pay your own premiums in full each month and then claim your total credit for the year when you file your taxes. The examples make the calculations relatively straightforward, although the standard advice applies. If in doubt at all, contact a tax professional for assistance.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Key takeaways Open enrollment extended through December 31, 2020Open enrollment for 2021 health plans has been extended through December 31, 2020 in Idaho. People who enroll by that date will have coverage effective January 1, 2021.

This is the first time Your Health Idaho (the state-run exchange) has ever issued a significant extension to the open enrollment period, but in announcing the extension, the exchange noted that “an unprecedented year calls for unprecedented measures.” (Open enrollment normally ends on December 15 in Idaho.) Once open enrollment ends, residents will only be able to enroll or make changes to their coverage if they experience a qualifying event.Idaho exchange overviewIdaho has a state-run exchange, Your Health Idaho. The state used HealthCare.gov’s enrollment platform during the first open enrollment period, but transitioned to its own enrollment platform in time for the second open enrollment period, and have been successfully using it ever since.Your Health Idaho is the only fully state-run exchange that did not open a erectile dysfunction treatment special enrollment period for people without health insurance (and without a qualifying event). The state explained that this is because “enhanced” short-term plans are available year-round in Idaho, but it’s important to note that those plans can have pre-existing condition waiting periods.While the majority of exchanges across the country had at least one carrier exiting at the end of 2016, all of Idaho’s exchange carriers continued to participate in the exchange in 2017.

Unlike many states, there were more plan options (including dental) for consumers in 2017 than there were in 2016 in the Idaho exchange. As of 2018, BridgeSpan left the exchange in Idaho, but Your Health Idaho remained one of the more robust exchanges in the country in terms of carrier participation, with four insurers offering plans in 2019 and 2020. And for 2021, Regence BlueShield of Idaho has joined the exchange — after previously offering off-exchange coverage — bringing the total number of participating individual market insurers to five.Governor Otter signed S.1288 in March 2018, allowing out-of-state insurers to sell health insurance policies in Idaho as long as they’re licensed and in good standing in the state in which they are domiciled, provide coverage for Idaho’s state-mandated benefits, and pay Idaho’s premium tax and high-risk pool fees.

The legislation allows Idaho to enter into compacts with other states to allow for interstate insurance sales. Several other states have passed similar legislation in recent years, including Oklahoma, Georgia, Kentucky, and Maine, but individual market insurers have shown little interest in selling policies across state lines, in part because the insurers don’t tend to have interstate provider networks.2021 rates and plans. 1% average rate increase, plus Regence joined the exchangeFor 2021, Regence BlueShield of Idaho opted to begin offering coverage through Your Health Idaho, after previously offering plans outside the exchange.

The Idaho Department of Insurance announced approved average rate changes in early October 2020, and Your Health Idaho enabled plan browsing at the start of October (plan selections can begin November 1).The following average rate changes were approved for individual market plans for 2021, amounting to an overall average rate increase of about 1 percent:Blue Cross of Idaho. 4 percent decreaseMountain Health CO-OP (an ACA-created CO-OP). 2% increase [In neighboring Montana, the same CO-OP, which goes by Montana Health CO-OP in that state, is increasing premiums by an average of just 0.68% for 2021.]SelectHealth.

5 percent increasePacificSource. 7 percent decreaseRegence BlueShield of Idaho. 1 percent decrease.

A look at previous rate changes in Idaho’s exchangeThe Idaho Department of Insurance does not have the authority to prevent health insurers from implementing rates that are deemed unjustified. But they do have a review and negotiation process during which they analyze the rates that have been filed for the coming year and work with carriers to ensure that proposed rates are actuarially justified, and it’s common for final rates in Idaho to be considerably different from what the insurers initially propose.Here’s a look at how premiums have changed in Idaho over the years. Note that these rate changes are calculated before subsidies are applied.

For people who receive premium subsidies, the subsidies grow to keep pace with the benchmark plan in each area, largely offsetting changes in premiums.2016. An estimated average rate increase of 20 percent, ranging from an 8 percent decrease for PacificSource, to a 26 percent increase for Montana Health CO-OP.Kaiser Family Foundation analyzed data on benchmark plan (second-lowest-cost Silver plan) premium changes from 2015 to 2016 in metropolitan areas across the country. In Boise, they found that the average benchmark plan for a 40-year-old non-smoker would be increasing from $210/month to $273/month – a 30 percent increase, which is three times the average they found nationwide.

But that’s before premium subsidies were applied. Most enrollees receive subsidies, and the subsidies change to keep pace with the cost of the benchmark plan.2017. Average increase of 24 percent, ranging from 15 percent for PacificSource, to 29 percent for SelectHealth.2018.

Average rate increase of 27 percent, but much of that was due to the termination of federal funding for cost-sharing reductions (CSR). The average approved rate increases for silver plans in Idaho (for on-exchange insurers) were much higher than the overall averages, at 44 percent (the average rate increase for bronze and gold plans was 11 percent and 9 percent, respectively).2019. Average increase of 5 percent, ranging from a 1 percent decrease for SelectHealth, to a 10 percent increase for Blue Cross of Idaho and PacificSource.

The cost of cost-sharing reductions continues to be added to silver plan rates in 2019.Although the federal government is no longer requiring meaningful differences in the plans that a carrier offers in the exchange, Idaho is continuing to require each insurer to have meaningful differences among their various plan offerings (this is detailed on page 15 of the state’s letter to issuers).2020. Overall, the average rate increase for 2020 was about 6 percent, versus the proposed overall average increase of 7 percent that insurers had initially proposed. Average rate changes ranged from a 1 percent increase for Regence (off-exchange only in 2020) to an 8 percent increase for SelectHealth.Medicaid expansion took effect in 2020.

More than 90,000 people covered by October 2020A significant change in Idaho for 2020 was the expansion of Medicaid under the terms of a ballot initiative that voters passed in the 2018 election. Medicaid expansion took effect in many states in 2014, and Idaho joined them as of 2020. Through 2019, premium subsidies were available through Your Health Idaho for people with income from 100 to 400 percent of the poverty level.

But as of 2020, people with income between 100 and 138 percent of the poverty level are instead eligible for expanded Medicaid.This has been a hotly contested point in Idaho. The state submitted a waiver proposal to the federal government, seeking permission to give these individuals a choice between Medicaid and subsidized plans in the exchange, but CMS rejected that proposal in August 2019. The agency indicated that the waiver proposal wasn’t complete, but that the concept wouldn’t be approvable even with revisions.

Governor Little and Idaho’s legislative leaders expressed surprise and disappointment that the waiver proposal was rejected, and said that they would continue to work towards federal approval for their “coverage choice” concept. [As described below, this is not the first time that CMS has rejected a proposal from Idaho.]However, the legislation that initiated the state’s efforts to modify the expansion of Medicaid (with the “coverage choice” proposal and a Medicaid work requirement that will also need federal approval) did clarify that full expansion would be implemented if the state was unable to obtain federal approval for a modified approach. So people with income between 100 and 138 percent of the poverty level became eligible for Medicaid as of January 2020, instead of premium subsidies in the exchange.Enrollment in expanded Medicaid in Idaho began November 1—the same day that open enrollment started for qualified health plans in the exchange—and coverage took effect starting January 1, 2020.

More than 90,000 people had enrolled as of October 2020.Your Health Idaho enrollment. 2014 – 2020Here’s a look at how enrollment in private individual market plans (during open enrollment) through Your Health Idaho has changed each year. Your Health Idaho’s enrollment reports (examples here and here) tend to have higher numbers than the CMS reports, because they include people who enrolled only in dental coverage, as well as those who signed up for medical plans (the CMS reports only count medical plans).Nationwide, enrollment in the exchanges peaked in 2016 and has declined since then, for a variety of reasons.

Some—like the Trump administration’s budget cuts for HealthCare.gov—don’t affect state-run exchanges like Your Health Idaho. But others, such as the elimination of the individual mandate penalty and the new federal rules that expand access to short-term health plans, have affected enrollment in Idaho. Premium increases have also played a role.

Although they’re mitigated by larger subsidies for people who are subsidy-eligible, people who don’t get premium subsidies must shoulder the full burden of rate hikes, and coverage has become unaffordable for some.And for 2020, it was expected that enrollment in private plans through the exchange would decline significantly as a result of Medicaid expansion. People with income between 100 and 138 percent of the poverty level are now eligible for Medicaid in Utah instead of premium subsidies in the exchange. The “enhanced” short-term health plans that became available in Idaho as of 2020 may have also contributed to the decline in exchange enrollment.Insurer participation.

2014 – 2021A new insurer was approved by the Idaho Department of Insurance for 2015. Mountain Health CO-OP, which is the Idaho branch of Montana Health CO-OP. The CO-OP joined Blue Cross of Idaho, BridgeSpan Health Company, PacificSource Health Plans, and SelectHealth, all of which returned to the exchange for 2015.The same five carriers offered coverage in 2016 and 2017.

But BridgeSpan exited the market at the end of 2017 (they initially planned to offer off-exchange plans in 2018, but ultimately left the individual market altogether), and SelectHealth reduced their coverage area for 2018.Compared with the rest of the country, however, Idaho remained among the states with the most robust exchanges in terms of insurer participation for 2018. Most counties in the state had four insurers offering plans in the exchange, and 12 counties had three. There were only a handful of other states where most counties had four or more insurers offering exchange plans for 2018.Your Health Idaho confirmed by email in December 2017 that while BridgeSpan enrollees and eastern Idaho enrollees with select Select Health plans were being mapped to comparable plans (assuming they didn’t pick their own new plan by December 15), there was no special enrollment period for BridgeSpan http://www.snackoverflow.uk/2019/01/sourdough-starter/ or SelectHealth members who had coverage through Your Health Idaho.The exchange noted that the comparable plans selected on behalf of these enrollees were the least expensive plan at the same metal level as the consumer’s 2017 plan, and that this was based on guidance from the Idaho Department of Insurance.

Enrollees with terminating BridgeSpan and Select Health coverage were notified of the impending plan cancellation and the plan that the exchange intended to map them to, and they were able to pick their own plan instead between November 1 and December 15. But there was not a special enrollment period for people who were mapped to a new plan by the exchange (this is in contrast to people in similar situations in states that use HealthCare.gov, where the special enrollment period is available, even after the exchange picks a replacement plan).Other than BridgeSpan’s exit, Idaho’s exchange has had very consistent insurer participation over the years. Blue Cross of Idaho, Mountain Health CO-OP, SelectHealth, and PacificSource all continued to offer plans in the exchange for 2019, and again in 2020.Starting in 2016, there were not any Platinum plans available in the Idaho exchange.

Only about 2 percent of Idaho exchange enrollees selected platinum plans in 2015, and the carriers opted not to offer those plans starting in 2016, as they aren’t required by the ACA and clearly were not a popular choice among enrollees.For 2021, Regence BlueShield of Idaho is joining the exchange, after previously offering off-exchange plans. So there are five on-exchange insurers as of 2021. Regence, Blue Cross of Idaho, Mountain Health CO-OP, PacificSource, and SelectHealth Idaho’s approach to the CSR funding uncertainty and eventual terminationThe Idaho Department of Insurance clarified that for 2018, “the proposed rate increases for silver-level plans on the exchange are significantly higher this year because cost-sharing reduction subsidies are assumed to not be funded by the federal government.” This assumption was correct, as the Trump Administration cut off CSR funding in October 2017, just before the start of open enrollment for 2018 coverage.According to the Idaho Department of Insurance, insurers didn’t have leeway to create new, similar-but-not-identical off-exchange plans at the silver level for 2018 (that’s the approach that California used).

Since on-exchange carriers that offer the same plan off-exchange are required to charge the same price on and off-exchange, the additional premium to cover the cost of CSRs was spread across the on and off-exchange silver plans in Idaho, unless the plan is offered only outside the exchange (this would be the case with all of Regence Blue Shield’s silver plans, since Regence doesn’t offer plans in the exchange).Instead, insurers in Idaho created new “extended bronze” plans, using the new de minimum range (-4/+5) that applies to bronze plan actuarial value starting in 2018 (this extended actuarial value range was part of the market stabilization rule that HHS finalized in April 2017). So insurers in Idaho began offering bronze plans with 65 percent actuarial value as of 2018. Compared with prior years’ actuarial value rules, this is in between a silver and a bronze plan, which have typically had actuarial values of roughly 70 and 60 percent, respectively.For silver plan enrollees in the exchange who are receiving premium subsidies, the additional CSR-related premium load on silver plans is covered or mostly covered by commensurately larger premiums subsidies.

And for enrollees in other metal levels who are receiving premium subsidies, net premiums are more affordable than they were in 2017, as the larger premium subsidies (to account for the CSR load on silver plans) can be applied to plans at other metal levels that don’t have the CSR load added to their pre-subsidy premiums.For non-silver plan enrollees who aren’t receiving premium subsidies, the cost of coverage has increased in line with normal annual rate increases, but the CSR load isn’t a factor, since it’s only being added to silver plans.For silver plan enrollees who aren’t receiving premiums subsidies, however, the full weight of the higher rates (driven in large part by the cost of CSR) began to apply in 2018. These enrollees could keep their silver plans, but many have found the new “extended bronze” plans, on or off-exchange, to be a better — and much less expensive — fit. Extended bronze plans continue to be an option in Idaho in 2019.Premium subsidies (which are different from cost-sharing reduction subsidies) are based on the cost of silver plans in the exchange.

So an approach like Idaho is taking (ie, applying the higher rates that come with a lack of CSR funding to silver on-exchange plans and the same silver plans offered off-exchange, rather than spreading them out across all plans) results in larger premium subsidies, as the subsidies grow to keep pace with the increasing silver plan premiums. Bronze and gold plans become an even better value for people who receive subsidies, as the larger subsidies are applicable to those plans too, despite the fact that the additional premiums to account for the lack of CSR funding is only added to silver plans.The subsidies are actually just tax credits, which means the Trump administration is taking from one hand to give to the other (ie, not funding CSRs, but having to pay out more in premium subsidies). The people who end up bearing the brunt of the rate increases are those who don’t qualify for premium subsidies.

That includes a few different categories of people. And as noted above, the people who bear the brunt of the additional premiums are only those who purchase silver plans (on-exchange, or the same qualified health plan sold off-exchange) and don’t receive premium subsidies.Idaho Insurance Director Dean Cameron has made it clear in past statements that he supports GOP efforts to repeal and replace the ACA. Cameron also supports a provision like the Cruz Amendment to the Better Care Reconciliation Act, which would have allowed non-ACA-compliant plans to be sold off-exchange.

These plans would certainly be less expensive, so if your only priority is lower premiums, this seems like a valid solution. But they would serve to destabilize the individual insurance market. Healthy people would opt for the less-robust plans (particularly if insurers were allowed to use medical underwriting to offer lower premiums to healthy people, as would have been the case under the Cruz Amendment), leaving sicker people on the ACA-compliant plans, which causes higher premiums, which drives more healthy people towards the non-compliant plans, and so on, until you end up with a death spiral.Cameron has also called for federal reinsurance, which is a valid solution.

The ACA included a reinsurance program, but it was temporary and only lasted through 2016. Reinstating it on a permanent basis would certainly serve to stabilize the insurance markets and minimize premium increases. As an alternative, several states have implemented their own reinsurance programs, although Idaho is not yet among them.

CMS rejected Idaho’s plan to allow insurers to sell state-based plans that aren’t compliant with the ACA, so Idaho has created “enhanced” short-term plans insteadSince President Trump took office, there has been considerable discussion about legislative and regulatory changes at the federal level that would allow individual and small group plans to be sold without complying with the full suite of ACA regulations. None of the legislative changes were enacted, although some of the regulatory changes were implemented (for example, expanded access to association health plans, and the relaxed rules for short-term health plans).States also have the option to submit 1332 waivers that (if approved) would allow them to get around some of the ACA’s requirements. But Idaho’s Department of Insurance opted to simply take the bull by the horns and issue a regulatory bulletin in 2018, outlining a new protocol for allowing insurers in Idaho to sell “state-based health benefit plans” that would avoid many of the ACA’s regulations.

The bulletin came three weeks after Governor Butch Otter issued an executive order calling on regulators to devise methods for “restoring choice in health insurance for Idahoans.University of Michigan law professor, Nicholas Bagley, called Idaho’s bulletin “crazypants illegal” and health policy experts expressed varying degrees of skepticism over the chances that the state’s new regulations would stand up to legal scrutiny. In March, after weeks of speculation over whether the federal government would step in to uphold federal law in Idaho, CMS sent a letter to Governor Otter and Idaho Insurance Commissioner, Dean Cameron, explaining that the “state-based” plans would run afoul of the ACA, and if Idaho were to proceed with implementing them, CMS would have to step in and enforce the ACA on behalf of the state. But CMS went out of their way to clarify that they don’t think the ACA is serving the people of Idaho well, and that they appreciate the state’s efforts to essentially circumvent the law.

Idaho’s “state-based” plans were simply too much a stretch.CMS clarified that if Idaho failed to enforce the ACA and CMS had to begin enforcing the law instead, the agency would issue cease and desist letters to any insurer offering “state-based” plans in Idaho (Blue Cross of Idaho had previously stated their intent to begin offering “state-based” plans under the terms of Idaho’s regulatory bulletin). If the insurer continued to offer the plans, it would be subject to financial penalties of up to $100 per day, per individual enrolled in the non-compliant plans.But CMS went on to state that the agency believes that “with certain modifications,” Idaho’s “state-based” plans could instead be offered as short-term plans, which are exempt from the ACA’s regulations. The federal government has since finalized new regulations that allow for much longer short-term plans, unless a state imposes its own restrictions.

Idaho allows short-term plans to have initial terms of up to a year, and although the state previously banned renewal of short-term plans, legislation was enacted in Idaho in 2019 to allow for “enhanced” short-term plans, which will be renewable if the policyholder chooses that option.Blue Cross of Idaho is the first insurer to create “enhanced” short-term plans (although SelectHealth appears poised to do so as well). The BCBSID Access Plans will be available for purchase as of December 2019. According to the plan filings for the new Access Plans (SERFF filing number BCOI-132140320), the policies will be guaranteed-issue, but with premiums based on medical history.

They’ll be renewable for up to 36 months of coverage, and although they’ll have a 12-month waiting period for pre-existing condition coverage, the waiting period can be reduced or eliminated if you had creditable prior coverage (this is how pre-existing condition waiting periods worked on employer-sponsored plans before the ACA eliminated them altogether). The new Access Plans have some features that resemble ACA-compliant plans, such as premiums only being charged for up to three children under the age of 21 on a family’s plan, and free preventive care. And they cover maternity care, mental health care, and prescription drugs, all of which are benefits that are often excluded on traditional short-term plans.

But the Access Plans have out-of-pocket caps that can be as high as $50,000, and as mentioned above, they also base premiums on medical history, which isn’t allowed on ACA-compliant plans. What was Idaho proposing?. At Health Affairs, Katie Keith has an excellent overview of what Idaho’s bulletin would have allowed and the implications of what would have happened if insurers had started offering these “state-based” plans.

In summary, the bulletin includes the following regulations:An insurer would only be allowed to offer a state-based plan in a given area if the insurer also offers at least one ACA-compliant plan in that area.Enrollment would be available year-round (ie, no open enrollment period).Coverage in state-based plans would be guaranteed-issue (ie, applications could not be rejected based on medical history), but applicants could be charged higher premiums (up to 50 percent above the plan index rate) based on their medical history.Pre-existing conditions could be subject to a waiting period before coverage applies, but that waiting period would be waived if the consumer had proof of continuous prior coverage.Most of the ACA’s essential health benefits would have to be offered, but there are some exceptions. Pediatric dental and pediatric vision coverage would not be required, and insurers would be able to offer state-based plans without maternity coverage as long as they offer at least one state-based plan with maternity coverage (and at least one ACA-compliant plan with maternity coverage, since that’s a requirement for insurers to be able to participate in the state-based coverage program). Blue Cross of Idaho has proposed five state-based plans—one of them does not include maternity coverage, and none of them include pediatric dental or vision coverage.Out-of-pocket costs would still have to be capped, but notably, insurers would be able to apply separate out-of-pocket maximums for various services, such as prescriptions versus other medical care.State-based plans could impose benefit caps of $1 million or more, but would have to assist consumers in switching seamlessly to their ACA-compliant plans if the consumer were to reach the state-based plan’s benefit cap.Insurers could use a 5:1 age rating ratio for state-based plans, as opposed to the ACA’s 3:1 age rating ratio.

Under the ACA, older applicants cannot be charged more than three times as much as younger applicants, but Idaho’s bulletin would allow insurers to offer state-based plans with premiums for older applicants that are up to five times as much as the premiums for younger applicants.Insurers would be required to place the state-based and ACA-compliant plans into a single risk pool, but Kaiser Family Foundation’s Larry Levitt notes that may be hard to enforce, especially given that the state-based plans would not participate in the ACA’s risk adjustment program.Clearly, some of those provisions would align well with the concept of short-term plans, which is the option CMS encouraged Idaho to pursue in order to implement their proposal within the parameters of the ACA (since the ACA doesn’t apply to short-term plans).In February, before CMS rejected Idaho’s proposal, Blue Cross of Idaho submitted five state-based plans to the Department of Insurance for review. The proposed BC of Idaho plans would have had $1 million annual benefit caps, would not have covered pediatric dental or vision, and one of the plans would not have included maternity coverage.The plans would have had premiums that would have varied considerably depending on medical history. The Wall Street Journal reported that a healthy 45-year-old would pay about $194.67 a month in premiums, but a 45-year-old with a poorer medical history might be charged as much as $525.69/month in premiums (no premium subsidies would be available).

For comparison, an ACA-compliant bronze plan from Blue Cross of Idaho would have pre-subsidy premiums of about $343.09/month for a 45-year-old, and those premiums don’t vary based on medical history (under the ACA, healthy people pay the same rates as sick people). For people who buy the ACA-compliant plans via Your Health Idaho, and who are eligible for premium subsidies, the subsidies offset a significant portion of the premium costs.The state-based plans would no doubt have appealed to younger, healthier applicants, particularly those who don’t qualify for premium subsidies in the exchange (most exchange enrollees do qualify for premium subsidies, but everyone who buys individual market coverage off-exchange is paying full price, with no available subsidies). A healthy person would be drawn to the cheaper premiums, while a person with medical conditions will be better off keeping their ACA-compliant plan.

This, in turn, would leave the ACA-compliant market with sicker, older enrollees, and higher premiums.Under Idaho’s new rules, an insurer’s state-based and ACA-compliant risk pools would have to have been merged, but it’s unclear how well that provision would have been enforced. But since the state would have required insurers to offer ACA-compliant plans in order to offer state-based plans, and since premium subsidies via Your Health Idaho continue to be available (and grow to keep pace with premiums), the ACA-compliant market would have continued to exist alongside the “state-based” plans, albeit likely with fewer enrollees than it has to today. Assuming the people who would have remained in the ACA-compliant market are primarily those who are older, sicker, and/or receiving premium subsidies, the total federal outlay for premium subsidies would likely have grown, placing an additional burden on taxpayers.Consumers who purchase state-based plans would ostensibly have been somewhat protected by the provision that requires insurers to transfer members to one of the insurer’s ACA-compliant plans if the member hits the state-based plan’s benefit cap.

But rescission could have become a major issue in scenarios in which members do hit the benefit cap. Since these plans would have been medically underwritten, a person who ended up hitting the benefit cap (ie, a million dollars worth of claims during the year) could have been subject to significant post-claims underwriting.Basically, the insurer would have been able to go back through the person’s medical records with a fine-toothed comb, checking to make sure that the person had been 100 percent honest when completing the initial medical underwriting questions. If the insurer found anything that the person hadn’t disclosed on the application, they would have potentially been able to rescind the policy for fraud or misrepresentation (this is still allowed under the ACA, but is much less of an issue on plans that don’t ask enrollees about their medical history).

At that point, not only would the person retroactively lose their coverage, they also wouldn’t be eligible to switch to an ACA-compliant plan until the next open enrollment period.It’s also unclear whether the out-of-pocket costs that the consumer had already paid would have been counted towards the ACA-compliant plan’s out-of-pocket exposure, or if the consumer would have been starting from zero mid-year in that scenario, assuming they were indeed able to transition to an ACA-compliant plan.And it’s also important to note that consumers who select a state-based plan and then find out that it doesn’t cover as much as they thought it did would not have been able to switch to an ACA-compliant plan until open enrollment, unless they have a qualifying event. For example, the consumer might not notice that a particular state-based plan doesn’t cover maternity, especially since people have become accustomed to the concept of all plans covering maternity. In that case, she might only find out about the lack of maternity coverage if and when she becomes pregnant, and she would not be able to switch to an ACA-compliant plan until open enrollment.This is an issue with short-term plans as well.

A person who enrolls in a short-term plan and subsequently finds out that it doesn’t cover his or her medical needs cannot switch to an ACA-compliant plan until the next open enrollment. And since short-term plans are not considered minimum essential coverage, the termination of a short-term plan does not count as a qualifying event to trigger a special enrollment period for ACA-compliant plans.Cameron and Otter expressed optimism in the face of the letter from CMS, noting that “we consider the letter an invitation from CMS to continue discussing the specifics of what can and cannot be included in state-based plans. We will consider all possible options and then continue discussions with CMS and HHS on how best to achieve our shared goals of reducing the costs of coverage and stabilizing our health insurance market.” As noted above, the state has largely shifted focus to enhanced short-term plans, but Cameron noted in late 2019 that Idaho “still may pursue the state-based plans.”Assessment fee increased to 1.99% — still far lower than Healthcare.gov feeYour Health Idaho was previously funded with a 1.5 percent assessment fee on all health insurance plans sold through the exchange (unlike many other states, the fee is not collected for plans sold outside the exchange).

The fee increased to 1.99 percent in 2016, which is still considerably lower than the 3.5 percent assessment that Healthcare.gov collects in states that use the federally-facilitated marketplace (HealthCare.gov’s fee is dropping to 3 percent as of 2020).The exchange does not receive any state funding, and had spent most of their initial federal start-up funding by 2016. The exchange must be self-sustaining going forward, which is why the assessment was increased.A Leavitt Partners study found Your Health Idaho to be an excellent example of an exchange that is operating well on a much smaller-than-average budget. Your Health Idaho mostly uses in-house support for its systems, and only contracts with vendors for highly specialized services, like marketing.

Many other state-run exchanges contract with vendors for much of their day-to-day operations, while Your Health Idaho staff handles most of the day-to-day operations of the exchange. This is part of the reason they’re able to operate at a lower cost than the rest of the state-run exchanges.But at the same time, Your Health Idaho has limited itself to only essential functions. The exchange leaves plan oversight and rate review entirely to the Idaho Department of Insurance, and the Idaho Department of Health and Welfare does all of the subsidy and Medicaid eligibility determination for exchange enrollees.

The exchange does not have to spend time or money being involved in these processes, or creating systems that would essentially duplicate the functionality of the DOI or DHW.SHOP exchange – direct enrollmentAs part of their cost-saving plan, Your Health Idaho opted not to build a SHOP (small business) exchange enrollment platform, and instead relies on direct enrollment through health insurance carriers (with agents and brokers providing enrollment assistance) when businesses want to enroll in SHOP plans.Your Health Idaho has a paper application that small businesses can complete, with contact information that the exchange can use to get in touch with the business and help them move forward with the enrollment process. But in general, Your Health Idaho recommends that small businesses reach out to a broker or agent for assistance with SHOP enrollment.This approach saves the exchange from having to administer and fund a SHOP platform, and in hindsight, is probably a wise decision—SHOP enrollments nationwide have been relatively lackluster, and Idaho’s decision means that the exchange is not having to fund and maintain a low-use enrollment platform.History of Idaho’s marketplace developmentRepublican Gov. Butch Otter announced in December 2012 that Idaho would implement a state-run health insurance exchange, and HHS gave conditional approval of the state’s plan in early January 2013.The state-run option was resisted by both the governor and many Republican legislators.

Like those in other “red” states, Idaho leaders hoped the U.S. Supreme Court would find the Affordable Care Act (ACA) unconstitutional. However, after the Court upheld most elements of the ACA and a state task force in October 2012 strongly recommended a state-run exchange, Otter began leaning toward that option as preferable to a federally run exchange.After Otter’s announcement in December 2012, legislators began considering legislation, and both chambers passed bills authorizing a state-run in exchange in the first quarter of 2013.

However, that left scant time to set up the exchange. Idaho used the federal site for the first open enrollment period, but transitioned to its state-run platform in time for the 2015 open enrollment period.In December 2015, a Leavitt Partners study called Your Health Idaho a “model for state based adoption [of an exchange]” and noted that the exchange has a budget well below average, a “lean organizational structure” and “strong financial controls.” The Leavitt study also indicates that Your Health Idaho benefited from the fact that they used Healthcare.gov during the first open enrollment, and waited until the second open enrollment period to debut their own enrollment platform. That allowed them to obtain lower-cost, better-developed software solutions, with the benefit of hindsight in terms of seeing what worked and what didn’t for the other state-run exchanges during year one.Idaho is the only state that opted to build its own marketplace, but rejected Medicaid expansion.

Medicaid is being expanded as of 2020, however, thanks to a voter-backed ballot initiative that passed in 2018.Idaho health insurance exchange linksYour Health Idaho855-YHIdaho (855-944-3246)State Exchange Profile. IdahoThe Henry J. Kaiser Family Foundation overview of Idaho’s progress toward creating a state health insurance exchange.Idaho Department of InsuranceAnswers questions about insurance bought on the individual market and insurance provided by an employer who only does business in Idaho.(208) 334-4250 / toll-free (800) 721-3272Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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"In corporate America, many, many companies have done full purchase levitra canada greenhouse gas inventories and set ambitious goals—that's not the case with this sector."Much of the problem has involved a lack of progress in addressing the single largest contributor to healthcare-related greenhouse gas emissions. The supply purchase levitra canada chain. Studies estimate more than 80% of greenhouse gas emissions came from sources like hospital waste disposal services, food and pharmaceutical production, and medical device and equipment makers.Those healthcare-related greenhouse gases are categorized as "Scope 3" emissions, which encompass sources not directly owned or controlled by hospitals and health systems.Download Modern Healthcare’s app to stay informed when industry news breaks.Some healthcare providers have launched initiatives focused on reducing Scope 3 emissions as part of their broader goal of becoming "carbon neutral" over the next few years. Providers set goals to limit business travel and employee commutes well prior purchase levitra canada to the levitra, and have reduced emissions from their food service and waste disposal operations. Kaiser Permanente employed similar strategies as part of their process to become the first health system in the country to achieve carbon neutral status in September purchase levitra canada 2020.But the conversation among climate advocates has shifted away from carbon neutrality in the years since health systems began committing to that goal.

Many advocates believe health systems need a more ambitious purchase levitra canada target of achieving "net zero" status."Carbon neutrality is a bit outdated because it permits overreliance on carbon offsets," said Dr. Jodi Sherman, founding director of the healthcare environmental sustainability program at the Yale School of Public Health's Center for Climate and Health. "We need to mitigate everything within our direct influence before purchasing offsets, and we can't ignore these [Scope 3] emissions."Both "carbon neutral" and "net zero" refer to entities that offset purchase levitra canada the amount of greenhouse gases they add to the atmosphere by removing an equal amount of emissions. But carbon neutrality sets purchase levitra canada a lower bar. Healthcare providers can focus largely on reducing their direct emissions and fossil fuel-based energy consumption while investing in non-related, "carbon offset" programs that reduce greenhouse emissions elsewhere as a means of reaching carbon neutrality.But net zero goes further because it encompasses reducing and eliminating all direct and indirect carbon emissions related to the operation of that healthcare organization, independent of carbon offsets."That's the next phase because it really points to a faster pace of decarbonization across all scopes," Wolff said.Going for 'zero'Calls have grown louder for healthcare stakeholders to be more proactive in addressing purchase levitra canada the greenhouse gases and pollutants emitted from their supply chains.

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Because of the switch, Providence hospitals in Oregon have reduced the amount of greenhouse emissions coming from the use of surgical anesthesia by 70%.Looking ahead, Santore said the health system has made environmental sustainability an integral part of its commitments to improve purchase levitra canada supplier diversity. In June, Providence announced plans to purchase $1 billion from women- and minority-owned businesses over the purchase levitra canada next five years. The health system has been collecting data on all of its current vendors to evaluate who and where it is buying its goods and have put in place an environmentally preferable purchasing program where sustainability expectations are built into contracts with vendors."We have tremendous leverage purchase levitra canada and a tremendous opportunity and responsibility to shape the Scope 3 emissions around the supply chain," said Santore, who estimated Providence's total annual supply chain budget was between $4 billion and $5 billion.Providence's plan is a first because of the health system's commitment to reach its emission-reduction goals without the use of carbon offsets, she said."We could become carbon negative tomorrow with the wholesale purchase of offsets, but we want to do this the right way," Santore said. "We have committed to doing the work."Other health systems have also sought to use their buying power to improve environmental sustainability within their supply chains.Mass General Brigham in Boston has set a goal of becoming carbon neutral from direct emissions by 2025 and has reduced its emissions by 78% compared to 2008 levels.But the health system has also been active in addressing supply chain issues. In 2016, Mass General Brigham along with nine other major health systems formed Greenhealth Exchange, a purchasing collaborative aimed at sourcing from suppliers of sustainable products.The exchange is planning on rolling out a new program, Greenhealth Approved, to purchase levitra canada evaluate products and certify green products."In this way we hope to make it easier for healthcare supply chain managers, and indeed supply chain managers in other market sectors, to select high quality environmentally responsible product," said Dennis Villanueva, senior manager of energy and sustainability, real estate and facilities for Mass General Brigham.Healthcare as a whole needs to make a more concerted effort in addressing Scope 3 emissions, according to Yale's Sherman.

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Providers set goals to limit business travel and employee commutes well prior levitra online shop to the levitra, and have reduced emissions from their food service and waste disposal operations. Kaiser Permanente employed similar strategies as part of their process to become the first health system in the country to levitra online shop achieve carbon neutral status in September 2020.But the conversation among climate advocates has shifted away from carbon neutrality in the years since health systems began committing to that goal. Many advocates believe health systems need a more ambitious target of achieving "net zero" status."Carbon neutrality is a bit outdated because it permits overreliance on levitra online shop carbon offsets," said Dr. Jodi Sherman, founding director of the healthcare environmental sustainability program at the Yale School of Public Health's Center for Climate and Health.

"We need to mitigate everything within our direct influence before purchasing offsets, and we levitra online shop can't ignore these [Scope 3] emissions."Both "carbon neutral" and "net zero" refer to entities that offset the amount of greenhouse gases they add to the atmosphere by removing an equal amount of emissions. But carbon neutrality sets a lower levitra online shop bar. Healthcare providers can focus largely on reducing their direct emissions and fossil fuel-based energy consumption while investing in non-related, "carbon offset" programs that reduce greenhouse emissions elsewhere as levitra online shop a means of reaching carbon neutrality.But net zero goes further because it encompasses reducing and eliminating all direct and indirect carbon emissions related to the operation of that healthcare organization, independent of carbon offsets."That's the next phase because it really points to a faster pace of decarbonization across all scopes," Wolff said.Going for 'zero'Calls have grown louder for healthcare stakeholders to be more proactive in addressing the greenhouse gases and pollutants emitted from their supply chains. In an opinion article published in the New England Journal of Medicine on Oct.

13, a group levitra online shop of authors that included National Academy of Medicine President Dr. Victor Dzau wrote that tackling carbon emissions that come from the healthcare supply chain was,"...central to decarbonizing the sector."Wolff said Health Care Without Harm has partnered with several providers over the past year to conduct Scope 3 assessments and identify certain emission "hot spots" within the supply chain.Kaiser Chair and CEO Greg Adams said he saw tackling the carbon intensity of the supply chain and other indirect emissions created through the integrated health system's business activities as its next big environmental levitra online shop sustainability goal."We have already undertaken a robust inventory of those indirect emissions and are exploring the next avenues for addressing the inseparable issues of climate change and health," Adams said.Renton, Wash.-based Providence is working with its vendors to reduce carbon emissions from its purchased goods and services. It's is a vital factor in the health-system's overall goal to become carbon negative levitra online shop by 2030, according to Alison Santore, chief advocacy and sustainability officer.She estimated greenhouse gases emanated from their supply chain accounted for nearly 40% of Providence's total carbon emission output.Providence hopes to reduce emissions from transportation by 40% by 2028 and cut its total waste to landfill or incineration by half by 2030. At Providence Portland Medical Center, clinicians began in 2019 replacing anesthetic gases containing the agent desflurane, which once released can last up to 14 years in the atmosphere, with sevoflurane, which has 20 times less impact on the climate and lasts up to one year in the atmosphere.

Because of the switch, Providence hospitals in Oregon have reduced the amount of greenhouse emissions coming from the use of surgical levitra online shop anesthesia by 70%.Looking ahead, Santore said the health system has made environmental sustainability an integral part of its commitments to improve supplier diversity. In June, levitra online shop Providence announced plans to purchase $1 billion from women- and minority-owned businesses over the next five years. The health system has been collecting data on all of its current vendors to evaluate who and where it is buying its goods and have put in place an environmentally preferable purchasing program where sustainability expectations are built into contracts with vendors."We have tremendous leverage and a tremendous opportunity and responsibility to shape the Scope 3 emissions around the supply chain," said Santore, who estimated Providence's total annual supply chain budget was between $4 billion and $5 levitra online shop billion.Providence's plan is a first because of the health system's commitment to reach its emission-reduction goals without the use of carbon offsets, she said."We could become carbon negative tomorrow with the wholesale purchase of offsets, but we want to do this the right way," Santore said. "We have committed to doing the work."Other health systems have also sought to use their buying power to improve environmental sustainability within their supply chains.Mass General Brigham in Boston has set a goal of becoming carbon neutral from direct emissions by 2025 and has reduced its emissions by 78% compared to 2008 levels.But the health system has also been active in addressing supply chain issues.

In 2016, Mass General Brigham along with nine other major health systems formed Greenhealth Exchange, a purchasing collaborative aimed at sourcing from suppliers of sustainable products.The exchange is planning on rolling out a new program, Greenhealth Approved, to evaluate products and certify green products."In this way we hope to make it easier for healthcare supply chain managers, and indeed supply chain managers in other levitra online shop market sectors, to select high quality environmentally responsible product," said Dennis Villanueva, senior manager of energy and sustainability, real estate and facilities for Mass General Brigham.Healthcare as a whole needs to make a more concerted effort in addressing Scope 3 emissions, according to Yale's Sherman. The lack levitra online shop of progress is largely stemming from an overreliance on individual providers' voluntary actions. That could change if regulators require healthcare organizations to report and mitigate their emission reduction efforts."This is very serious business—we have to do it and we have to do it quickly," Sherman said..

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acid Antibacterials for systemic use 1 Apixaban Antithrombotic agents 3 Apremilast Immunosuppressants 8 Argatroban Antithrombotic agents 1 Atorvastatin Lipid modifying agents 1 Atorvastatin calcium Lipid modifying agents 1 Atovaquone Antiprotozoals 1 Azacitidine Antineoplastic agents 4 Bendamustine hydrochloride Antineoplastic agents 2 Betahistine hydrochloride Other nervous system drugs 1 Betamethasone dipropionate, calcipotriol monohydrate Antipsoriatics 1 Bisoprolol fumarate Beta blocking agents 1 Bivalirudin Antithrombotic agents 1 Bosentan Antihypertensives 1 Brimonidine tartrate Ophthalmologicals 1 Buprenorphine hydrochloride, naloxone hydrochloride dihydrate Other nervous system drugs 1 Buspirone hydrochloride Psycholeptics 1 Busulfan Antineoplastic agents 2 Calcium polystyrene sulphonate All other therapeutic products 1 Canagliflozin Drugs used in diabetes 2 Carbidopa, entacapone, levodopa Anti-parkinson drugs 1 Carboprost tromethamine Other gynecologicals 1 Caspofungin acetate 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hydrochloride, timolol maleate Ophthalmologicals 1 Doxepin hydrochloride Psychoanaleptics 2 Doxycycline Antibacterials for systemic use 1 Efavrienz, emtricitabine, tenofovir disoproxil fumarate Antivirals for systemic use 1 Efinaconazole Antifungals for dermatological use 7 Eombopag olamine Antihemorrhagics 1 Emtricitabine, tenofovir disoproxil fumarate Antivirals for systemic use 1 Enzalutamide Endocrine therapy 2 Ethinyl estradiol, etonogestrel Other gynecologicals 1 Ethinyl estradiol, levonorgestrel Sex hormones and modulators of the genital system 1 Felodipine Calcium channel blockers 1 Fesoterodine fumarate Urologicals 1 Fingolimod hydrochloride Immunosuppressants 1 Fludrocortisone 21-acetate Corticosteroids for systemic use 1 Fluoxetine hydrochloride Psychoanaleptics 2 Fulvestrant Endocrine therapy 2 Furosemide Diuretics 3 Fusidic acid Antibiotics and chemotherapy for dermatological use 1 Gefitinib Antineoplastic agents 1 Glatiramer acetate Immunostimulants 1 Glycopyrrolate Drugs for functional gastrointestinal disorders 1 Guanfacine hydrochloride Antihypertensives 1 Hydralazine hydrochloride Antihypertensives 1 Hydrochlorothiazide, olmesartan medoxomil Agents acting on the renin-angiotensin system 1 Hydromorphone hydrochloride Analgesics 1 Hydroxychloroquine sulfate Antiprotozoals 1 Ibrutinib Antineoplastic agents 1 Icatibant acetate Other hematological agents 3 Irinotecan hydrochloride trihydrate Antineoplastic agents 1 Ketorolac tromethamine Antiinflammatory and antirheumatic products 3 Labetalol hydrochloride Beta blocking agents 1 Lenalidomide Immunosuppressants 6 Lenalidomide hydrochloride Immunosuppressants 1 Lidocaine hydrochloride Cardiac therapy 1 Linagliptin Drugs used in diabetes 2 Linezolid Antibacterials for systemic use 1 Lurasidone hydrochloride Psycholeptics 6 Macitentan Antihypertensives 3 Medroxyprogesterone acetate Sex hormones and modulators of the genital system 1 Melphalan hydrochloride Antineoplastic agents 1 Metformin hydrochloride 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Paliperidone Psycholeptics 1 Paliperidone palmitate Psycholeptics 2 Pantoprazole sodium sesquihydrate Drugs for acid related disorders 1 Pemetrexed disodium hemipentahydrate Antineoplastic agents 1 Pentamidine isetionate Antiprotozoals 1 Perampanel Antiepileptics 1 Perindopril erbumine Agents acting on the renin-angiotensin system 1 Pirfenidone Immunosuppressants 5 Plerixafor Immunostimulants 1 Pomalidomide Immunosuppressants 6 Quinapril hydrochloride Agents acting on the renin-angiotensin system 1 Ritonavir Antivirals for systemic use 1 Rivaroxaban Antithrombotic agents 7 Rocuronium bromide Muscle relaxants 1 Rosuvastatin calcium Lipid modifying agents 1 Sapropterin dihydrochloride Other alimentary tract and metabolism products 1 Silodosin Urologicals 1 Sitagliptin Drugs used in diabetes 1 Sitagliptin hydrochloride monohydrate Drugs used in diabetes 1 Sitagliptin malate Drugs used in diabetes 2 Sitagliptin phosphate Drugs used in diabetes 2 Sitagliptin phosphate monohydrate Drugs used in diabetes 1 Spironolactone Diuretics 1 Sulfamethoxazole, trimethoprim Antibacterials for systemic use 1 Sumatriptan succinate Analgesics 3 Sunitinib Antineoplastic agents 2 Sunitinib malate Antineoplastic agents 2 Tacrolimus Immunosuppressants 2 Tadalafil Urologicals 2 Tamsulosin hydrochloride Urologicals 1 Temozolomide Antineoplastic agents 1 Teriflunomide Immunosuppressants 10 Thiotepa Antineoplastic agents 1 Ticagrelor Antithrombotic agents 3 Timolol maleate Ophthalmologicals 1 Tofacitinib Immunosuppressants 1 Tofacitinib citrate Immunosuppressants 3 Tolvaptan Diuretics 1 Trabectedin Antineoplastic agents 1 Tramadol hydrochloride Analgesics 1 Treprostinil Antithrombotic agents 2 Tretinoin Antineoplastic agents 1 Valproic acid Antineoplastic agents 1 Vancomycin hydrochloride Antidiarrheals, intestinal anti-inflammatory/anti-infective agents 1 Varenicline tartrate Other nervous system drugs 2.

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The "Read me" file contains the data structure required to download the zipped files.The NOC extract files have been updated. They contain Health Canada authorization dates for all drugs dating back to 1994 that levitra online shop have received an NOC. All NOCs issued between 1991 and 1993 can be found in the NOC listings.Please note any Portable Document Format (PDF) files visible on the NOC database are not part of the data extracts.For more information, please go to the Read Me File.Data Extracts - Last updated.

2021-05-28 CopyrightFor information on copyright and who to contact, please visit the Notice of Compliance Online Database Terms and Conditions.Abacavir sulfate, dolutegravir sodium, lamivudine Antivirals for systemic use 1 Abiraterone acetate Endocrine therapy 3 Acetaminophen Analgesics 1 Acetylcysteine Cough and cold preparations 1 Acyclovir Antivirals for systemic use 1 Afatinib Antineoplastic agents 1 Afatinib dimaleate Antineoplastic agents 3 Alendronic acid, vitamin D3 Drugs for treatment of bone diseases 1 Allopurinol Antigout preparations 1 Amikacin sulfate Antibacterials for systemic use 1 Amiodarone hydrochloride Cardiac therapy 1 Amlodipine besylate Calcium channel blockers 1 Amoxicillin trihydrate, clavulanic acid Antibacterials for systemic use 1 Apixaban Antithrombotic agents 3 Apremilast Immunosuppressants 8 Argatroban Antithrombotic agents 1 Atorvastatin Lipid modifying agents 1 Atorvastatin calcium Lipid modifying agents 1 Atovaquone Antiprotozoals 1 Azacitidine Antineoplastic agents 4 Bendamustine hydrochloride Antineoplastic agents 2 Betahistine hydrochloride Other nervous system drugs 1 Betamethasone dipropionate, calcipotriol monohydrate Antipsoriatics 1 Bisoprolol fumarate Beta blocking agents 1 Bivalirudin Antithrombotic agents 1 Bosentan Antihypertensives 1 Brimonidine tartrate Ophthalmologicals 1 Buprenorphine hydrochloride, naloxone hydrochloride dihydrate Other nervous system drugs 1 Buspirone hydrochloride Psycholeptics 1 Busulfan Antineoplastic agents 2 Calcium polystyrene sulphonate All other therapeutic products 1 Canagliflozin Drugs used in diabetes 2 Carbidopa, entacapone, levodopa Anti-parkinson drugs 1 Carboprost tromethamine Other gynecologicals 1 Caspofungin acetate Antimycotics for systemic use 1 Cephalexin monohydrate Antibacterials for systemic use 1 Cetirizine hydrochloride Antihistamines for systemic use 1 Clobetasol propionate Corticosteroids, dermatological preparations 1 Clonidine hydrochloride Antihypertensives 2 Cyclosporine Ophthalmologicals 1 Dantrolene sodium Muscle relaxants 1 Dapagliflozin Drugs used in diabetes 4 Daptomycin Antibacterials for systemic use 1 Darifenacin hydrobromide Urologicals 1 Darunavir ethanolate Antivirals for systemic use 1 Dasatinib Antineoplastic agents 1 Deferasirox All other therapeutic products 4 Degarelix acetate Endocrine therapy 1 Desvenlafaxine succinate Psychoanaleptics 1 Dimethyl fumarate Immunosuppressants 9 Dipyridamole Antithrombotic agents 1 Divalproex sodium Antiepileptics 1 Docetaxel Antineoplastic agents 2 Dolutegravir Antivirals for systemic use 1 Domperidone Drugs for functional gastrointestinal disorders 1 Domperidone maleate Drugs for functional gastrointestinal disorders 1 Dorzolamide hydrochloride, timolol maleate Ophthalmologicals 1 Doxepin hydrochloride Psychoanaleptics 2 Doxycycline Antibacterials for systemic use 1 Efavrienz, emtricitabine, tenofovir disoproxil fumarate Antivirals for systemic use 1 Efinaconazole Antifungals for dermatological use 7 Eombopag olamine Antihemorrhagics 1 Emtricitabine, tenofovir disoproxil fumarate Antivirals for systemic use 1 Enzalutamide Endocrine therapy 2 Ethinyl estradiol, etonogestrel Other gynecologicals 1 Ethinyl estradiol, levonorgestrel Sex hormones and modulators of the genital system 1 Felodipine Calcium channel blockers 1 Fesoterodine fumarate Urologicals 1 Fingolimod hydrochloride Immunosuppressants 1 Fludrocortisone 21-acetate Corticosteroids for systemic use 1 Fluoxetine hydrochloride Psychoanaleptics 2 Fulvestrant Endocrine therapy 2 Furosemide Diuretics 3 Fusidic acid Antibiotics and chemotherapy for dermatological use 1 Gefitinib Antineoplastic agents 1 Glatiramer acetate Immunostimulants 1 Glycopyrrolate Drugs for functional gastrointestinal disorders 1 Guanfacine hydrochloride Antihypertensives 1 Hydralazine hydrochloride Antihypertensives 1 Hydrochlorothiazide, olmesartan medoxomil Agents acting on the renin-angiotensin system 1 Hydromorphone hydrochloride Analgesics 1 Hydroxychloroquine sulfate Antiprotozoals 1 Ibrutinib Antineoplastic agents 1 Icatibant acetate Other hematological agents 3 Irinotecan hydrochloride trihydrate Antineoplastic agents 1 Ketorolac tromethamine Antiinflammatory and antirheumatic products 3 Labetalol hydrochloride Beta blocking agents 1 Lenalidomide Immunosuppressants 6 Lenalidomide hydrochloride Immunosuppressants 1 Lidocaine hydrochloride Cardiac therapy 1 Linagliptin Drugs used in diabetes 2 Linezolid Antibacterials for systemic use 1 Lurasidone hydrochloride Psycholeptics 6 Macitentan Antihypertensives 3 Medroxyprogesterone acetate Sex hormones and modulators of the genital system 1 Melphalan hydrochloride Antineoplastic agents 1 Metformin hydrochloride Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin malate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin phosphate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin phosphate monohydrate Drugs used in diabetes 3 Methotrexate sodium Antineoplastic agents 1 Methylprednisolone acetate Corticosteroids for systemic use 1 Metoclopramide hydrochloride Drugs for functional gastrointestinal disorders 1 Micafungin sodium Antimycotics for systemic use 2 Midodrine hydrochloride Cardiac therapy 1 Milrinone Cardiac therapy 1 Mitomycin Antineoplastic agents 1 Naloxone hydrochloride All other therapeutic products 2 Naexone hydrochloride Other nervous system drugs 1 Nebivolol hydrochloride Beta blocking agents 1 Olmesartan medoxomil Agents acting on the renin-angiotensin system 1 Ondansetron hydrochloride dihydrate Antiemetics and antinauseants 1 Oseltamivir phosphate Antivirals for systemic use 1 Paliperidone Psycholeptics 1 Paliperidone palmitate Psycholeptics 2 Pantoprazole sodium sesquihydrate Drugs for acid related disorders 1 Pemetrexed disodium hemipentahydrate Antineoplastic agents 1 Pentamidine isetionate Antiprotozoals 1 Perampanel Antiepileptics 1 Perindopril erbumine Agents acting on the renin-angiotensin system 1 Pirfenidone Immunosuppressants 5 Plerixafor Immunostimulants 1 Pomalidomide Immunosuppressants 6 Quinapril hydrochloride Agents acting on the renin-angiotensin system 1 Ritonavir Antivirals for systemic use 1 Rivaroxaban Antithrombotic agents 7 Rocuronium bromide Muscle relaxants 1 Rosuvastatin calcium Lipid modifying agents 1 Sapropterin dihydrochloride Other alimentary tract and metabolism products 1 Silodosin Urologicals 1 Sitagliptin Drugs used in diabetes 1 Sitagliptin hydrochloride monohydrate Drugs used in diabetes 1 Sitagliptin malate Drugs used in diabetes 2 Sitagliptin phosphate Drugs used in diabetes 2 Sitagliptin phosphate monohydrate Drugs used in diabetes 1 Spironolactone Diuretics 1 Sulfamethoxazole, trimethoprim Antibacterials for systemic use 1 Sumatriptan succinate Analgesics 3 Sunitinib Antineoplastic agents 2 Sunitinib malate Antineoplastic agents 2 Tacrolimus Immunosuppressants 2 Tadalafil Urologicals 2 Tamsulosin hydrochloride Urologicals 1 Temozolomide Antineoplastic agents 1 Teriflunomide Immunosuppressants 10 Thiotepa Antineoplastic agents 1 Ticagrelor Antithrombotic agents 3 Timolol maleate Ophthalmologicals 1 Tofacitinib Immunosuppressants 1 Tofacitinib citrate Immunosuppressants 3 Tolvaptan Diuretics 1 Trabectedin Antineoplastic agents 1 Tramadol hydrochloride Analgesics 1 Treprostinil Antithrombotic agents 2 Tretinoin Antineoplastic agents 1 Valproic acid Antineoplastic agents 1 Vancomycin hydrochloride Antidiarrheals, intestinal anti-inflammatory/anti-infective agents 1 Varenicline tartrate Other nervous system drugs 2.

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