Renova zero cost

At this point in http://www.typo3support.com/renova-zero-pod-price/ the renova, your days might feel as though they’re getting longer and more renova zero cost repetitive. You might also find yourself having problems focusing. But instead of endlessly renova zero cost staring at your screen, you might want to try giving up and getting up — at least for a short while.Taking a break to exercise has been consistently shown to have benefits on cognition.

That’s according to Charles Hillman, the co-director of the Center for Cognitive and Brain Health at Northeastern University in Boston. Hillman has been studying the relationship between exercise and cognition for decades renova zero cost and has generally found that making time for a 20-minute brisk walk can improve work performance and brain function.Take a WalkHillman and his colleagues have tested the mental effects of walking on children and young adults at their lab. Generally, they measure the effects of a single dose of exercise (which they’ve defined as a 20-minute walk) on both cognitive test performance and changes to the neural electrical system in the brain.

Based on which regions of the brain light up after exercise, they can draw some associations between renova zero cost exercise and different aspects of brain function — including allocation of attention, processing speed, working memory, and the ability to multitask.Overall, they’ve found that the effects of walking on cognitive function last around an hour. But Hillman noted that the lab has not yet tested multiple bouts of exercise throughout the day. But note that you probably don’t need to schedule multiple, 20-minute walks renova zero cost to reach peak productivity.

Smaller changes can have other impacts as well.How this plays out in real-world situations is more difficult to test. Several studies on how exercise impacts student performance in the classroom have not shown significant improvements renova zero cost. But exercise doesn’t seem to have negative impacts on academic achievement, either.Standing TimeAmong adults, simply standing while working might be a good thing.

In one recent study, renova zero cost researchers measured how standing desks affected productivity and health for employees in an office setting. Washington State University ergonomics researchers Jia-Hua Lin and Stephen Bao examined how different sitting and standing work schedules affected employees’ productivity at a call center. To do this, renova zero cost they randomly assigned four days of different sit-stand schedules, and they looked at the length of time spent on calls and filling out forms.

Lin cautioned that the study was too small to provide statistically significant results, but they did see a trend in which employees that spent more time standing were able to wrap up phone calls more quickly.Overall, Lin noticed that the point of the study was to show that standing wouldn’t make productivity worse, as employers might use that as an excuse to not purchase standing desks. In addition to renova zero cost boosting productivity, the study found that standing desks made employees feel better physically. Employees with the longest standing schedule had less swollen feet and better posture at the end of the day.Lin worries that people working from home might not have access to ergonomically correct chairs and standing desks.“In the workplace, the employer can provide this kind of help, but for people working from home, we cannot send experts to individual houses to set things up,” Lin says.Working from home, however, might allow some people to take more breaks to get up and move.

This could offset some of the downsides of less-than-ideal working conditions renova zero cost. In Lin’s research, employees that took breaks in the workday — whether to go on a walk or engage in another type of downtime — had better physiological measures at the end of the day, as well as less foot swelling and better posture.So, if you’re slumped over your makeshift bedroom desk, the best thing you can do for productivity and mood is to get up and go for a walk..

Renova topical

As skin care continues its global spread, it’s possible that one of the pillars of skin care products renova control — universal facial masking — might help reduce the severity of disease and renova topical ensure that a greater proportion of new s are asymptomatic. If this hypothesis is borne out, universal masking could become a form of “variolation” that would generate immunity and thereby slow the spread of the renova in the United States and elsewhere, as we await a treatment.One important reason for population-wide facial masking became apparent in March, when reports started to circulate describing the high rates of skin care viral shedding from the noses and mouths of patients who were presymptomatic or asymptomatic — shedding rates equivalent to those among symptomatic patients.1 Universal facial masking seemed to be a possible way to prevent transmission from asymptomatic infected people. The Centers for Disease Control and Prevention (CDC) therefore recommended on April 3 that the public wear cloth face coverings in areas with high rates of community transmission — a recommendation that has been unevenly followed across the United States.Past evidence related to other respiratory renovaes indicates that facial masking can also protect the wearer from becoming infected, by blocking viral particles from entering the nose and mouth.2 Epidemiologic investigations conducted around the world — especially in Asian countries that became accustomed to population-wide masking during the 2003 SARS renova — have suggested that there is a strong relationship between public masking and renova topical renova control. Recent data from Boston demonstrate that skin care s decreased among health care workers after universal masking was implemented in municipal hospitals in late March.skin care has the protean ability to cause myriad clinical manifestations, ranging from a complete lack of symptoms to pneumonia, acute respiratory distress syndrome, and death.

Recent virologic, epidemiologic, and ecologic renova topical data have led to the hypothesis that facial masking may also reduce the severity of disease among people who do become infected.3 This possibility is consistent with a long-standing theory of viral pathogenesis, which holds that the severity of disease is proportionate to the viral inoculum received. Since 1938, researchers have explored, primarily in animal models, the concept of the lethal dose of a renova — or the dose at which 50% of exposed hosts die (LD50). With viral s in which host immune renova topical responses play a predominant role in viral pathogenesis, such as skin care, high doses of viral inoculum can overwhelm and dysregulate innate immune defenses, increasing the severity of disease. Indeed, down-regulating immunopathology is one mechanism by which dexamethasone improves outcomes in severe skin care products .

As proof renova topical of concept of viral inocula influencing disease manifestations, higher doses of administered renova led to more severe manifestations of skin care products in a Syrian hamster model of skin care .4If the viral inoculum matters in determining the severity of skin care , an additional hypothesized reason for wearing facial masks would be to reduce the viral inoculum to which the wearer is exposed and the subsequent clinical impact of the disease. Since masks can filter out some renova-containing droplets (with filtering capacity determined by mask type),2 masking might reduce the inoculum that an exposed person inhales. If this renova topical theory bears out, population-wide masking, with any type of mask that increases acceptability and adherence,2 might contribute to increasing the proportion of skin care s that are asymptomatic. The typical rate of asymptomatic with skin care was estimated to be 40% by the CDC in mid-July, but asymptomatic rates are reported to be higher than 80% in settings with universal facial masking, which provides observational evidence for this hypothesis.

Countries that have adopted population-wide masking have fared better in terms of rates of severe skin care products-related illnesses and death, which, in environments with limited renova topical testing, suggests a shift from symptomatic to asymptomatic s. Another experiment in the Syrian hamster model simulated surgical masking of the animals and showed that with simulated masking, hamsters were less likely to get infected, and if they did get infected, they either were asymptomatic or had milder symptoms than unmasked hamsters.The most obvious way to spare society the devastating effects of skin care products is to promote measures to reduce both transmission and severity of illness. But skin care is highly transmissible, renova topical cannot be contained by syndromic-based surveillance alone,1 and is proving difficult to eradicate, even in regions that implemented strict initial control measures. Efforts to increase testing and containment in the United States have been ongoing and variably successful, owing in part to the recent increase in demand for testing.The hopes for treatments are pinned not just on prevention.

Most treatment renova topical trials include a secondary outcome of decreasing the severity of illness, since increasing the proportion of cases in which disease is mild or asymptomatic would be a public health victory. Universal masking seems to reduce the rate of new s. We hypothesize that by reducing the viral inoculum, it would also increase the proportion of renova topical infected people who remain asymptomatic.3In an outbreak on a closed Argentinian cruise ship, for example, where passengers were provided with surgical masks and staff with N95 masks, the rate of asymptomatic was 81% (as compared with 20% in earlier cruise ship outbreaks without universal masking). In two recent outbreaks in U.S.

Food-processing plants, where all workers were issued masks each day and were required to wear them, the proportion of asymptomatic s among the more than 500 people who became infected was 95%, with only 5% in each outbreak experiencing mild-to-moderate symptoms.3 Case-fatality rates in countries with mandatory or enforced population-wide masking have remained low, even with resurgences of cases after lockdowns were lifted.Variolation was a process whereby people who were susceptible renova topical to smallpox were inoculated with material taken from a vesicle of a person with smallpox, with the intent of causing a mild and subsequent immunity. Variolation was practiced only until the introduction of the variola treatment, which ultimately eradicated smallpox. Despite concerns regarding safety, worldwide distribution, and eventual uptake, the world has high hopes for a highly effective skin care treatment, and as of early September, 34 treatment candidates were in clinical evaluation, with hundreds more in development.While we await the results of treatment trials, however, any public health measure that could increase the proportion of asymptomatic skin care s may both make the less deadly and renova topical increase population-wide immunity without severe illnesses and deaths. Re with skin care seems to be rare, despite more than 8 months of circulation worldwide and as suggested by a macaque model.

The scientific community has been clarifying for some time the humoral and cell-mediated components of the adaptive immune response to skin care and the inadequacy of antibody-based seroprevalence studies to estimate the level of more durable T-cell and memory B-cell immunity renova topical to skin care. Promising data have been emerging in recent weeks suggesting that strong cell-mediated immunity results from even mild or asymptomatic skin care ,5 so any public health strategy that could reduce the severity of disease should increase population-wide immunity as well.To test our hypothesis that population-wide masking is one of those strategies, we need further studies comparing the rate of asymptomatic in areas with and areas without universal masking. To test the variolation hypothesis, we will need more studies comparing the strength and durability of skin care–specific T-cell immunity between people with asymptomatic and those with symptomatic , as well as a demonstration of the natural slowing of skin care spread in areas with a high proportion of asymptomatic s.Ultimately, combating the renova will involve driving renova topical down both transmission rates and severity of disease. Increasing evidence suggests that population-wide facial masking might benefit both components of the response..

As skin care continues its global spread, it’s possible that one of the pillars of skin care products renova control — universal renova zero cost facial masking — might help reduce the severity of disease and ensure that a greater proportion of new s are asymptomatic. If this hypothesis is borne out, universal masking could become a form of “variolation” that would generate immunity and thereby slow the spread of the renova in the United States and elsewhere, as we await a treatment.One important reason for population-wide facial masking became apparent in March, when reports started to circulate describing the high rates of skin care viral shedding from the noses and mouths of patients who were presymptomatic or asymptomatic — shedding rates equivalent to those among symptomatic patients.1 Universal facial masking seemed to be a possible way to prevent transmission from asymptomatic infected people. The Centers for Disease Control and Prevention (CDC) therefore recommended on April 3 that the public wear cloth face coverings renova zero cost in areas with high rates of community transmission — a recommendation that has been unevenly followed across the United States.Past evidence related to other respiratory renovaes indicates that facial masking can also protect the wearer from becoming infected, by blocking viral particles from entering the nose and mouth.2 Epidemiologic investigations conducted around the world — especially in Asian countries that became accustomed to population-wide masking during the 2003 SARS renova — have suggested that there is a strong relationship between public masking and renova control. Recent data from Boston demonstrate that skin care s decreased among health care workers after universal masking was implemented in municipal hospitals in late March.skin care has the protean ability to cause myriad clinical manifestations, ranging from a complete lack of symptoms to pneumonia, acute respiratory distress syndrome, and death.

Recent virologic, renova zero cost epidemiologic, and ecologic data have led to the hypothesis that facial masking may also reduce the severity of disease among people who do become infected.3 This possibility is consistent with a long-standing theory of viral pathogenesis, which holds that the severity of disease is proportionate to the viral inoculum received. Since 1938, researchers have explored, primarily in animal models, the concept of the lethal dose of a renova — or the dose at which 50% of exposed hosts die (LD50). With viral s in which host immune responses play a predominant role in viral renova zero cost pathogenesis, such as skin care, high doses of viral inoculum can overwhelm and dysregulate innate immune defenses, increasing the severity of disease. Indeed, down-regulating immunopathology is one mechanism by which dexamethasone improves outcomes in severe skin care products .

As proof of concept of viral inocula influencing disease manifestations, higher doses of administered renova led to more severe manifestations of skin care products in a Syrian hamster model of skin care .4If the viral inoculum matters in determining the severity of skin care , an additional hypothesized reason for wearing facial masks would be to reduce the viral inoculum to which the wearer is renova zero cost exposed and the subsequent clinical impact of the disease. Since masks can filter out some renova-containing droplets (with filtering capacity determined by mask type),2 masking might reduce the inoculum that an exposed person inhales. If this theory bears out, population-wide masking, with any type renova zero cost of mask that increases acceptability and adherence,2 might contribute to increasing the proportion of skin care s that are asymptomatic. The typical rate of asymptomatic with skin care was estimated to be 40% by the CDC in mid-July, but asymptomatic rates are reported to be higher than 80% in settings with universal facial masking, which provides observational evidence for this hypothesis.

Countries that have adopted population-wide masking have fared better in terms of rates of severe skin care products-related illnesses and death, which, in renova zero cost environments with limited testing, suggests a shift from symptomatic to asymptomatic s. Another experiment in the Syrian hamster model simulated surgical masking of the animals and showed that with simulated masking, hamsters were less likely to get infected, and if they did get infected, they either were asymptomatic or had milder symptoms than unmasked hamsters.The most obvious way to spare society the devastating effects of skin care products is to promote measures to reduce both transmission and severity of illness. But skin care is highly transmissible, cannot be contained by syndromic-based surveillance alone,1 and is proving difficult renova zero cost to eradicate, even in regions that implemented strict initial control measures. Efforts to increase testing and containment in the United States have been ongoing and variably successful, owing in part to the recent increase in demand for testing.The hopes for treatments are pinned not just on prevention.

Most treatment trials include a secondary outcome of decreasing the severity of illness, since increasing the proportion of cases in which disease is mild or asymptomatic would be a renova zero cost public health victory. Universal masking seems to reduce the rate of new s. We hypothesize that by reducing the viral inoculum, it would also increase the proportion of infected people who remain asymptomatic.3In an outbreak on a closed Argentinian cruise ship, for example, where passengers were provided with surgical masks and renova zero cost staff with N95 masks, the rate of asymptomatic was 81% (as compared with 20% in earlier cruise ship outbreaks without universal masking). In two recent outbreaks in U.S.

Food-processing plants, where all workers were issued masks each day and were required to wear them, the proportion of asymptomatic s among the more renova zero cost than 500 people who became infected was 95%, with only 5% in each outbreak experiencing mild-to-moderate symptoms.3 Case-fatality rates in countries with mandatory or enforced population-wide masking have remained low, even with resurgences of cases after lockdowns were lifted.Variolation was a process whereby people who were susceptible to smallpox were inoculated with material taken from a vesicle of a person with smallpox, with the intent of causing a mild and subsequent immunity. Variolation was practiced only until the introduction of the variola treatment, which ultimately eradicated smallpox. Despite concerns regarding safety, worldwide distribution, and eventual uptake, the world has high hopes for a highly effective skin care treatment, and as of early September, 34 treatment candidates were in clinical evaluation, with hundreds more in development.While we await the results of treatment trials, however, any public health measure that renova zero cost could increase the proportion of asymptomatic skin care s may both make the less deadly and increase population-wide immunity without severe illnesses and deaths. Re with skin care seems to be rare, despite more than 8 months of circulation worldwide and as suggested by a macaque model.

The scientific community has been clarifying for some time the humoral and cell-mediated components of the adaptive immune response to skin care and the inadequacy of antibody-based seroprevalence studies to estimate the level of more durable T-cell and memory renova zero cost B-cell immunity to skin care. Promising data have been emerging in recent weeks suggesting that strong cell-mediated immunity results from even mild or asymptomatic skin care ,5 so any public health strategy that could reduce the severity of disease should increase population-wide immunity as well.To test our hypothesis that population-wide masking is one of those strategies, we need further studies comparing the rate of asymptomatic in areas with and areas without universal masking. To test the variolation hypothesis, we will need more studies comparing the strength and durability of skin care–specific T-cell immunity between people with asymptomatic and those with symptomatic , as well as a demonstration of the natural slowing of skin care spread in areas with a high proportion of asymptomatic s.Ultimately, combating the renova will involve driving down both transmission renova zero cost rates and severity of disease. Increasing evidence suggests that population-wide facial masking might benefit both components of the response..

What side effects may I notice from Renova?

Side effects that you should report to your doctor or health care professional as soon as possible:

• darkening or lightening of the treated areas
• severe burning, itching, crusting, or swelling of the treated areas

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

• increased sensitivity to the sun
• itching
• mild stinging
• red, inflamed, and irritated skin, the skin may peel after a few days

This list may not describe all possible side effects.

Refissa vs renova

2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A. Summary Chart of MSP Programs 2.

Income Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?.

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

Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare What is Application Process?. 6.

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

Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?.

YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &. B deductibles &.

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

(No retro for January application). See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?.

YES YES NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down.

2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL).

2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below. NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented.

During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.

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

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

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

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

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

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

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

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

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

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

(Link is to NYC HRA form, can be adapted for other counties). 3. The Three Medicare Savings Programs - what are they and how are they different?.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D.

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

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

Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too.

One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person.

Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare.

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

NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district.

See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare.

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

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

EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability).

Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund.

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

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

Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are.

· Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center).

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

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

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

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

SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!.

!. !. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS).

​Can the MSP be retroactive like Medicaid, back to 3 months before the application?. ​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application.

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

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

However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid.

Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules.

This article was authored by the Empire Justice Center.THE PROBLEM. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations.

Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay.

Read below to find out -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider.

Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance.

Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them.

These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections.

Download the 2020 Medicare Handbook here. See pp. 53, 86.

1. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs).

The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?.

If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining.

42 U.S.C. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan.

3. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016.

In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans.

The answer also differs based on the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down.

Payments are reduced if the beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200).

See more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr.

John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down.

In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature.

Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage. If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20.

If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected.

hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is.

This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd.

1(d)(iv), added 2016. EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate.

ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules. The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120.

Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50.

The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37.

Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget.

. 4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?.

No. Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C.

§ 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider.

If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments.

This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing.

Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals.

See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB.

It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information.

By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services.

CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed.

Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid.

The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card dos not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits.

Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly.

6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer.

See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters.

Include a link to the CMS Medicare Learning Network Notice.

Those in QMB receive renova zero cost additional subsidies for Medicare costs. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y.

§ 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A.

Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3.

The Three MSP Programs - What are they and how are they Different?. 4. FOUR Special Benefits of MSP Programs.

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

6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1.

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

SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &.

B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application.

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

Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid.

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

The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below. NOTE.

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

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

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

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

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

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

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

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

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

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

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

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

In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). 3.

The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB).

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

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

2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only.

SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1).

For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year.

(GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both.

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

Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments.

Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit.

People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients.

The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application.

The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2.

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

Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life..

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

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

In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs.

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

Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections.

Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?. And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification.

Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification.

Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar.

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

Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below.

Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP.

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

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

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

Since MSP applications take a while, at least the filing date will be retroactive. Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application.

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

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

8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04.

Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address. See the application form for other instructions.

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

Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan.

GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability.

Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare.

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

For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit.

Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down. If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare.

This is called Continuous Eligibility. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016.

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

He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan.

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

19). Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply.

The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium.

See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013.

In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements.

SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period.

(The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid.

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

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

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

No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing.

QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid.

Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance.

Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.THE PROBLEM. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB).

His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay.

Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations.

First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service.

However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries.

Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights.

The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here. See pp.

53, 86. 1. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?.

"Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2.

How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care).

Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid.

The provider must include the amount it received from Medicare Advantage plan. 3. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?.

The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further.

The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay.

Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met.

For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020.

For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible.

If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below.

This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage. If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service.

For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate.

ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd.

1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them.

SSL 367-a, subd. 1(d)(iv), added 2016. EXCEPTIONS.

The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules. The Medicare rate for Mary's specialist visit is $185.

The Medicaid rate for the same service is $120. Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan).

Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients.

Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate.

The proposal to eliminate this exception was rejected by the legislature in 2019 budget. . 4.

May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997.

42 U.S.C. § 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance.

This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing.

The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.

QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018.

CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?.

It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer.

See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN.

The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here.

They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability.

These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017).

QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card dos not indicate QMB eligibility.

Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney.

The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer.

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Justice, one of the four Beauchamp and Childress prima facie renova ms basic principles of biomedical buy generic renova ethics, is explored in two excellent papers in the current issue of the journal. The papers stem from a British Medical Association (BMA) essay competition on justice and fairness in medical practice and policy. Although the competition was open to (almost) all comers, of the renova ms 235 entries both the winning paper by Alistair Wardrope1 and the highly commended runner-up by Zoe Fritz and Caitríona Cox2 were written by practising doctors—a welcome indication of the growing importance being accorded to philosophical reflection about medical practice and practices within medicine itself. Both papers are thoroughly thought provoking and represent two very different approaches to the topic. Each deserves a careful read.The competition was a component of a BMA 2019/2020 ‘Presidential project’ on fairness and justice and asked candidates to ‘use ethical reasoning and theory to tackle challenging, practical, contemporary, problems in health care and help provide a solution based on an explained and defended sense of fairness/justice’.In this guest editorial I’d like to explain why, in 2018 on becoming president-elect of the BMA, I chose the theme of justice and fairness in medical ethics for my 2019–2020 Presidential project—and why in a world of massive and ever-increasing and remediable health inequalities biomedical ethics requires greater international and interdisciplinary efforts to try to reach agreement on the need to achieve greater ‘health justice’ and to reach agreement on what that commitment actually means and on what in practice it requires.First, some background.

As president I was offered the wonderful opportunity to pursue, renova ms with the organisation’s formidable assistance, a ‘project’ consistent with the BMA’s interests and values. As a hybrid of general medical practitioner and philosopher/medical ethicist, and as a firm defender of the Beauchamp and Childress four principles approach to medical ethics,3 I chose to try to raise the ethical profile of justice and fairness within medical ethics.My first objective was to ask the BMA to ask the World Medical Association (WMA) to add an explicit commitment ‘to strive to practise fairly and justly throughout my professional life’ to its contemporary version of the Hippocratic Oath—the Declaration of Geneva4—and to the companion document the International Code of Medical Ethics.5 The stimulus for this proposal was the WMA’s addition in 2017 of the principle of respect for patients’ autonomy. Important as that addition is, it is widely perceived (though in my own view mistakenly) as being too much renova ms focused on individual patients and not enough on communities, groups and populations. The simple addition of a commitment to fairness and justice would provide a ‘balancing’ moral commitment.Adding the fourth principleIt would also explicitly add the fourth of those four prima facie moral commitments, increasingly widely accepted by doctors internationally. Two of them—benefiting our patients (beneficence) and doing so with as little harm as possible (non-maleficence)—have been an integral part of medical ethics since Hippocratic times.

Respect for autonomy and justice are very much renova ms more recent additions to medical ethics. The WMA, having added respect for autonomy to the Declaration of Geneva, should, I proposed, complete the quartet by adding the ‘balancing’ principle of fairness and justice.Since the Declaration is unlikely to be revised for several years, it seems likely that the proposal to add to it an explicit commitment to practise fairly and justly will have to wait. However, an explicit commitment to justice and fairness has, at the BMA’s request, been added to the draft of the International Code of Medical Ethics and it seems reasonable to hope and expect that it will remain in the final document.Adding a commitment to fairness and justice renova ms is the easy part!. Few doctors would on reflection deny that they ought to try to practise fairly and justly. It is far more difficult to say what is actually meant by this.

Two additional components of my Presidential project—the essay competition and a conference (which with luck will have been held, virtually, shortly before publication of this editorial)—sought to help elucidate just what is meant by practising fairly and justly.One of the most striking features of the essay competition was the readiness of many writers to point to injustices in the context of medical practice and policy and describe ways of remedying them, but without giving a specific account of justice and fairness on the basis of which the diagnosis of injustice was made and the remedy offered.Wardrope’s winning essay comes close to such an approach by challenging the implied premise that an account of justice and fairness must provide some such formal theory renova ms. In preference, he points to the evident injustice and unsustainability of humans’ degradation of ‘the Land’ and its atmosphere and its inhabitants and then challenges some assumptions of contemporary philosophy and ethics, especially what he sees as their anthropocentric and individualistic focus. Instead, he invokes Leopold Aldo’s ‘Land Ethic’ (as well as drawing in aid renova ms Isabelle Stenger’s focus on ‘the intrusion of Gaia’). In his thoughtful and challenging paper, he seeks to refocus our ethics—including our medical ethics and our sense of justice and fairness—on mankind’s exploitative threat, during this contemporary ‘anthropocene’ stage of evolution, to the continuing existence of humans and of all forms of life in our ‘biotic community’. As remedy, the author, allying his approach to those of contemporary virtue ethics, recommends the beneficial outcomes that would be brought about by a sense of fairness and justice—a developed and sensitive ‘ecological conscience’ as he calls it—that embraces the interests of the entire biotic community of which we humans are but a part.Fritz and Cox pursue a very different and philosophically more conventional approach to the essay competition’s question and offer a combination and development of two established philosophical theories, those of John Rawls and Thomas Scanlon, to provide a philosophically robust and practically beneficial methodology for justice and fairness in medical practice and policy.

Briefly summarised, they recommend a renova ms two-stage approach for healthcare justice. First, those faced with a problem of fairness or justice in healthcare or policy should use Thomas Scanlon’s proposed contractualist approach whereby reasonable people seek solutions that they and others could not ‘reasonably reject’. This stage would involve committees of decision-makers and representatives of relevant stakeholders looking at the immediate and longer term impact on existing stakeholders of proposed solutions. They would renova ms then check those solutions against substantive criteria of justice derived from Rawls’ theory (which, via his theoretical device of the ‘veil of ignorance’, Rawls and the authors argue that all reasonable people can be expected to accept!. ).

The Rawlsian criteria relied on by renova ms Fritz and Cox are equity of access to healthcare. The ‘difference principle’ whereby avoidable inequalities of primary goods can only be justified if they benefit the most disadvantaged. The just savings principle, of particular importance for ensuring intergenerational justice and sustainability. And a criterion of increased openness, transparency and accountability.It would of course be naïve to expect a single universalisable solution to the question ‘what do we mean renova ms by fairness and justice in health care?. €™ As the papers by Wardrope1 and Fritz and Cox2 demonstrate, there can be very wide differences of approach in well-defended accounts.

My own renova ms hope for my project is to emphasise the importance first of committing ourselves within medicine to practising fairly and justly in whatever branch we practise. And then to think carefully about what we do mean by that and act accordingly.Following AristotleFor my own part, over 40 years of looking, I have not yet found a single substantive theory of justice that is plausibly universalisable and have had to content myself with Aristotle’s formal, almost content-free but probably universalisable theory, according to which equals should be treated equally and unequals unequally in proportion to the relevant inequalities—what some health economists refer to as horizontal and vertical justice or equity.6Beauchamp and Childress in their recent eighth and ‘perhaps final’ edition of their foundational ‘Principles of biomedical ethics’1 acknowledge that ‘[t]he construction of a unified theory of justice that captures our diverse conceptions and principles of justice in biomedical ethics continues to be controversial and difficult to pin down’.They still cite Aristotle’s formal principle (though with less explanation than in their first edition back in 1979) and they still believe that this formal principle requires substantive or ‘material’ content if it is to be useful in practice. They then describe six different theories of justice—four ‘traditional’ (utilitarian, libertarian, communitarian and egalitarian) and two newer theories, which they suggest may be more helpful in the context of health justice, one based on capabilities and the other on actual well-being.They again end their discussion of justice with their reminder that ‘Policies of just access to health care, strategies of efficiencies in health care institutions, and global needs for the reduction of health-impairing conditions dwarf in social importance every other issue considered in this book’ ……. €˜every society must ration its resources but many societies can close renova ms gaps in fair rationing more conscientiously than they have to date’ [emphasis added]. And they go on to stress their own support for ‘recognition of global rights to health and enforceable rights to health care in nation-states’.For my own part I recommend, perhaps less ambitiously, that across the globe we extract from Aristotle’s formal theory of justice a starting point that ethically requires us to focus on equality and always to treat others as equals and treat them equally unless there are moral justifications for not doing so.

Where such justifications exist we should say what they are, explain the moral assumptions that justify them and, to the extent possible, seek the agreement of those affected.IntroductionIt did not occur to the Governor that there might be more than one definition of what is good … It did not occur renova ms to him that while the courts were writing one definition of goodness in the law books, fires were writing quite another one on the face of the land. (Leopold, ‘Good Oak’1, pp 10–11)As I wrote the abstract that would become this essay, wildfires were spreading across Australia’s east coast. By the time I was invited to write the essay, back-to-back winter storms were flooding communities all around my home. The essay renova ms has been written in moments of respite between shifts during the skin care products renova. Every one of these events was described as ‘unprecedented’.

Yet each is becoming increasingly likely, and that due to our interactions with our environment.Public discourse surrounding these events is dominated by questions of justice and fairness. How to balance competing renova ms imperatives of protecting individual lives against risk of spreading contagion. How best to allocate scarce resources like intensive care beds or mechanical ventilators. The conceptual tools of clinical ethics are renova ms well tailored to these sorts of questions. The rights of the individual versus the community, issues of distributive justice—these are familiar to anyone with even a passing acquaintance with its canonical debates.What biomedical ethics has remained largely silent on is how we have been left to confront these decisions.

How human activity has eroded Earth’s life support systems to make the ‘unprecedented’ the new normal. A medical ethic fit renova ms for the Anthropocene—our (still tentative) geological epoch defined by human influence on natural systems—must be able not just to react to the consequences of our exploitation of the natural world, but reimagine our relationship with it.Those reimaginations already exist, if we know where to look for them. The ‘Land Ethic’ of the US conservationist Aldo Leopold offers one such vision.i Developed over decades of experience working in and teaching land management, the Land Ethic is most famously formulated in an essay of the same name published shortly before Leopold’s death fighting a wildfire on a neighbour’s farm. It begins renova ms with a reinterpretation of the ethical relationship between humanity and the ‘land community’, the ecosystems we live within and depend upon. Moving us from ‘conqueror’ to ‘plain member and citizen’ of that community1 (p 204).

Land ceases to be a resource to be exploited for human need once we view ourselves as part of, and only existing within, the land community. Our moral evaluations shift consonantly:A thing is right when it tends to preserve the integrity, renova ms stability, and beauty of the biotic community. It is wrong when it tends otherwise.1 (pp 224–225)The justice of the Land Ethic questions many presuppositions of biomedical ethics. By valuing the community in itself—in a way irreducible to the welfare of its members—it steps away from the individualism axiomatic in contemporary bioethics.2 Viewing ourselves as citizens of the land community also extends the moral horizons of healthcare from a renova ms solely human focus, taking seriously the interests of the non-human members of that community. Taking into account the ‘stability’ of the community requires intergenerational justice—that we consider those affected by our actions now, and their implications for future generations.3 The resulting vision of justice in healthcare—one that takes climate and environmental justice seriously—could offer health workers an ethic fit for the future, demonstrating ways in which practice must change to do justice to patients, public and planet—now and in years to come.Healthcare in the AnthropoceneSeemeth it a small thing unto you to have fed upon good pasture, but ye must tread down with your feet the residue of your pasture?.

And to have drunk of the clear waters, but ye must foul the residue with your feet?. (Ezekiel 34:18, quoted in Leopold, ‘Conservation in the Southwest’4, p 94)The majority of the development of human societies worldwide—including all of recorded human history—has taken place within a single geological epoch, a roughly 11 600 renova ms yearlong period of relative warmth and climatic stability known as the Holocene. That stability, however, can no longer be taken for granted. The epoch that has sustained most of human development is giving way to one shaped by the planetary consequences of that development—the Anthropocene.The Anthropocene is marked by accelerating degradation of the ecosystems that have sustained human societies. Human activity is already estimated to have raised global temperatures 1°C above preindustrial levels, and if emissions continue at current levels we are likely to reach 1.5°C between 2030 and 2052.5 The global rate of species extinction is orders of magnitude higher than the average over the past 10 million years.6 Ocean acidification, deforestation and disruption of nitrogen and phosphorus flows renova ms are likely at or beyond sustainable planetary boundaries.7Yet this period has also seen rapid (if uneven) improvements in human health, with improved life expectancy, falling child mortality and falling numbers of people living in extreme poverty.

The 2015 report of the Rockefeller Foundation-Lancet Commission on planetary health explained this dissonance in stark terms. €˜we have been mortgaging the health of future generations to realise economic and development gains in renova ms the present.’7In the instrumental rationality of modernity, nature has featured only as inexhaustible resource and infinite sink to fuel social and economic ends. But this disenchanted worldview can no longer hide from the implausibility of these assumptions. It cannot resist what the philosopher Isabelle Stengers has called ‘the intrusion of Gaia’.8 The present renova—made more likely by deforestation, land use change and biodiversity loss9—is just the most immediately salient of these intrusions. Anthropogenic environmental changes are increasing undernutrition, increasing range and transmissibility of many vectorborne and waterborne diseases like dengue fever and cholera, increasing frequency and renova ms severity of extreme weather events like heatwaves and wildfires, and driving population exposure to air pollution—which already accounts for over 7 million deaths annually.10These intrusions will shape healthcare in the Anthropocene.

This is because health workers will have to deal with their consequences, and because modern industrialised healthcare as practised in most high-income countries—and considered aspirational elsewhere—was borne of the same worldview that has mortgaged the health of future generations. The health sector in the USA is estimated to account for 8% of the country’s greenhouse gas footprint.11 Pharmaceutical production renova ms and waste causes more local environmental degradation, accumulating in water supplies with damaging effects for local flora and fauna.12 Public health has similarly embraced short-term gains with neglect of long-term consequences. Health messaging was instrumental to the development and popularisation of many disposable and single-use products, while a 1947 report funded by the Rockefeller Foundation (who would later fund the landmark 2015 Lancet report on planetary health) popularised the high-meat, high-dairy ‘American’ diet—dependent on fossil fuel-driven intensive agricultural practices—as the healthy ideal.13Healthcare fit for the Anthropocene requires a shift in perspectives that allows us to see and work with the intrusion of Gaia. But can dominant approaches in bioethics incorporate that shift?. A perfect moral stormWe have built a beautiful piece of social machinery … which is coughing along on two cylinders because we have been too timid, and too anxious for quick success, to tell the farmer the true magnitude of his obligations renova ms.

(Leopold, ‘The Ecological Conscience’4, p 341)At local, national and international scales, the lifestyles of the wealthiest pose an existential threat to the poorest and most marginalised in society. Our actions now are renova ms depriving future generations of the environmental prerequisites of good health and social flourishing. If justice means, as Ranaan Gillon parses it, ‘the moral obligation to act on the basis of fair adjudication between competing claims’,14 then this state of affairs certainly seems unjust. However, the tools available for grappling with questions of justice in bioethics seem ill equipped to deal with these sorts of injustice.To illustrate this problem, consider how Gillon further fleshes out his description of justice. In terms of fair distribution of scarce resources, respect for people’s renova ms rights, and respect for morally acceptable laws.

The first of these—labelled distributive justice—concerns how fairly to allot finite resources among potential beneficiaries. Classic problems of distributive justice in healthcare concern a group of people at a particular time (usually patients), who could each benefit from a particular resource (historically, discussions have often focused on transplant organs. More recently, renova ms intensive care beds and ventilators have come to the fore). But there are fewer of these resources than there are people with a need for them. Such discussions are not easy, but they are at least familiar—we know where to renova ms begin with them.

We can consider each party’s need, their potential to benefit from the resource, any special rights or other claims they may have to it, and so forth. The distribution of benefits and harms in the Anthropocene, however, does not comfortably fit this formalism. It is one thing to say that there is but one intensive care bed, from which Smith has a good chance of gaining another year of life, Jones a renova ms poor chance, and so offer it to Smith. Another entirely to say that production of the materials consumed in Smith’s care has contributed to the degradation of scarce water supplies on the other side of the globe, or that the unsustainable pattern of energy use will affect innumerable other future persons in poorly quantifiable ways through fuelling climate change. The calculations of distributive justice are well suited to problems renova ms where there are a set pool of potential beneficiaries, and the use of the scarce resources available affects only those within that pool.

But global environmental problems do not fit this pattern—the effects of our actions are spatially and temporally dispersed, so that large numbers of present and future people are affected in different ways.Nor can this problem be readily addressed by turning to Gillon’s second category of obligations of justice, those grounded in human rights. For while it might be plausible (if not entirely uncontroversial) to say that those communities whose water supplies are degraded by pharmaceutical production have a right to clean water, it is another thing entirely to say that Smith’s healthcare is directly violating that right. It would not be true to say that, were it not for the resources used in caring for Smith, that the communities in question would face no threat to water security—indeed, they would likely make no appreciable renova ms difference. Similarly for the effects of Smith’s care on future generations facing accelerating environmental change.iiThe issue here is of fragmentation of agency. While it is not the case that Smith’s care is directly responsible for these environmental harms, the cumulative consequences of many such acts—and the ways in which these acts are embedded in particular systems of energy generation, waste renova ms management, international trade, and so on—are reliably producing these harms.

The injustice is structural, in Iris Marion Young’s terminology—arising from the ways in which social structures constrain individuals from pursuing certain courses of action, and enable them to follow others, with side effects that cumulatively produce devastating impacts.15Gillon describes the third component of justice as respect for morally acceptable laws. But there is little reason to believe that existing legal frameworks provide sufficient guidance to address these structural injustices. While the intricacies of global governance are well beyond what I can hope to address here, the stark fact remains that, despite the international commitment of the 2015 Paris Agreement to attempt to keep global temperature rise to 1.5°C above preindustrial levels, the Intergovernmental Panel on Climate Change estimates that present national commitments—even if these are substantially increased in coming years—will take us well beyond that target.5 Confronted by such institutional inadequacy, respect for the rule of law is inadequate to remedy injustice.The confluence of renova ms these particular features—dispersion of causes and effects, fragmentation of agency and institutional inadequacy—makes it difficult for us to reason ethically about the choices we where to buy generic renova have to make. Stephen Gardiner calls this a ‘perfect moral storm’.16 Each of these factors individually would be difficult to address using the resources of contemporary biomedical ethics. Their convergence makes it seem insurmountable.This perfect storm was not, however, unpredictable.

Van Rensselaer Potter, renova ms a professor of Oncology responsible for introducing the term ‘bioethics’ into Anglophone discourse, observed that since he coined the phrase, the study of bioethics had diverged from his original usage (governing all issues at the intersection of ethics and the biological sciences) to a narrow focus on the moral dilemmas arising in interactions between individuals in biomedical contexts. Potter predicted that the short-term, individualistic and medicalised focus of this approach would result in a neglect of population-level and ecological-level issues affecting human and planetary health, with catastrophic consequences.17 His proposed solution was a new ‘global bioethics’, grounded in a new understanding of humanity’s position within planetary systems—one articulated by the Land Ethic.The Land EthicA land ethic changes the role of Homo sapiens from conqueror of the land-community to plain member and citizen of it. It implies respect for his fellow-members, and also respect for the community as such.iii (Leopold, ‘The Land Ethic’1, p 204)Developed throughout a career in forestry, conservation and wildlife management, the Land Ethic is less an attempt to provide a set of renova ms maxims for moral action, than to shift our perspectives of the moral landscape. In his working life, Aldo Leopold witnessed how actions intended to optimise short-term economic outcomes eroded the environments on which we depend—whether soil degradation arising from intensive farming and deforestation, or disruption of freshwater ecosystems by industrial dairy farming. He also saw that contemporary morality remained silent on such actions, even when their consequences were to the collective detriment of all.Leopold argued that a series of ‘historical accidents’ left our morality particularly ill suited to handle these intrusions of Gaia—with a worldview that considered them ‘intrusions’, rather than the predictable response of our biotic community.

These ‘accidents’ renova ms were. The unusual resilience of European ecological communities to anthropogenic interference (England survived an almost wholesale deforestation without consequent loss of ecosystem resilience, while similar changes elsewhere resulted in permanent environmental degradation). And the legacy renova ms of European settler colonialism, meaning that an ethic arising in these particular conditions came to dominate global social arrangements4 (p 311). The first of these supported a worldview in which ‘Land … is … something to be tamed rather than something to be understood, loved, and lived with. Resources are still regarded as separate entities, indeed, as commodities, rather than as our cohabitants in the land community’4 (p 311).

The second renova ms enabled the marginalisation of other views. In this genealogy, Leopold anticipated the perfect moral storm discussed above. His intent with the Land Ethic was to navigate it.There are three renova ms key components of the Land Ethic that comprise the first three sections of Leopold’s final essay on the subject. (1) the ‘community concept’ that allows communities as wholes to have intrinsic value. (2) the ‘ethical sequence’ that situates the value of such communities as extending, not replacing, values assigned to individuals.

And (3) the ‘ecological conscience’ that views ethical action not in terms of following a particular code, but in developing appropriate moral perception.The community conceptThe most widely quoted passage of Leopold’s opus—already cited above, and frequently (mis)taken as a summary maxim of the ethic—states that:A thing is right renova ms when it tends to preserve the integrity, stability, and beauty of the biotic community. It is wrong when it tends otherwise.1 (pp 224–225)This passage makes the primary object of our moral responsibilities ‘the biotic community’, a term Leopold uses interchangeably with the ‘land community’. Leopold’s community concept is notable in at least three respects. Its holism—an embrace of the moral significance of communities in a way that is not simply reducible to the renova ms significance of its individual members. Its understanding of communities as temporally extended, placing importance on their ‘integrity’ and ‘stability’.

And its rejection of anthropocentrism, affording humanity a place as ‘plain member and citizen’ of a broader land community.Individualism is so prevalent in biomedical ethics that it is scarcely argued renova ms for, instead forming part of the ‘background constellation of values’2 tacitly assumed within the field. We are used to evaluating the well-being of a community as a function of the well-being of its individual members—this is the rationale underlying quality-adjusted life year calculations endemic within health economics, and most discussions of distributive justice adopt some variation of this approach. Holism instead proposes that this makes no more sense than evaluating a person’s well-being as an aggregate of the well-being of their individual organs. While we renova ms can sensibly talk about people’s hearts, livers or kidneys, their health is defined in terms of and constitutively dependent on the health of the person as a whole. Similarly, holism proposes, while individuals can be identified separately, it only makes sense to talk about them and their well-being in the context of the larger biotic community which supports and defines us.Holism helps us to negotiate the issues that confront individualistic accounts of collective well-being in Anthropocene health injustices.

In the previous section, we found in the environmental consequences of industrialised healthcare that it is difficult to renova ms identify which parties in particular are harmed, and how much each individual action contributes to those harms. But our intuition that the overall result is unfair or unjust is itself a holistic assessment of the overall outcome, not dependent on our calculation of the welfare of every party involved. Holism respects the intuition that says—no matter the individuals involved—a world where people now exploit ecological resources in a fashion that deprives people in the future of the prerequisites of survival, is worse than one where communities now and in the future live in a sustainable relationship with their environment.The second aspect of Leopold’s community concept is that the community is something that does not exist at a single time and place—it is defined in terms of its development through time. Promoting the ‘integrity’ and ‘stability’ of the community renova ms requires that we not just consider its immediate interests, but how that will affect its long-term sustainability or resilience. We saw earlier the difficulties in trying to say just who is harmed and how when we approach harm to future generations individualistically.

But from the perspective of the Land Ethic, when we exploit environmental resources in ways that will have predictable damaging results for future generations, the object of our harm is not just renova ms some purely notional future person. It is a presently existing, temporally extended entity—the community of which they will be part.Lastly, Leopold’s community is quite consciously a biotic—not merely human—community. Leopold defines the land community as the open network of energy and mineral exchange that sustains all aspects of that network:Land… is not merely soil. It is a renova ms fountain of energy flowing through a circuit of soils, plants, and animals. Food chains are the living channels which conduct energy upward.

Death and decay return it to the soil. The circuit is not renova ms closed. Some energy is dissipated in decay, some is added by absorption, some is stored in soils, peats, and forests, but it is a sustained circuit, like a slowly augmented revolving fund of life.4 (pp 268–269)While the components within this network may change, the land community as a whole remains stable when the overall complexity of the network is not disrupted—other components are able to adjust to these changes, or new ones arise to take their place.ivThe normative inference Leopold makes from his understanding of the land community is this. It makes no sense to single out individual entities within the community as being especially valuable or useful, without taking into account the renova ms whole community upon which they mutually depend. To do so is self-defeating.

By privileging the interests of a few members of the community, we ultimately undermine the prerequisites of their existence.The ethical sequenceThe Land Ethic’s holism is in fact its most frequently critiqued feature. Its emphasis on the value of the biotic community leads some to allege a subjugation of renova ms individual interests to the needs of the environment. This critique neglects how Leopold positions the Land Ethic in what he calls the ‘ethical sequence’. This is the gradual extension of scope of ethical considerations, both in renova ms terms of the complexity of social interactions they cover (from interactions between two people, to the structure of progressively larger social groups), and in the kinds of person they acknowledge as worthy of moral consideration (as we resist, for example, classist, sexist or racist exclusions from personhood).This sequence serves less as a description of the history of morality, than a prescription for how we should understand the Land Ethic as adding to, rather than supplanting, our responsibilities to others. We do not argue that taking seriously health workers’ responsibilities for public health and health promotion supplants their duties to the patients they work with on a daily basis.

Similarly, the Land Ethic implies ‘respect for [our] fellow members, and also respect for the community as such’1 (p 204). At times, renova ms our responsibilities towards these different parties may come into tension. But balancing these responsibilities has always been part of the work of clinical ethics.The ecological conscienceIf the community concept gives a definition of the good, and the ethical sequence situates this definition within the existing moral landscape, neither offers an explicit decision procedure to guide right action. In arguing for the ‘ecological conscience’, Leopold explains his rationale for not attempting to articulate such renova ms a procedure. In his career as conservationist, Leopold witnessed time and again laws nominally introduced in the name of environmental protection that did little to achieve their long-term goals, while exacerbating other environmental threats.v This is not surprising, given the ‘perfect moral storm’ of Anthropocene global health and environmental threats discussed above.

The cumulative results of apparently innocent actions can be widespread and damaging.Leopold’s response to this problem is to advocate the cultivation of an ‘ecological conscience’. What is needed to promote a healthy human relationship with the land community is not for us to be told exactly how and how not to act in the face of renova ms environmental health threats, but rather to shift our view of the land from ‘a commodity belonging to us’ towards ‘a community to which we belong’1 (p viii). To understand what the Land Ethic requires of us, therefore, we should learn more about the land community and our relationship with it, to develop our moral perception and extend its scope to embrace the non-human members of our community.Seen in this light, the Land Ethic shares much in common with virtue ethics, where right action is defined in terms of what the moral agent would do, rather than vice versa. But rather than the Eudaimonia of individual human flourishing proposed by Aristotle, the phronimos of the Land Ethic sees their telos coming from their position within the land community. While clinical virtue ethicists have traditionally taken the virtues renova ms of medical practice to be grounded in the interaction with individual patients, the realities of healthcare in the Anthropocene mean that limiting our moral perceptions in this way would ultimately be self-defeating—hurting those very patients we mean to serve (and many more besides).18 The virtuous clinician must adopt a view of the moral world that can focus on a person both as an individual, and simultaneously as member of the land community.

I will close by exploring how adopting that perspective might change our practice.Justice in the AnthropoceneFailing this, it seems to me we fail in the ultimate test of our vaunted superiority—the self-control of environment. We fall renova ms back into the biological category of the potato bug which exterminated the potato, and thereby exterminated itself. (Leopold, ‘The River of the Mother of God’4, p 127)I have articulated some of the challenges healthcare faces in the Anthropocene. I have suggested that the tools presently available to clinical ethics may be inadequate to meet them. The Land renova ms Ethic invites us to reimagine our position in and relationship with the land community.

I want to close by suggesting how the development of an ecological conscience might support a transition to more just healthcare. I will not renova ms endeavour to give detailed prescriptions for action, given Leopold’s warnings about the limitations of such codifications. Rather, I will attempt to show how the cultivation of an ecological conscience might change our perception of what justice demands. Following the tradition of virtue ethics with which the Land Ethic holds much in common, this is best achieved by looking at models of virtuous action, and exploring what makes it virtuous.19Industrialised healthcare developed within a paradigm that saw the environment as inert resource and held that the scope of clinical ethics ranged only over the clinician’s interaction with their patients. When we begin to see clinician and patient not as standing apart from the environment, but as ‘member and citizen of the land community’, their relationship with one another and with the world renova ms around them changes consonantly.

The present renova has only begun to make commonplace the idea that health workers do not simply treat infectious diseases, but interact with them in a range of ways, including as vector—and as a result our moral obligations in confronting them may extend beyond the immediate clinical encounter, to cover all the other ways we may contract or spread disease. But we may be responsible for disease outbreaks with conditions other than skin care products, and in ways beyond simply renova ms becoming infected. The development of an ecological conscience would show how our practices of consumption may fuel deforestation that accelerates the emergence of novel pathogens, or support intensive animal rearing that drives antibiotic resistance.18The Land Ethic also challenges us not to abstract our work away from the places in which it takes place. General practitioner surgeries and hospitals are situated within social and land communities alike, shaping and shaped by them. These spaces can be used in renova ms ways that support or undermine those communities.

Surgeries can work to empower their communities to pursue more sustainable and healthy diets by doubling as food cooperatives, or providing resources and ‘social prescriptions’ for increased walking and cycling. Hospitals can use their extensive real estate to provide publicly accessible green and wild spaces within urban environments, and use their role as major nodes in transport infrastructure to change that infrastructure to support active travel alternatives.ivThe Land Ethic reminds us that a community (human or land) is not healthy if its flourishing cannot be sustainably maintained. An essential component of Anthropocene health justice is intergenerational renova ms justice. Contemporary industrialised healthcare has an unsustainable ecological footprint. Continuing with such a model of care would serve only to mortgage the health of future renova ms generations for the sake of those living now.

Ecologically conscious practice must take seriously the sorts of downstream, distributed consequences of activity that produce anthropogenic global health threats, and evaluate to what extent our most intensive healthcare practices truly serve to promote public and planetary health. It is not enough for the clinician to assume that our resource usage is a necessary evil in the pursuit of best clinical outcomes, for it is already apparent that much of our environmental exploitation is of minimal or even negative long-term value. The work of the National Health Service (NHS) Sustainable Development Unit has renova ms seen a 10% reduction in greenhouse gas emissions in the NHS from 2007 to 2015 despite an 18% increase in clinical activity,20 while different models of care used in less industrialised nations manage to provide high-quality health outcomes in less resource-intensive fashion.21ConclusionOur present problem is one of attitudes and implements. We are remodelling the Alhambra with a steam-shovel. We shall hardly relinquish the steam-shovel, which after all has many good points, but we are in need of gentler and more objective criteria for renova ms its successful use.

(Leopold, ‘The Land Ethic’1, p 226)The moral challenges of the Anthropocene do not solely confront health workers. But the potentially catastrophic health effects of anthropogenic global environmental change, and the contribution of healthcare activity to driving these changes provide a specific and unique imperative for action from health workers.Yet it is hard to articulate this imperative in the language of contemporary clinical ethics, ill equipped for this intrusion of Gaia. Justice in the Anthropocene requires us to be able to adopt a perspective from which renova ms these changes no longer appear as unexpected intrusions, but that acknowledges the land community as part of our moral community. The Land Ethic articulates an understanding of justice that is holistic, structural, intergenerational, and rejects anthropocentrism. This understanding seeks not to supplant, but to augment, our renova ms existing one.

It aims to do so by helping us to develop an ‘ecological conscience’, seeing ourselves as ‘plain member and citizen’ of the land community. The Land Ethic does not provide a step-by-step guide to just action. Nor does it definitively adjudicate on how to balance the interests of our patients, other populations now and in the future, and the planet renova ms. It could, however, help us on the first step towards that change—showing how to cultivate the ‘internal change in our intellectual emphasis, loyalties, affections, and convictions’1 (pp 209–210) necessary to realise the virtues of just healthcare in the Anthropocene.AcknowledgmentsThis essay was written as a submission for the BMA Presidential Essay Prize. I am grateful to the organisers and judging panel for the opportunity..

Justice, one of the four Beauchamp renova zero cost and Childress prima facie basic principles of website link biomedical ethics, is explored in two excellent papers in the current issue of the journal. The papers stem from a British Medical Association (BMA) essay competition on justice and fairness in medical practice and policy. Although the competition was open to (almost) all comers, of the 235 entries both the winning paper by Alistair Wardrope1 and the highly commended runner-up by Zoe Fritz and Caitríona Cox2 were written by renova zero cost practising doctors—a welcome indication of the growing importance being accorded to philosophical reflection about medical practice and practices within medicine itself.

Both papers are thoroughly thought provoking and represent two very different approaches to the topic. Each deserves a careful read.The competition was a component of a BMA 2019/2020 ‘Presidential project’ on fairness and justice and asked candidates to ‘use ethical reasoning and theory to tackle challenging, practical, contemporary, problems in health care and help provide a solution based on an explained and defended sense of fairness/justice’.In this guest editorial I’d like to explain why, in 2018 on becoming president-elect of the BMA, I chose the theme of justice and fairness in medical ethics for my 2019–2020 Presidential project—and why in a world of massive and ever-increasing and remediable health inequalities biomedical ethics requires greater international and interdisciplinary efforts to try to reach agreement on the need to achieve greater ‘health justice’ and to reach agreement on what that commitment actually means and on what in practice it requires.First, some background. As president I was offered the wonderful opportunity renova zero cost to pursue, with the organisation’s formidable assistance, a ‘project’ consistent with the BMA’s interests and values.

As a hybrid of general medical practitioner and philosopher/medical ethicist, and as a firm defender of the Beauchamp and Childress four principles approach to medical ethics,3 I chose to try to raise the ethical profile of justice and fairness within medical ethics.My first objective was to ask the BMA to ask the World Medical Association (WMA) to add an explicit commitment ‘to strive to practise fairly and justly throughout my professional life’ to its contemporary version of the Hippocratic Oath—the Declaration of Geneva4—and to the companion document the International Code of Medical Ethics.5 The stimulus for this proposal was the WMA’s addition in 2017 of the principle of respect for patients’ autonomy. Important as that addition is, it is widely perceived (though in my own renova zero cost view mistakenly) as being too much focused on individual patients and not enough on communities, groups and populations. The simple addition of a commitment to fairness and justice would provide a ‘balancing’ moral commitment.Adding the fourth principleIt would also explicitly add the fourth of those four prima facie moral commitments, increasingly widely accepted by doctors internationally.

Two of them—benefiting our patients (beneficence) and doing so with as little harm as possible (non-maleficence)—have been an integral part of medical ethics since Hippocratic times. Respect for autonomy and justice are very renova zero cost much more recent additions to medical ethics. The WMA, having added respect for autonomy to the Declaration of Geneva, should, I proposed, complete the quartet by adding the ‘balancing’ principle of fairness and justice.Since the Declaration is unlikely to be revised for several years, it seems likely that the proposal to add to it an explicit commitment to practise fairly and justly will have to wait.

However, an renova zero cost explicit commitment to justice and fairness has, at the BMA’s request, been added to the draft of the International Code of Medical Ethics and it seems reasonable to hope and expect that it will remain in the final document.Adding a commitment to fairness and justice is the easy part!. Few doctors would on reflection deny that they ought to try to practise fairly and justly. It is far more difficult to say what is actually meant by this.

Two additional components of my Presidential project—the essay competition and a conference (which with luck will have been held, virtually, shortly before publication of this editorial)—sought to help elucidate just what is meant by practising fairly and justly.One of the most striking features of the essay competition was the readiness of many writers to point to injustices in the context of medical practice and policy and describe ways of remedying them, but without giving a specific account of justice and fairness on the basis of which the diagnosis of injustice was made and the remedy offered.Wardrope’s winning essay comes close to such an approach by challenging the implied premise that an account of justice and fairness must provide some renova zero cost such formal theory. In preference, he points to the evident injustice and unsustainability of humans’ degradation of ‘the Land’ and its atmosphere and its inhabitants and then challenges some assumptions of contemporary philosophy and ethics, especially what he sees as their anthropocentric and individualistic focus. Instead, he invokes Leopold Aldo’s ‘Land Ethic’ (as well as drawing renova zero cost in aid Isabelle Stenger’s focus on ‘the intrusion of Gaia’).

In his thoughtful and challenging paper, he seeks to refocus our ethics—including our medical ethics and our sense of justice and fairness—on mankind’s exploitative threat, during this contemporary ‘anthropocene’ stage of evolution, to the continuing existence of humans and of all forms of life in our ‘biotic community’. As remedy, the author, allying his approach to those of contemporary virtue ethics, recommends the beneficial outcomes that would be brought about by a sense of fairness and justice—a developed and sensitive ‘ecological conscience’ as he calls it—that embraces the interests of the entire biotic community of which we humans are but a part.Fritz and Cox pursue a very different and philosophically more conventional approach to the essay competition’s question and offer a combination and development of two established philosophical theories, those of John Rawls and Thomas Scanlon, to provide a philosophically robust and practically beneficial methodology for justice and fairness in medical practice and policy. Briefly summarised, they recommend a renova zero cost two-stage approach for healthcare justice.

First, those faced with a problem of fairness or justice in healthcare or policy should use Thomas Scanlon’s proposed contractualist approach whereby reasonable people seek solutions that they and others could not ‘reasonably reject’. This stage would involve committees of decision-makers and representatives of relevant stakeholders looking at the immediate and longer term impact on existing stakeholders of proposed solutions. They would then check those solutions against substantive criteria of justice derived from Rawls’ theory (which, via his theoretical device of the ‘veil of ignorance’, Rawls and the renova zero cost authors argue that all reasonable people can be expected to accept!.

). The Rawlsian criteria relied renova zero cost on by Fritz and Cox are equity of access to healthcare. The ‘difference principle’ whereby avoidable inequalities of primary goods can only be justified if they benefit the most disadvantaged.

The just savings principle, of particular importance for ensuring intergenerational justice and sustainability. And a criterion of increased openness, transparency and accountability.It would of renova zero cost course be naïve to expect a single universalisable solution to the question ‘what do we mean by fairness and justice in health care?. €™ As the papers by Wardrope1 and Fritz and Cox2 demonstrate, there can be very wide differences of approach in well-defended accounts.

My own hope for my project is to emphasise the importance first of committing ourselves within medicine renova zero cost to practising fairly and justly in whatever branch we practise. And then to think carefully about what we do mean by that and act accordingly.Following AristotleFor my own part, over 40 years of looking, I have not yet found a single substantive theory of justice that is plausibly universalisable and have had to content myself with Aristotle’s formal, almost content-free but probably universalisable theory, according to which equals should be treated equally and unequals unequally in proportion to the relevant inequalities—what some health economists refer to as horizontal and vertical justice or equity.6Beauchamp and Childress in their recent eighth and ‘perhaps final’ edition of their foundational ‘Principles of biomedical ethics’1 acknowledge that ‘[t]he construction of a unified theory of justice that captures our diverse conceptions and principles of justice in biomedical ethics continues to be controversial and difficult to pin down’.They still cite Aristotle’s formal principle (though with less explanation than in their first edition back in 1979) and they still believe that this formal principle requires substantive or ‘material’ content if it is to be useful in practice. They then describe six different theories of justice—four ‘traditional’ (utilitarian, libertarian, communitarian and egalitarian) and two newer theories, which they suggest may be more helpful in the context of health justice, one based on capabilities and the other on actual well-being.They again end their discussion of justice with their reminder that ‘Policies of just access to health care, strategies of efficiencies in health care institutions, and global needs for the reduction of health-impairing conditions dwarf in social importance every other issue considered in this book’ …….

€˜every society must ration its resources but many renova zero cost societies can close gaps in fair rationing more conscientiously than they have to date’ [emphasis added]. And they go on to stress their own support for ‘recognition of global rights to health and enforceable rights to health care in nation-states’.For my own part I recommend, perhaps less ambitiously, that across the globe we extract from Aristotle’s formal theory of justice a starting point that ethically requires us to focus on equality and always to treat others as equals and treat them equally unless there are moral justifications for not doing so. Where such renova zero cost justifications exist we should say what they are, explain the moral assumptions that justify them and, to the extent possible, seek the agreement of those affected.IntroductionIt did not occur to the Governor that there might be more than one definition of what is good … It did not occur to him that while the courts were writing one definition of goodness in the law books, fires were writing quite another one on the face of the land.

(Leopold, ‘Good Oak’1, pp 10–11)As I wrote the abstract that would become this essay, wildfires were spreading across Australia’s east coast. By the time I was invited to write the essay, back-to-back winter storms were flooding communities all around my home. The essay has been written in moments of respite between shifts during renova zero cost the skin care products renova.

Every one of these events was described as ‘unprecedented’. Yet each is becoming increasingly likely, and that due to our interactions with our environment.Public discourse surrounding these events is dominated by questions of justice and fairness. How to balance competing imperatives of renova zero cost protecting individual lives against risk of spreading contagion.

How best to allocate scarce resources like intensive care beds or mechanical ventilators. The conceptual tools of clinical ethics are well tailored to these sorts of renova zero cost questions. The rights of the individual versus the community, issues of distributive justice—these are familiar to anyone with even a passing acquaintance with its canonical debates.What biomedical ethics has remained largely silent on is how we have been left to confront these decisions.

How human activity has eroded Earth’s life support systems to make the ‘unprecedented’ the new normal. A medical ethic fit for the Anthropocene—our (still tentative) geological epoch defined by human influence on natural systems—must be able not just to react to the consequences of our exploitation of the natural world, but renova zero cost reimagine our relationship with it.Those reimaginations already exist, if we know where to look for them. The ‘Land Ethic’ of the US conservationist Aldo Leopold offers one such vision.i Developed over decades of experience working in and teaching land management, the Land Ethic is most famously formulated in an essay of the same name published shortly before Leopold’s death fighting a wildfire on a neighbour’s farm.

It begins with a reinterpretation of the ethical relationship between humanity and the ‘land community’, the renova zero cost ecosystems we live within and depend upon. Moving us from ‘conqueror’ to ‘plain member and citizen’ of that community1 (p 204). Land ceases to be a resource to be exploited for human need once we view ourselves as part of, and only existing within, the land community.

Our moral evaluations renova zero cost shift consonantly:A thing is right when it tends to preserve the integrity, stability, and beauty of the biotic community. It is wrong when it tends otherwise.1 (pp 224–225)The justice of the Land Ethic questions many presuppositions of biomedical ethics. By valuing the community in itself—in a way irreducible to the welfare of its members—it steps away from the individualism axiomatic in contemporary bioethics.2 Viewing ourselves as citizens of the land community also extends the moral horizons of renova zero cost healthcare from a solely human focus, taking seriously the interests of the non-human members of that community.

Taking into account the ‘stability’ of the community requires intergenerational justice—that we consider those affected by our actions now, and their implications for future generations.3 The resulting vision of justice in healthcare—one that takes climate and environmental justice seriously—could offer health workers an ethic fit for the future, demonstrating ways in which practice must change to do justice to patients, public and planet—now and in years to come.Healthcare in the AnthropoceneSeemeth it a small thing unto you to have fed upon good pasture, but ye must tread down with your feet the residue of your pasture?. And to have drunk of the clear waters, but ye must foul the residue with your feet?. (Ezekiel 34:18, quoted renova zero cost in Leopold, ‘Conservation in the Southwest’4, p 94)The majority of the development of human societies worldwide—including all of recorded human history—has taken place within a single geological epoch, a roughly 11 600 yearlong period of relative warmth and climatic stability known as the Holocene.

That stability, however, can no longer be taken for granted. The epoch that has sustained most of human development is giving way to one shaped by the planetary consequences of that development—the Anthropocene.The Anthropocene is marked by accelerating degradation of the ecosystems that have sustained human societies. Human activity is already estimated to have raised global temperatures 1°C above preindustrial levels, and if emissions continue at current levels we are likely to reach 1.5°C between 2030 and 2052.5 The global rate of species extinction is orders of magnitude higher than the average over the past 10 million years.6 Ocean acidification, deforestation and disruption of nitrogen renova zero cost and phosphorus flows are likely at or beyond sustainable planetary boundaries.7Yet this period has also seen rapid (if uneven) improvements in human health, with improved life expectancy, falling child mortality and falling numbers of people living in extreme poverty.

The 2015 report of the Rockefeller Foundation-Lancet Commission on planetary health explained this dissonance in stark terms. €˜we have been mortgaging the health of future generations to realise economic and development gains in the present.’7In the instrumental rationality of modernity, nature has featured only as inexhaustible resource renova zero cost and infinite sink to fuel social and economic ends. But this disenchanted worldview can no longer hide from the implausibility of these assumptions.

It cannot resist what the philosopher Isabelle Stengers has called ‘the intrusion of Gaia’.8 The present renova—made more likely by deforestation, land use change and biodiversity loss9—is just the most immediately salient of these intrusions. Anthropogenic environmental changes are increasing undernutrition, increasing range and transmissibility of many vectorborne and waterborne diseases like dengue fever and cholera, increasing frequency and severity of extreme weather events like heatwaves and wildfires, and driving population exposure to air pollution—which already accounts for over 7 million deaths annually.10These intrusions will renova zero cost shape healthcare in the Anthropocene. This is because health workers will have to deal with their consequences, and because modern industrialised healthcare as practised in most high-income countries—and considered aspirational elsewhere—was borne of the same worldview that has mortgaged the health of future generations.

The health sector in the USA is estimated to account for 8% of the country’s greenhouse gas footprint.11 Pharmaceutical production and waste causes more local environmental degradation, accumulating in water supplies with renova zero cost damaging effects for local flora and fauna.12 Public health has similarly embraced short-term gains with neglect of long-term consequences. Health messaging was instrumental to the development and popularisation of many disposable and single-use products, while a 1947 report funded by the Rockefeller Foundation (who would later fund the landmark 2015 Lancet report on planetary health) popularised the high-meat, high-dairy ‘American’ diet—dependent on fossil fuel-driven intensive agricultural practices—as the healthy ideal.13Healthcare fit for the Anthropocene requires a shift in perspectives that allows us to see and work with the intrusion of Gaia. But can dominant approaches in bioethics incorporate that shift?.

A perfect moral stormWe have built a beautiful piece of social machinery … which is coughing along on two cylinders because we have been too timid, and too anxious for quick renova zero cost success, to tell the farmer the true magnitude of his obligations. (Leopold, ‘The Ecological Conscience’4, p 341)At local, national and international scales, the lifestyles of the wealthiest pose an existential threat to the poorest and most marginalised in society. Our actions now are depriving future generations renova zero cost of the environmental prerequisites of good health and social flourishing.

If justice means, as Ranaan Gillon parses it, ‘the moral obligation to act on the basis of fair adjudication between competing claims’,14 then this state of affairs certainly seems unjust. However, the tools available for grappling with questions of justice in bioethics seem ill equipped to deal with these sorts of injustice.To illustrate this problem, consider how Gillon further fleshes out his description of justice. In terms renova zero cost of fair distribution of scarce resources, respect for people’s rights, and respect for morally acceptable laws.

The first of these—labelled distributive justice—concerns how fairly to allot finite resources among potential beneficiaries. Classic problems of distributive justice in healthcare concern a group of people at a particular time (usually patients), who could each benefit from a particular resource (historically, discussions have often focused on transplant organs. More recently, intensive renova zero cost care beds and ventilators have come to the fore).

But there are fewer of these resources than there are people with a need for them. Such discussions are not easy, but they are at least familiar—we know where to begin renova zero cost with them. We can consider each party’s need, their potential to benefit from the resource, any special rights or other claims they may have to it, and so forth.

The distribution of benefits and harms in the Anthropocene, however, does not comfortably fit this formalism. It is one thing to say that renova zero cost there is but one intensive care bed, from which Smith has a good chance of gaining another year of life, Jones a poor chance, and so offer it to Smith. Another entirely to say that production of the materials consumed in Smith’s care has contributed to the degradation of scarce water supplies on the other side of the globe, or that the unsustainable pattern of energy use will affect innumerable other future persons in poorly quantifiable ways through fuelling climate change.

The calculations of distributive justice are well suited renova zero cost to problems where there are a set pool of potential beneficiaries, and the use of the scarce resources available affects only those within that pool. But global environmental problems do not fit this pattern—the effects of our actions are spatially and temporally dispersed, so that large numbers of present and future people are affected in different ways.Nor can this problem be readily addressed by turning to Gillon’s second category of obligations of justice, those grounded in human rights. For while it might be plausible (if not entirely uncontroversial) to say that those communities whose water supplies are degraded by pharmaceutical production have a right to clean water, it is another thing entirely to say that Smith’s healthcare is directly violating that right.

It would not be true to say that, were it not for the resources used in caring for Smith, that the communities renova zero cost in question would face no threat to water security—indeed, they would likely make no appreciable difference. Similarly for the effects of Smith’s care on future generations facing accelerating environmental change.iiThe issue here is of fragmentation of agency. While it is not the case that Smith’s care is directly responsible for these environmental harms, the cumulative consequences renova zero cost of many such acts—and the ways in which these acts are embedded in particular systems of energy generation, waste management, international trade, and so on—are reliably producing these harms.

The injustice is structural, in Iris Marion Young’s terminology—arising from the ways in which social structures constrain individuals from pursuing certain courses of action, and enable them to follow others, with side effects that cumulatively produce devastating impacts.15Gillon describes the third component of justice as respect for morally acceptable laws. But there is little reason to believe that existing legal frameworks provide sufficient guidance to address these structural injustices. While the intricacies of global governance are well beyond what I can hope to address here, the stark fact remains that, despite the international commitment of the 2015 Paris Agreement to attempt to keep global temperature rise to 1.5°C above preindustrial levels, the Intergovernmental Panel on Climate Change estimates that present national commitments—even if these are substantially increased in coming years—will take us well beyond that target.5 Confronted by such institutional inadequacy, respect for the rule of renova zero cost law is inadequate to remedy injustice.The confluence of these particular features—dispersion of causes and effects, fragmentation of agency and institutional inadequacy—makes it difficult for us where can you get renova to reason ethically about the choices we have to make.

Stephen Gardiner calls this a ‘perfect moral storm’.16 Each of these factors individually would be difficult to address using the resources of contemporary biomedical ethics. Their convergence makes it seem insurmountable.This perfect storm was not, however, unpredictable. Van Rensselaer Potter, a professor of Oncology responsible for introducing renova zero cost the term ‘bioethics’ into Anglophone discourse, observed that since he coined the phrase, the study of bioethics had diverged from his original usage (governing all issues at the intersection of ethics and the biological sciences) to a narrow focus on the moral dilemmas arising in interactions between individuals in biomedical contexts.

Potter predicted that the short-term, individualistic and medicalised focus of this approach would result in a neglect of population-level and ecological-level issues affecting human and planetary health, with catastrophic consequences.17 His proposed solution was a new ‘global bioethics’, grounded in a new understanding of humanity’s position within planetary systems—one articulated by the Land Ethic.The Land EthicA land ethic changes the role of Homo sapiens from conqueror of the land-community to plain member and citizen of it. It implies respect for his fellow-members, and also respect for the community as such.iii (Leopold, ‘The Land Ethic’1, p 204)Developed throughout a career in forestry, conservation and wildlife management, the Land Ethic is less an attempt to provide renova zero cost a set of maxims for moral action, than to shift our perspectives of the moral landscape. In his working life, Aldo Leopold witnessed how actions intended to optimise short-term economic outcomes eroded the environments on which we depend—whether soil degradation arising from intensive farming and deforestation, or disruption of freshwater ecosystems by industrial dairy farming.

He also saw that contemporary morality remained silent on such actions, even when their consequences were to the collective detriment of all.Leopold argued that a series of ‘historical accidents’ left our morality particularly ill suited to handle these intrusions of Gaia—with a worldview that considered them ‘intrusions’, rather than the predictable response of our biotic community. These ‘accidents’ renova zero cost were. The unusual resilience of European ecological communities to anthropogenic interference (England survived an almost wholesale deforestation without consequent loss of ecosystem resilience, while similar changes elsewhere resulted in permanent environmental degradation).

And the renova zero cost legacy of European settler colonialism, meaning that an ethic arising in these particular conditions came to dominate global social arrangements4 (p 311). The first of these supported a worldview in which ‘Land … is … something to be tamed rather than something to be understood, loved, and lived with. Resources are still regarded as separate entities, indeed, as commodities, rather than as our cohabitants in the land community’4 (p 311).

The second enabled the renova zero cost marginalisation of other views. In this genealogy, Leopold anticipated the perfect moral storm discussed above. His intent with the Land Ethic was to navigate it.There are three key components of the Land Ethic that renova zero cost comprise the first three sections of Leopold’s final essay on the subject.

(1) the ‘community concept’ that allows communities as wholes to have intrinsic value. (2) the ‘ethical sequence’ that situates the value of such communities as extending, not replacing, values assigned to individuals. And (3) the ‘ecological conscience’ that views ethical action not in terms of following a particular code, but in developing appropriate moral perception.The community conceptThe most widely quoted passage of Leopold’s opus—already cited above, and frequently (mis)taken as renova zero cost a summary maxim of the ethic—states that:A thing is right when it tends to preserve the integrity, stability, and beauty of the biotic community.

It is wrong when it tends otherwise.1 (pp 224–225)This passage makes the primary object of our moral responsibilities ‘the biotic community’, a term Leopold uses interchangeably with the ‘land community’. Leopold’s community concept is notable in at least three respects. Its holism—an embrace of the renova zero cost moral significance of communities in a way that is not simply reducible to the significance of its individual members.

Its understanding of communities as temporally extended, placing importance on their ‘integrity’ and ‘stability’. And its rejection of anthropocentrism, affording humanity a place as ‘plain member and citizen’ of a broader land community.Individualism is so prevalent in biomedical ethics that it is renova zero cost scarcely argued for, instead forming part of the ‘background constellation of values’2 tacitly assumed within the field. We are used to evaluating the well-being of a community as a function of the well-being of its individual members—this is the rationale underlying quality-adjusted life year calculations endemic within health economics, and most discussions of distributive justice adopt some variation of this approach.

Holism instead proposes that this makes no more sense than evaluating a person’s well-being as an aggregate of the well-being of their individual organs. While we can sensibly talk about people’s hearts, livers or kidneys, their health renova zero cost is defined in terms of and constitutively dependent on the health of the person as a whole. Similarly, holism proposes, while individuals can be identified separately, it only makes sense to talk about them and their well-being in the context of the larger biotic community which supports and defines us.Holism helps us to negotiate the issues that confront individualistic accounts of collective well-being in Anthropocene health injustices.

In the previous section, we found in the environmental consequences of industrialised healthcare that it is difficult to identify which renova zero cost parties in particular are harmed, and how much each individual action contributes to those harms. But our intuition that the overall result is unfair or unjust is itself a holistic assessment of the overall outcome, not dependent on our calculation of the welfare of every party involved. Holism respects the intuition that says—no matter the individuals involved—a world where people now exploit ecological resources in a fashion that deprives people in the future of the prerequisites of survival, is worse than one where communities now and in the future live in a sustainable relationship with their environment.The second aspect of Leopold’s community concept is that the community is something that does not exist at a single time and place—it is defined in terms of its development through time.

Promoting the ‘integrity’ and ‘stability’ of the community requires that we not just consider renova zero cost its immediate interests, but how that will affect its long-term sustainability or resilience. We saw earlier the difficulties in trying to say just who is harmed and how when we approach harm to future generations individualistically. But from the perspective renova zero cost of the Land Ethic, when we exploit environmental resources in ways that will have predictable damaging results for future generations, the object of our harm is not just some purely notional future person.

It is a presently existing, temporally extended entity—the community of which they will be part.Lastly, Leopold’s community is quite consciously a biotic—not merely human—community. Leopold defines the land community as the open network of energy and mineral exchange that sustains all aspects of that network:Land… is not merely soil. It is a fountain renova zero cost of energy flowing through a circuit of soils, plants, and animals.

Food chains are the living channels which conduct energy upward. Death and decay return it to the soil. The circuit is renova zero cost not closed.

Some energy is dissipated in decay, some is added by absorption, some is stored in soils, peats, and forests, but it is a sustained circuit, like a slowly augmented revolving fund of life.4 (pp 268–269)While the components within this network may change, the land community as a whole remains stable when the overall complexity of the network is not disrupted—other components are able to adjust to these changes, or new ones arise to take their place.ivThe normative inference Leopold makes from his understanding of the land community is this. It makes no sense to single out individual entities within the community as being especially valuable or useful, without taking into account the whole renova zero cost community upon which they mutually depend. To do so is self-defeating.

By privileging the interests of a few members of the community, we ultimately undermine the prerequisites of their existence.The ethical sequenceThe Land Ethic’s holism is in fact its most frequently critiqued feature. Its emphasis on the value of the biotic renova zero cost community leads some to allege a subjugation of individual interests to the needs of the environment. This critique neglects how Leopold positions the Land Ethic in what he calls the ‘ethical sequence’.

This is the gradual extension of scope of ethical considerations, both in terms of the complexity renova zero cost of social interactions they cover (from interactions between two people, to the structure of progressively larger social groups), and in the kinds of person they acknowledge as worthy of moral consideration (as we resist, for example, classist, sexist or racist exclusions from personhood).This sequence serves less as a description of the history of morality, than a prescription for how we should understand the Land Ethic as adding to, rather than supplanting, our responsibilities to others. We do not argue that taking seriously health workers’ responsibilities for public health and health promotion supplants their duties to the patients they work with on a daily basis. Similarly, the Land Ethic implies ‘respect for [our] fellow members, and also respect for the community as such’1 (p 204).

At times, our responsibilities towards these different renova zero cost parties may come into tension. But balancing these responsibilities has always been part of the work of clinical ethics.The ecological conscienceIf the community concept gives a definition of the good, and the ethical sequence situates this definition within the existing moral landscape, neither offers an explicit decision procedure to guide right action. In arguing for the renova zero cost ‘ecological conscience’, Leopold explains his rationale for not attempting to articulate such a procedure.

In his career as conservationist, Leopold witnessed time and again laws nominally introduced in the name of environmental protection that did little to achieve their long-term goals, while exacerbating other environmental threats.v This is not surprising, given the ‘perfect moral storm’ of Anthropocene global health and environmental threats discussed above. The cumulative results of apparently innocent actions can be widespread and damaging.Leopold’s response to this problem is to advocate the cultivation of an ‘ecological conscience’. What is needed to promote a healthy human relationship with the land community is not for us to be told exactly how and how not to act in the face of environmental health threats, but rather to shift our view of the land from ‘a commodity renova zero cost belonging to us’ towards ‘a community to which we belong’1 (p viii).

To understand what the Land Ethic requires of us, therefore, we should learn more about the land community and our relationship with it, to develop our moral perception and extend its scope to embrace the non-human members of our community.Seen in this light, the Land Ethic shares much in common with virtue ethics, where right action is defined in terms of what the moral agent would do, rather than vice versa. But rather than the Eudaimonia of individual human flourishing proposed by Aristotle, the phronimos of the Land Ethic sees their telos coming from their position within the land community. While clinical virtue ethicists have traditionally taken the virtues of medical practice to be grounded in the interaction with individual patients, the realities renova zero cost of healthcare in the Anthropocene mean that limiting our moral perceptions in this way would ultimately be self-defeating—hurting those very patients we mean to serve (and many more besides).18 The virtuous clinician must adopt a view of the moral world that can focus on a person both as an individual, and simultaneously as member of the land community.

I will close by exploring how adopting that perspective might change our practice.Justice in the AnthropoceneFailing this, it seems to me we fail in the ultimate test of our vaunted superiority—the self-control of environment. We fall back into the biological category of the potato bug which renova zero cost exterminated the potato, and thereby exterminated itself. (Leopold, ‘The River of the Mother of God’4, p 127)I have articulated some of the challenges healthcare faces in the Anthropocene.

I have suggested that the tools presently available to clinical ethics may be inadequate to meet them. The Land Ethic invites us to reimagine our position in and relationship with the renova zero cost land community. I want to close by suggesting how the development of an ecological conscience might support a transition to more just healthcare.

I will not endeavour to give detailed prescriptions for action, renova zero cost given Leopold’s warnings about the limitations of such codifications. Rather, I will attempt to show how the cultivation of an ecological conscience might change our perception of what justice demands. Following the tradition of virtue ethics with which the Land Ethic holds much in common, this is best achieved by looking at models of virtuous action, and exploring what makes it virtuous.19Industrialised healthcare developed within a paradigm that saw the environment as inert resource and held that the scope of clinical ethics ranged only over the clinician’s interaction with their patients.

When we begin to see clinician and patient not as standing apart from the environment, but as ‘member renova zero cost and citizen of the land community’, their relationship with one another and with the world around them changes consonantly. The present renova has only begun to make commonplace the idea that health workers do not simply treat infectious diseases, but interact with them in a range of ways, including as vector—and as a result our moral obligations in confronting them may extend beyond the immediate clinical encounter, to cover all the other ways we may contract or spread disease. But we may be responsible for disease outbreaks with conditions other than skin care products, and in ways beyond simply becoming infected renova zero cost.

The development of an ecological conscience would show how our practices of consumption may fuel deforestation that accelerates the emergence of novel pathogens, or support intensive animal rearing that drives antibiotic resistance.18The Land Ethic also challenges us not to abstract our work away from the places in which it takes place. General practitioner surgeries and hospitals are situated within social and land communities alike, shaping and shaped by them. These spaces can be used in ways that support or renova zero cost undermine those communities.

Surgeries can work to empower their communities to pursue more sustainable and healthy diets by doubling as food cooperatives, or providing resources and ‘social prescriptions’ for increased walking and cycling. Hospitals can use their extensive real estate to provide publicly accessible green and wild spaces within urban environments, and use their role as major nodes in transport infrastructure to change that infrastructure to support active travel alternatives.ivThe Land Ethic reminds us that a community (human or land) is not healthy if its flourishing cannot be sustainably maintained. An essential renova zero cost component of Anthropocene health justice is intergenerational justice.

Contemporary industrialised healthcare has an unsustainable ecological footprint. Continuing with such a model of care would serve only renova zero cost to mortgage the health of future generations for the sake of those living now. Ecologically conscious practice must take seriously the sorts of downstream, distributed consequences of activity that produce anthropogenic global health threats, and evaluate to what extent our most intensive healthcare practices truly serve to promote public and planetary health.

It is not enough for the clinician to assume that our resource usage is a necessary evil in the pursuit of best clinical outcomes, for it is already apparent that much of our environmental exploitation is of minimal or even negative long-term value. The work of the National Health Service (NHS) Sustainable Development Unit has seen a 10% reduction in greenhouse gas emissions in the NHS from 2007 to renova zero cost 2015 despite an 18% increase in clinical activity,20 while different models of care used in less industrialised nations manage to provide high-quality health outcomes in less resource-intensive fashion.21ConclusionOur present problem is one of attitudes and implements. We are remodelling the Alhambra with a steam-shovel.

We shall hardly relinquish the steam-shovel, renova zero cost which after all has many good points, but we are in need of gentler and more objective criteria for its successful use. (Leopold, ‘The Land Ethic’1, p 226)The moral challenges of the Anthropocene do not solely confront health workers. But the potentially catastrophic health effects of anthropogenic global environmental change, and the contribution of healthcare activity to driving these changes provide a specific and unique imperative for action from health workers.Yet it is hard to articulate this imperative in the language of contemporary clinical ethics, ill equipped for this intrusion of Gaia.

Justice in the renova zero cost Anthropocene requires us to be able to adopt a perspective from which these changes no longer appear as unexpected intrusions, but that acknowledges the land community as part of our moral community. The Land Ethic articulates an understanding of justice that is holistic, structural, intergenerational, and rejects anthropocentrism. This understanding seeks not to supplant, but to augment, renova zero cost our existing one.

It aims to do so by helping us to develop an ‘ecological conscience’, seeing ourselves as ‘plain member and citizen’ of the land community. The Land Ethic does not provide a step-by-step guide to just action. Nor does it definitively adjudicate on renova zero cost how to balance the interests of our patients, other populations now and in the future, and the planet.

It could, however, help us on the first step towards that change—showing how to cultivate the ‘internal change in our intellectual emphasis, loyalties, affections, and convictions’1 (pp 209–210) necessary to realise the virtues of just healthcare in the Anthropocene.AcknowledgmentsThis essay was written as a submission for the BMA Presidential Essay Prize. I am grateful to the organisers and judging panel for the opportunity..

Renova implants

skin care products is teaching everyone go now in renova implants medicine lessons about health care and public health. Mine have been up close, personal, and frightening.One day I was a healthy 44-year-old doctor, CEO of a health care company, and a triathlete who was prepared to do another triathlon. Then I was a skin care products renova implants patient a few shallow breaths away from being put on a ventilator.

A nurse saved me from that fate.A journey that made me ponder new questions and opened my eyes to a new sense of purpose and perspective started innocuously enough. The soreness and aches renova implants began on a Monday night. A fever followed.

I woke up Tuesday morning feeling awful. I got tested and it was official — I was one of the thousands of new skin care products patients that day.advertisementBy Friday, renova implants I was having trouble taking deep breaths. My pulse oximeter showed 95%.

Not bad, but not renova implants normal for me — that would have been 99% to 100%. Over the next two days, things got worse. Sunday morning, six days after first feeling sick, I walked to the bathroom and felt a new sensation. I was winded and light-headed.

My oxygen level was still 97%, but I was breathing much renova implants faster. As I sat on the edge of the bathtub, my respiratory rate was 18 breaths per minute (50% higher than usual) and my heart rate was 85 beats per minute (up from my baseline of 50).advertisementWhen you come from a family of doctors and lead a company of doctors, getting a second, third, and fourth opinion is easy. Everyone I renova implants reached had the same advice.

Go to the hospital. Before we left, my wife, Stephanie, called family members, friends, and my colleagues at ChenMed and asked everyone to pray for me. We weren’t sure how things would turn out, and we needed as many people as possible appealing to a higher power on my behalf.At the hospital, a CT scan showed skin care products-related pneumonia in all renova implants parts of my lungs.

I was given a dose of steroids (dexamethasone) to decrease skin care products-related inflammation in my lungs, a shot of a blood thinner to prevent blood clots, and was then admitted.The hospital was fantastic. I knew many of the doctors, including the chief medical officer and the chief of renova implants cardiology. They would walk by the window of my room, knock on the glass, then call my cell and reassure me I was in good hands.Even so, I began feeling despondent.

It didn’t help that I kept feeling worse and worse. I felt like I was staring renova implants into a dark tunnel — standing alone and worrying about myself, my wife and children, my parents, and my company. Sure, nurses would come in frequently, but only fully gowned for two minutes or less.

Doctors would review my renova implants numbers and then call my phone to speak with me. I was alone, and I was lonely. Nights were the worst. That’s when the fevers were highest and my breathing was most labored.

I felt like I was renova implants wasting away. Covered in sweat, unable to bathe or shower, tied down by a web of wires, lines, and tubes and trying desperately to breathe. I got renova implants an inkling of what my heart failure patients experience when they cannot breathe due to fluid buildup in their lungs and feel like they are drowning from the inside out.I prayed for hope but feared the worst.

I knew I was getting sicker, and had just heard that remdesivir, a promising antiviral drug, was in short supply. I was enrolled in a study to receive convalescent plasma — the liquid portion of blood from someone who had recovered from skin care products which is filled with antibodies against the renova — but was on the waiting list.I knew that everyone was working tirelessly to stop my skin care products from progressing, but I was losing ground. Without a firm date for treatment, I felt sad and hopeless.On Tuesday night, my ICU nurse was a 6-foot-tall woman from Jamaica named renova implants Helen, though I’m pretty sure she had been a drill instructor in another life.

If she wanted me to sit on the edge of the bed and I said “no,” we reached an understanding. I sat on the renova implants edge of the bed. Helen started her shift by changing my gown and sheets, then helped me take a chlorhexidine towel bath.

Those small acts of kindness felt wonderful.Despite having trouble breathing, I sometimes fell asleep. Then my breathing would renova implants slow and my blood oxygen level would drop to unsafe levels. Helen would open the door to my room and yell, “Chris, c’mon.

You’ve got to breathe renova implants. Breathe for me.” I knew what she was doing. Waking me up so I would breathe http://ribbonebrewingcompany.com/?p=60 faster.

When I took faster breaths, my blood oxygen would rise and the alarm attached to my pulse oximeter would stop chirping.If I couldn’t breathe renova implants on my own, I would be put on a ventilator and, if that happened, my chance of dying would skyrocket. I believe that Helen saved my life that night.Around 3 a.m. She came into my room again renova implants.

When I heard her voice, I immediately started to breathe faster. But this time she had a different message. €œChris, your plasma renova implants has arrived,” she told me.

€œI’m going to get it.”“Are you sure?. € I asked, since the plasma wasn’t supposed to get to the hospital renova implants for a few more days.“The blood bank just called,” she replied.All I could say was, “Praise God.” It was my first glimmer of hope.I received the plasma as the shift was changing in the morning. I wanted to give Helen a hug or at least shake her hand, but the best I could do in the time of skin care was to say an emotional “Thank you for getting me through last night” as she headed home.The following morning, my brother, who is a cardiologist, called and said remdesivir had been secured for me and I would get my first dose at 11 a.m.

That afternoon, I began feeling better. I was able to sit in the chair next to renova implants my bed. I wondered if the plasma and remdesivir were working, or whether my body was finally fighting its way back.I remained fever-free.

When Saturday renova implants morning rolled around, my light-headedness had cleared. My breathing felt less labored and I was able to take deeper breaths. My aches were subsiding, and I felt stronger and more alert.

I walked around my room renova implants without becoming short of breath. I was ready to go home.As I was wheeled out of the ICU room, I looked around. When I arrived, half of the rooms — renova implants all reserved for skin care products patients — were empty.

As I left, all of them were full and many of the occupants were on ventilators. I asked to stop for a moment so I could say a prayer for my brothers and sisters with skin care products.Stephanie and my oldest son were waiting outside the hospital in a carport reserved for skin care products patients. I was renova implants overcome with emotion.

We hugged and held each other tight. For the first time since entering the ICU, I realized I would renova implants still get to be a husband, father, brother, and son, and would continue to lead ChenMed. I was overwhelmed.As I write this, it’s been 20 days since I first started feeling sick, and I am still recovering.

I still have questions, but they are far different than the ones I thought about when I was in the hospital. I’ve realized how naïve I was about what it is like to be a patient. Coming out of medical training, critical care was one of renova implants my strongest skills. I conducted countless blood gasses, which means drawing blood from an artery to test for oxygen and carbon dioxide levels, but never had one done to me.

I’ve heard renova implants the constant din of hospital bells and alarms, but never from a hospital bed. I’ve poked and prodded patients every few hours never knowing what it felt like. I knew that the jumble of cords and wires attached to my patients made it hard for them to move, and now feel foolish for suggesting that they “Try and get some sleep.” And I never could have imagined the feeling of being weighed down and immobilized by sensors and intravenous lines and other tubes.The experience of being in an intensive care unit for skin care products is making me ponder a whole new set of issues.

How can I be a renova implants better husband and father?. How do I show appreciation for the amazing care that saved my life?. How can I convince others of renova implants the severity of skin care products?.

How can I help health care workers empathize with the pain and anguish of being hospitalized — and alone — so we all rise to the challenges caring for the patients we serve?. How can I better lead ChenMed?. And how does God want me to use what I learned? renova implants.

Before this experience, I thought I knew a lot about skin care products. I was wrong renova implants. But here’s one thing I know for sure.

If you haven’t been taking the risk of this renova seriously, you should start now.When you’re an ICU patient with skin care products, it is like dying in solitary confinement.Christopher Chen is a cardiologist and CEO of ChenMed, which focuses on providing primary care for seniors..

skin care products is teaching everyone renova zero cost in medicine lessons renova cheap about health care and public health. Mine have been up close, personal, and frightening.One day I was a healthy 44-year-old doctor, CEO of a health care company, and a triathlete who was prepared to do another triathlon. Then I was a skin care products patient a few renova zero cost shallow breaths away from being put on a ventilator. A nurse saved me from that fate.A journey that made me ponder new questions and opened my eyes to a new sense of purpose and perspective started innocuously enough.

The soreness and aches began renova zero cost on a Monday night. A fever followed. I woke up Tuesday morning feeling awful. I got renova zero cost tested and it was official — I was one of the thousands of new skin care products patients that day.advertisementBy Friday, I was having trouble taking deep breaths.

My pulse oximeter showed 95%. Not bad, but not renova zero cost normal for me — that would have been 99% to 100%. Over the next two days, things got worse. Sunday morning, six days after first feeling sick, I walked to the bathroom and felt a new sensation. I was winded and light-headed.

My oxygen level was still 97%, but renova zero cost I was breathing much faster. As I sat on the edge of the bathtub, my respiratory rate was 18 breaths per minute (50% higher than usual) and my heart rate was 85 beats per minute (up from my baseline of 50).advertisementWhen you come from a family of doctors and lead a company of doctors, getting a second, third, and fourth opinion is easy. Everyone I reached had the same advice renova zero cost. Go to the hospital.

Before we left, my wife, Stephanie, called family members, friends, and my colleagues at ChenMed and asked everyone to pray for me. We weren’t sure how things would turn out, and we needed as many people as possible appealing to a higher power on my behalf.At the hospital, a CT scan showed skin care products-related pneumonia in all renova zero cost parts of my lungs. I was given a dose of steroids (dexamethasone) to decrease skin care products-related inflammation in my lungs, a shot of a blood thinner to prevent blood clots, and was then admitted.The hospital was fantastic. I knew many of the doctors, including the chief medical officer and the chief renova zero cost of cardiology.

They would walk by the window of my room, knock on the glass, then call my cell and reassure me I was in good hands.Even so, I began feeling despondent. It didn’t help that I kept feeling worse and worse. I felt like I was staring into a dark tunnel — standing alone and worrying about myself, my wife and children, my parents, and my renova zero cost company. Sure, nurses would come in frequently, but only fully gowned for two minutes or less.

Doctors would review my numbers renova zero cost and then call my phone to speak with me. I was alone, and I was lonely. Nights were the worst. That’s when the fevers were highest and my breathing was most labored. I felt like I was renova zero cost wasting away.

Covered in sweat, unable to bathe or shower, tied down by a web of wires, lines, and tubes and trying desperately to breathe. I got an inkling of what my heart failure patients experience when they cannot breathe due to fluid buildup in their lungs and feel like they are drowning from the inside out.I prayed for hope but feared the worst renova zero cost. I knew I was getting sicker, and had just heard that remdesivir, a promising antiviral drug, was in short supply. I was enrolled in a study to receive convalescent plasma — the liquid portion of blood from someone who had recovered from skin care products which is filled with antibodies against the renova — but was on the waiting list.I knew that everyone was working tirelessly to stop my skin care products from progressing, but I was losing ground.

Without a firm date for treatment, I felt renova zero cost sad and hopeless.On Tuesday night, my ICU nurse was a 6-foot-tall woman from Jamaica named Helen, though I’m pretty sure she had been a drill instructor in another life. If she wanted me to sit on the edge of the bed and I said “no,” we reached an understanding. I sat renova zero cost on the edge of the bed. Helen started her shift by changing my gown and sheets, then helped me take a chlorhexidine towel bath.

Those small acts of kindness felt wonderful.Despite having trouble breathing, I sometimes fell asleep. Then my breathing renova zero cost would slow and my blood oxygen level would drop to unsafe levels. Helen would open the door to my room and yell, “Chris, c’mon. You’ve got renova zero cost to breathe.

Breathe for me.” I knew what she was doing. Waking me up so you can look here I would breathe faster. When I took faster breaths, my blood oxygen would rise and the alarm attached to my pulse oximeter would stop chirping.If I couldn’t breathe renova zero cost on my own, I would be put on a ventilator and, if that happened, my chance of dying would skyrocket. I believe that Helen saved my life that night.Around 3 a.m.

She came into my renova zero cost room again. When I heard her voice, I immediately started to breathe faster. But this time she had a different message. €œChris, your plasma has arrived,” renova zero cost she told me.

€œI’m going to get it.”“Are you sure?. € I asked, since the plasma wasn’t supposed to get to the hospital for a few more days.“The blood bank just called,” she replied.All I could say renova zero cost was, “Praise God.” It was my first glimmer of hope.I received the plasma as the shift was changing in the morning. I wanted to give Helen a hug or at least shake her hand, but the best I could do in the time of skin care was to say an emotional “Thank you for getting me through last night” as she headed home.The following morning, my brother, who is a cardiologist, called and said remdesivir had been secured for me and I would get my first dose at 11 a.m. That afternoon, I began feeling better.

I was able to sit in the chair next to my renova zero cost bed. I wondered if the plasma and remdesivir were working, or whether my body was finally fighting its way back.I remained fever-free. When Saturday renova zero cost morning rolled around, my light-headedness had cleared. My breathing felt less labored and I was able to take deeper breaths.

My aches were subsiding, and I felt stronger and more alert. I walked around my renova zero cost room without becoming short of breath. I was ready to go home.As I was wheeled out of the ICU room, I looked around. When I arrived, half of the renova zero cost rooms — all reserved for skin care products patients — were empty.

As I left, all of them were full and many of the occupants were on ventilators. I asked to stop for a moment so I could say a prayer for my brothers and sisters with skin care products.Stephanie and my oldest son were waiting outside the hospital in a carport reserved for skin care products patients. I was overcome with emotion renova zero cost. We hugged and held each other tight.

For the first time since entering the ICU, I realized renova zero cost I would still get to be a husband, father, brother, and son, and would continue to lead ChenMed. I was overwhelmed.As I write this, it’s been 20 days since I first started feeling sick, and I am still recovering. I still have questions, but they are far different than the ones I thought about when I was in the hospital. I’ve realized how naïve I was about what it is like to be a patient. Coming out of medical training, renova zero cost critical care was one of my strongest skills.

I conducted countless blood gasses, which means drawing blood from an artery to test for oxygen and carbon dioxide levels, but never had one done to me. I’ve heard the constant din of hospital bells and renova zero cost alarms, but never from a hospital bed. I’ve poked and prodded patients every few hours never knowing what it felt like. I knew that the jumble of cords and wires attached to my patients made it hard for them to move, and now feel foolish for suggesting that they “Try and get some sleep.” And I never could have imagined the feeling of being weighed down and immobilized by sensors and intravenous lines and other tubes.The experience of being in an intensive care unit for skin care products is making me ponder a whole new set of issues.

How can I be a better husband and renova zero cost father?. How do I show appreciation for the amazing care that saved my life?. How can renova zero cost I convince others of the severity of skin care products?. How can I help health care workers empathize with the pain and anguish of being hospitalized — and alone — so we all rise to the challenges caring for the patients we serve?.

How can I better lead ChenMed?. And how does God want renova zero cost me to use what I learned?. Before this experience, I thought I knew a lot about skin care products. I was renova zero cost wrong.

But here’s one thing I know for sure. If you haven’t been taking the risk of this renova seriously, you should start now.When you’re an ICU patient with skin care products, it is like dying in solitary confinement.Christopher Chen is a cardiologist and CEO of ChenMed, which focuses on providing primary care for seniors..

Standard dimensioner og legeringer
Teoretisk vægt for standard dimensioner kg/m

D x d mm

JM 1-15 Rødgods

JM 3-15
Tin-bronze

JM 5-15
Bly-tin-bronze

JM 7-15/20 Aluminiumbronze

10x0

EXT 0,6

13x0

1.2

1.2

EXT 1,0

16x0

1.8

1.8

EXT 1,5

19x0

2.5

2.5

EXT 2,2

21x0

3.1

3.1

3.1

EXT 2,6

23x0

3,7

*3,7

EXT 3,2

26x0

4.7

4.7

4.7

EXT 4,0

26x14

3.5

3.5

3.5

26x18

2.5

28x0

5,9

5,9

EXT 4,7

29x13

4.7

4.7

4.7

29x19

3.6

31x0

6.7

6.7

6.7

EXT 5,7

31x14

5.5

*5,5

5.5

31x19

*4,5

33x0

7.6

7.6

EXT 6,5

33x13

6.4

*6,4

33x19

5.3

5.3

4.6

33x23

3.9

36x0

9.1

9.1

EXT 7,7

36x14

7.9

36x19

6.8

6.8

6.8

36x24

5.4

38x0

10.6

*10,6

EXT 9,1

39x26

5.9

39x28

5.2

41x0

11.8

11.8

11.8

EXT 10,0

41x13

10.6

10.6

41x18

9.5

9.5

9.5

41x23

8.1

41x28

6.3

42x28

5.9

43x0

12.9

12.9

43x26

*8.2

8.2

8.2

43x33

5.3

46x0

14.8

14.8

EXT 12,6

46x13

13.6

13.6

46x18

12.5

46x23

11.1

11.1

11.1

46x28

9.3

46x33

7.2

7.2

7.2

47x23

10.0

47x28

8.5

51x0

18.2

18.2

18.2

15.5

51x18

15.9

15.9

15.9

51x23

14.5

51x28

12.7

12.7

12.7

51x33

10.6

51x38

8.1

8.1

52x18

14.2

52x23

13.0

52x28

11.5

52x38

7.5

56x0

21.9

21.9

18.7

56x18

*19.6

56x23

18.2

56x28

16.4

56x33

14.3

14.3

56x38

11.8

56x43

9,0

57x43

8.4

61x0

26.0

26.0

26.0

22.2

61x18

23.7

23.7

61x23

22.3

61x28

20.5

20.5

61x33

18.4

61x38

15.9

15.9

61x43

13.1

61x48

9.9

9.9

9.9

62x18

21.0

62x28

18.3

62x38

14.3

62x48

9.2

67x0

31.0

31.0

26.8

67x18

29.1

67x23

*27,7

67x28

25.9

67x33

*23,8

67x38

21.3

67x43

18.5

18.5

15.8

67x48

15.3

67x53

11.7

72x0

35.8

35.8

35.8

30.9

72x18

34.0

34.0

72x23

*32,5

27.8

72x28

30.8

30.8

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28.6

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26.1

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23.3

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20.1

20.1

17.2

72x53

16.6

16.6

72x58

12.7

10.9

77x0

41.0

41.0

35.4

77x23

37.7

77x28

*35,9

77x33

33.8

77x38

31.4

31.4

77x43

28.5

77x48

25.3

77x53

21.8

21.8

77x58

17.9

15.3

77x63

*13.7

82x0

46.4

46.4

46.4

40.1

82x28

41.5

41.5

41.5

82x33

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82x38

36.9

31.5

82x43

34.1

34.1

82x48

30.9

26.4

82x53

27.4

82x58

23.5

23.5

20.1

82x63

19.3

82x68

14.7

12.5

87x0

52.3

52.3

45.2

87x28

47.4

*47,4

87x33

*45,3

87x38

*42,8

36.6

87x43

*40,0

87x48

36.8

87x53

33.3

87x58

29.4

29.4

25.1

87x63

25.2

87x68

20.6

87x73

15.7

92x0

58.5

58.5

58.5

50.5

92x28

53.7

92x33

*51,5

*51,5

92x38

49.0

92x43

*46.2

92x48

43.1

43.1

36.8

92x53

*39.5

92x58

35.6

30.4

92x63

31.4

92x68

26.8

26.8

22.9

92x73

21.9

92x78

16.6

97x0

65.8

65.8

56.2

97x38

55.6

97x43

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97x48

49.6

97x53

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97x58

*42,3

97x63

38.0

97x68

33.4

33.4

97x73

28.5

97x78

23.2

97x83

*17.6

102x0

72.7

72.7

72.7

62.1

102x38

62.6

102x48

56.6

56.6

48.4

102x58

49.2

49.2

42.0

102x68

40.4

34.5

102x73

35.0

102x78

30.2

25.8

102x83

*24.6

102x88

18.6

107x58

56.7

107x63

52.2

52.2

107x73

*42.8

107x78

37.5

107x83

31.9

107x88

25.9

112x0

87.7

87.7

87.7

74.9

112x38

77.6

112x48

71.5

71.5

61.1

112x58

64.1

54.8

112x63

60.0

112x68

55.3

47.3

112x78

45.1

45.1

112x88

33.6

28.7

112x93

27.2

117x63

67.9

117x73

58.4

58.4

117x83

47.5

117x93

*35.2

117x98

28.6

122x0

104.0

104.0

104.0

88.9

122x68

71.7

71.7

61.2

122x78

61.5

122x88

49.2

42.6

122x98

36.9

31.5

122x103

*29,9

127x63

85.0

85.0

85.0

127x73

75.5

127x83

64.6

127x93

52.3

127x103

38.6

127x108

31.2

132x0

121.8

121.8

122.0

104.0

132x68

89.1

132x78

79.2

67.7

132x88

67.6

132x98

53.9

132x108

40.2

135x0

108.7

137x73

93.9

137x93

*70,7

137x103

57.0

142x0

140.9

140.9

141.5

120.4

142x58

117.4

142x78

98.4

98.4

142x88

74.1

142x98

73.0

142x108

58.7

142x118

43.6

147x103

76.9

147x123

45.3

152x0

161.5

161.5

162.0

137.9

152x88

107.3

152x98

94.3

94.3

80.6

152x108

79.9

152x118

64.1

64.1

152x128

47.0

162x0

183.4

183.4

183.5

156.7

162x98

116.3

116.3

116.3

162x118

86.1

73.5

162x128

68.9

162x138

50.3

50.3

172x0

207.0

207.0

172x108

125.2

*107,0

172x128

92.2

172x138

73.6

172x148

53.7

53.7

182x0

232.0

232.0

EXT 197.8

182x118

134.1

182x128

117.5

*99,9

182x138

98.4

182x148

78.4

182x158

57.0

57.0

192x0

258.0

258.0

EXT 220.1

192x128

143.1

192x148

104.5

*89,3

192x168

60.4

202x0

285.0

285.0

202x98

218.0

218.0

218.0

202x138

152.0

152.0

202x148

*112,8

202x158

110.7

202x178

63.7

205x82

*246,8

212x138

180.4

212x148

161.0

212x158

*119,2

212x168

116.8

212x178

92.6

212x188

66.0

222x0

344.0

344.0

222x98

277.2

277.2

222x148

191.3

222x168

147.1

*125,7

222x178

123.0

222x188

97.4

232x158

201.6

201.6

232x178

154.7

*132,1

232x188

129.1

232x198

102.1

242x168

212.0

212.0

242x188

162.2

*138,6

242x198

135.3

242x208

106.9

252x0

444.0

444.0

252x178

222.3

*189,9

252x198

169.8

252x208

141.4

252x218

111.6

262x198

*175,7

262x218

147.6

262x228

116.4

272x168

319.7

319.7

272x228

153.7

272x238

121.1

276x0

*532,5

282x218

*191,0

282x238

159.9

282x248

125.9

292x188

348.8

292x248

166.0

302x148

484.4

302x198

363.3

363.3

*310,4

302x258

172.1

322x238

*280,8

332x248

*290,9

332x273

249.4

352x148

713.0

362x293

315.8

*269,8

392x343

251.6

402x148

976.5

402x348

*241,8

Firkant stænger
Standard dimensioner og legeringer
Standardlængder: 500, 1000, 2000 mm

A x B mm

JM 1-15 Rødgods

JM 3-15
Tin-bronze

JM 7-15/20 Aluminiumbronze

30x30

*6,8

32x32

9,1

9,1

40x40

*12,0

42x42

15,7

15,7

45x45

*15,2

52x12

5,6

5,6

52x14

6,5

6,5

52x18

8,3

8,3

52x22

10,2

10,2

52x52

24,1

24,1

55x55

*22,7

60x60

*27,4

67x12

7,2

7,2

67x14

8,3

8,3

67x18

10,7

10,7

67x22

13,1

13,1

67x32

19,1

19,1

16,3

70x70

*43,6

80x42

25,8

80x51

31.3

82x12

8,8

8,8

82x14

10,2

10,2

82x18

13,1

13,1

82x22

16,1

16,1

102x12

10,9

10,9

102x14

12,7

12,7

102x18

16,3

16,3

102x22

20,2

20,2

102x52

47

103x30

*23,5

105x55

44.2

122x18

19,5

19,5

122x22

23,9

23,9

130x63

62.6

130x65

74,7

142x18

22,7

22,7

142x22

27,8

27,8

150x70

*79,8

150x90

102,6

162x18

26

26

162x22

31,7

31,7

162x72

103

182x18

29,2

29,2

182x22

35,6

35,6

185x90

*126,5

202x18

32,4

32,4

202x22

39,6

39,6

202x30

*46,1

Sekskant stænger
Standard dimensioner og legeringer
Standardlængder: 500, 1000, 2000, 3000 mm. Sekskantstænger m/ hul fremstilles på bestilling

NV mm

JM 1-15 Rødgods

17

2,2

18

2,5

22

3,7

24

4,4

26

5,2

28

6

32

7,9

36

10

44

14,9

50

19,3