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€‹15 full-time equivalent specialist counsellors will be deployed across rural NSW to help prevent suicide, with the first two carafate best price counsellors starting in the Eurobodalla and Snowy Mountains regions.NSW Mental Health Minister Bronnie Taylor said the relatively high rates of suicide in rural areas are devastating families and communities, and the $6.75 million investment will add another layer of help.“Many factors can contribute to suicide, from domestic violence, to relationship issues or unemployment, to stress and hardship,” Mrs Taylor said. €œThese specialist mental health counsellors are there on the ground to support people thinking of suicide or impacted by suicide, and I encourage communities across the state to lean on them for support.”Director Mental Health Drug and Alcohol for Southern NSW Local Health District Damien Eggleton said he wants more people to ask for help when they need it. €œOur rural communities have proven beyond a doubt they’re resilient and fearless when faced with adversity, carafate best price whether that be geographic isolation, searing drought or the impact of the current pandemic – but they don’t need to go it alone,” Mr Eggleton said. €œThe support provided by these counsellors will complement the peer work and drought support provided by our Farm Gate Counsellors and Drought Counsellors.”Rural counsellor Samara Byrne said she wants young people to know there are people you can turn to when feeling overwhelmed with life or feeling like a burden on others.

€œWe are here for you and here to listen if you are feeling distressed, anxious carafate best price or a burden to loved ones. The service is easily accessible through the Mental Health Line. Just ask for the Rural Counsellor.”“Having moved from Sydney in 2016 to our beautiful farm in SNSW, I am so pleased to be able to do what I am most passionate about, supporting people’s wellbeing in Rural Australia and carafate best price building on the natural local community resilience”.Minister Taylor urges people in the bush to get help by contacting these rural counsellors. €œSupport is available, all you need to do is pick up the phone and make an appointment by calling the NSW Mental Health Line on 1800 011 511.”The 15 rural counselling positions are part of the Towards Zero Suicides.

A $87 million investment over three years in new suicide prevention initiatives carafate best price. A NSW Premier’s Priority, this is a whole-of-government commitment to transforming the way we identify and support anyone impacted by suicide.If you, or someone you know, is thinking about suicide or experiencing a personal crisis or distress, please seek help immediately in a life-threatening situation by calling 000 or seek support though one of these services:Lifeline 13 11 14Suicide Call Back Service 1300 659 467NSW Mental Health Line 1800 011 511Minister for Mental Health Bronnie Taylor and Minister for Police and Emergency Services David Elliott today announced the expansion of the Police Ambulance and Clinical Early Response (PACER) pilot program.“This ground breaking collaboration embeds mental health experts with first responders to support them to appropriately recognise, assess, and respond to mental health emergencies live at the scene,” Mrs Taylor said. €œThe pilot program has had incredible results with significant reductions in emergency department presentations, police and ambulance time carafate best price on scene. €œThis approach has enormous potential to change lives, with the community getting more appropriate care at the time when they need it most.” Mr Elliott welcomed the support for the police officers who are deeply committed to serving and protecting the people of NSW “During the pilot program, police time-on-scene was reduced by an average of 45 minutes, not only supporting first responders to appropriately recognise and respond to psychiatric incidents in the community, but also freeing up officers to serve thecommunity in other areas,” Mr Elliott said.

€œThe presence and availability of a PACER clinician in a police station increases the knowledge and understanding of mental health issues amongst officers This initiative is crucial, now more than ever, following the devastating ‘Black Summer’ bushfires and the COVID-19 pandemic, which have affected us all.” NSW Police Force Deputy Commissioner, carafate best price Malcolm Lanyon APM, said the PACER model has been a success at the trial site in St George Police Area Command. €œDuring the trial we saw a significant reduction in time taken for police to respond to these matters. It translated carafate best price to a better outcome for both our officers and the individuals in need of assistance,” Mr Lanyon said. The PACER program will expand to Campbelltown, Nepean, Northern Beaches, Sutherland Shire, Blacktown, Eastern Beaches, Kuring-gai, Metro Combined consisting of Kings Cross/Surry Hills/City of Sydney, South Sydney and Bankstown Police Area Commands with recruitment underway for the specialist mental health clinicians from July 2020.

This investment is part of the $73 million suite of mental health measures recently announced by the NSW Government carafate best price. This includes 216 new mental health staff, additional funding for the NSW Mental Health Line, extra support for Telehealth, funding for extra therapeutic programs to aid recovery in mental health units and a $6 million investment in Lifeline to expand their invaluable service..

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Comfort and pain management have always been paramount in the child-centered approach to care at UC how to get carafate in the us Davis Children’s Hospital. A new hospital initiative called Comfort Commitment launched this month, which provides a standardized approach to how to get carafate in the us help pediatric patients better cope with distressing procedures and decrease pain and anxiety. Child life specialist Emily McDaniel and nurse Carter Todd discuss comfort planning with a patient.It involves four steps to managing a patient’s comfort:Ask the child and caregiver what they know and understand about the procedureShare more about the procedure in simple terms using honest, age-appropriate languagePlan for the procedure, considering medicine and numbing options, refocusing techniques (toys, electronics, music), comfort positions (chest-to-chest for small children with their caregiver, swaddle for infants and young toddlers) and a calming environment (with lights, noises and words)Follow the agreed-upon plan and ensure the child feels heard and modify comfort measures to meet the patient’s needs“Our ultimate goal is to establish an environment where hospital experiences can be growth-promoting for children and families,” said child life specialist Emily McDaniel. €œThrough individualizing procedural how to get carafate in the us comfort plans with this collaborative four-step process, we are consistently able to provide coping support and empower the child to customize a plan that uniquely meets their specific needs.”The initiative was funded by a Children's Miracle Network at UC Davis grant. For more information, visit https://ucdavis.health/comfort.A pandemic is probably not the best time to refer to someone’s personality as ‘infectious.’ Shalaine Reddic has always believed she could do more than people thought she could.But you don’t have to talk with Shalaine Reddic for long, even on the phone, to feel the positive energy and can-do spirit of this UC Davis Medical Center nurse.Reddic’s desire to help patients blends perfectly with her strong drive to succeed, academic muscle and never-say-die attitude – all wrapped up in what she calls her fashion-forward style.A single mother of three, Reddic has never stopped moving up the career ladder.

She started out doing clerical how to get carafate in the us work on the Davis campus years ago. Today, Reddic is on the verge of how to get carafate in the us becoming a licensed nurse practitioner.“I always like to stay busy,” said Reddic.That’s an understatement. She was deftly juggling the phone conversation after a long work week while providing cooking instruction to her 16-year-old son. €œAnd I’ve always believed that I could do more than people thought I could,” she said.When she first started working, the Rancho Cordova resident didn’t consider the patient how to get carafate in the us side of health care. She didn’t enjoy the thought of seeing blood or being in the clinic environment.

But after becoming a clinical quality improvement coordinator at UC Davis Health, she started working with nurses and quickly gained an appreciation for the profession.Reddic spent nearly 10 years slowly but steadily taking classes and moving from one nursing degree to the next – from an associate of art’s degree at a community college to a bachelor’s degree (cum laude, of course) from Sacramento State – all while how to get carafate in the us working and almost single-handedly raising her children.“I have seen her push through personal issues on numerous occasions,” said Darrell Desmond, nurse manager of Reddic’s hospital unit. €œBut she just keeps moving forward with an always positive attitude despite life’s many challenges.”It was how to get carafate in the us while volunteering at a community clinic for underserved women in Sacramento that Reddic had what she calls an epiphany. It was a moment of intense clarity for someone who already had a rewarding nursing career.“I saw nurse practitioners working with patients, diagnosing health problems, prescribing medications,” Reddic said. €œThey were providers how to get carafate in the us. They had the autonomy to make patient-care decisions.

For me, that was how to get carafate in the us it. I was in tears because I knew then and there that was what I really wanted to do.”So, Reddic decided to add another academic achievement to her three nursing degrees and an AA degree in business administration. A graduate degree as a family nurse practitioner.Always on the move, Reddic never stops seeking new goals and achievements.Three years and many commute miles later, she recently completed how to get carafate in the us her master’s from Sonoma State and is now studying for her boards. While working full time, of course.Reddic admits to being overwhelmed how to get carafate in the us at times over the years. But she said strong faith and prayer helped her put things in perspective when she felt defeated and exhausted.“It’s been a journey and a learning process,” Reddic said.

€œI’ve got a few bruises, but I’m how to get carafate in the us still here and excited about each day. When I face adversity, I always step it up a notch.”As if it wasn’t enough to become a nurse practitioner, Reddic is considering going back to school for a certificate in psychiatry and, perhaps, a doctorate at some point.She’s also dreaming about plans for starting two independent clinics. One would be dedicated to how to get carafate in the us serving underprivileged communities. The other would be an IV hydration bar, a trending intravenous therapy program how to get carafate in the us for wellness, beauty and health.“Shalaine has organized her life for success,” said Joleen Lonigan, an executive director of Patient Care Services at UC Davis Medical Center. €œShe’s turned her motivation into achievements and her pathway into inspiration that can benefit others.”Her story is undoubtedly motivational for anyone who knows Reddic.

Colleagues say how to get carafate in the us her determination is impressive. Her attitude always stays positive, undoubtedly enhanced by that fashion-forward sensibility that can be seen, despite the required nursing apparel, in some colorful shoe choices and unique earrings. And those how to get carafate in the us academic and clinical accomplishments?. They’re likely just steppingstones leading toward further personal and professional goals.In short, Shalaine Reddic and the spirit with which she approaches life seem – even in a pandemic age – wonderfully contagious..

Comfort and pain management have always been paramount in the child-centered approach to care at UC Davis Children’s Hospital carafate best price. A new hospital initiative called Comfort Commitment launched this month, which provides a standardized approach to help pediatric patients better cope with distressing procedures and decrease pain and carafate best price anxiety. Child life specialist Emily McDaniel and nurse Carter Todd discuss comfort planning with a patient.It involves four steps to managing a patient’s comfort:Ask the child and caregiver what they know and understand about the procedureShare more about the procedure in simple terms using honest, age-appropriate languagePlan for the procedure, considering medicine and numbing options, refocusing techniques (toys, electronics, music), comfort positions (chest-to-chest for small children with their caregiver, swaddle for infants and young toddlers) and a calming environment (with lights, noises and words)Follow the agreed-upon plan and ensure the child feels heard and modify comfort measures to meet the patient’s needs“Our ultimate goal is to establish an environment where hospital experiences can be growth-promoting for children and families,” said child life specialist Emily McDaniel. €œThrough individualizing procedural comfort plans with this collaborative four-step process, we are consistently able to provide coping support carafate best price and empower the child to customize a plan that uniquely meets their specific needs.”The initiative was funded by a Children's Miracle Network at UC Davis grant. For more information, visit https://ucdavis.health/comfort.A pandemic is probably not the best time to refer to someone’s personality as ‘infectious.’ Shalaine Reddic has always believed she could do more than people thought she could.But you don’t have to talk with Shalaine Reddic for long, even on the phone, to feel the positive energy and can-do spirit of this UC Davis Medical Center nurse.Reddic’s desire to help patients blends perfectly with her strong drive to succeed, academic muscle and never-say-die attitude – all wrapped up in what she calls her fashion-forward style.A single mother of three, Reddic has never stopped moving up the career ladder.

She started out doing clerical work on the Davis campus carafate best price years ago. Today, Reddic is on the verge of becoming a licensed nurse practitioner.“I always like to stay carafate best price busy,” said Reddic.That’s an understatement. She was deftly juggling the phone conversation after a long work week while providing cooking instruction to her 16-year-old son. €œAnd I’ve always believed that I carafate best price could do more than people thought I could,” she said.When she first started working, the Rancho Cordova resident didn’t consider the patient side of health care. She didn’t enjoy the thought of seeing blood or being in the clinic environment.

But after becoming a clinical quality improvement coordinator at UC Davis Health, she started working with nurses and quickly gained an appreciation for the profession.Reddic spent nearly 10 years slowly but steadily taking classes and moving from one nursing degree to the next – from an associate of art’s degree at a community college to a bachelor’s degree (cum laude, of course) from Sacramento State – all while working and almost single-handedly raising her children.“I have seen her push carafate best price through personal issues on numerous occasions,” said Darrell Desmond, nurse manager of Reddic’s hospital unit. €œBut she carafate best price just keeps moving forward with an always positive attitude despite life’s many challenges.”It was while volunteering at a community clinic for underserved women in Sacramento that Reddic had what she calls an epiphany. It was a moment of intense clarity for someone who already had a rewarding nursing career.“I saw nurse practitioners working with patients, diagnosing health problems, prescribing medications,” Reddic said. €œThey were carafate best price providers. They had the autonomy to make patient-care decisions.

For me, that was it carafate best price. I was in tears because I knew then and there that was what I really wanted to do.”So, Reddic decided to add another academic achievement to her three nursing degrees and an AA degree in business administration. A graduate degree as a family nurse practitioner.Always on the move, Reddic never stops seeking new goals and achievements.Three years and many commute miles later, carafate best price she recently completed her master’s from Sonoma State and is now studying for her boards. While working full time, of course.Reddic admits to being overwhelmed at carafate best price times over the years. But she said strong faith and prayer helped her put things in perspective when she felt defeated and exhausted.“It’s been a journey and a learning process,” Reddic said.

€œI’ve got a few bruises, but I’m still here and excited carafate best price about each day. When I face adversity, I always step it up a notch.”As if it wasn’t enough to become a nurse practitioner, Reddic is considering going back to school for a certificate in psychiatry and, perhaps, a doctorate at some point.She’s also dreaming about plans for starting two independent clinics. One would be dedicated to serving underprivileged carafate best price communities. The other would be an IV hydration bar, a trending intravenous therapy program for wellness, beauty and health.“Shalaine has organized her life carafate best price for success,” said Joleen Lonigan, an executive director of Patient Care Services at UC Davis Medical Center. €œShe’s turned her motivation into achievements and her pathway into inspiration that can benefit others.”Her story is undoubtedly motivational for anyone who knows Reddic.

Colleagues say her determination carafate best price is impressive. Her attitude always stays positive, undoubtedly enhanced by that fashion-forward sensibility that can be seen, despite the required nursing apparel, in some colorful shoe choices and unique earrings. And those academic and clinical carafate best price accomplishments?. They’re likely just steppingstones leading toward further personal and professional goals.In short, Shalaine Reddic and the spirit with which she approaches life seem – even in a pandemic age – wonderfully contagious..

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High burden of antibiotic-resistant Mycoplasma genitalium in symptomatic urethritisMycoplasma genitalium is an aetiological agent of sexually where can i get carafate transmitted urethritis. A cohort study investigated M. Genitalium prevalence, antibiotic resistance and association with previous macrolide exposure among 1816 Chinese men who presented with symptomatic urethritis where can i get carafate between 2011 and 2015. Infection was diagnosed by PCR, and sequencing was used to detect mutations that confer resistance to macrolides and fluoroquinolones.

In 11% where can i get carafate of men, M. Genitalium was the sole pathogen identified. Nearly 90% where can i get carafate of infections were resistant to macrolides and fluoroquinolones. Previous macrolide exposure was associated with higher prevalence of resistance (97%).

The findings point where can i get carafate to the need for routine screening for M. Genitalium in symptomatic men with urethritis. Treatment strategies to overcome where can i get carafate antibiotic resistance in M. Genitalium are needed.Yang L, Xiaohong S, Wenjing L, et al.

Mycoplasma genitalium in symptomatic where can i get carafate male urethritis. Macrolide use is associated with increased resistance. Clin Infect Dis 2020;5:805–10. Doi:10.1093/cid/ciz294.A new entry inhibitor offers promise for treatment-experienced patients where can i get carafate with multidrug-resistant HIVFostemsavir, the prodrug of temsavir, is an attachment inhibitor.

By targeting the gp120 protein on the HIV-1 envelope, it prevents viral interaction with the CD4 receptor. No cross-resistance has been described with where can i get carafate other antiretroviral agents, including those that target viral entry by other modalities. In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who had exhausted ≥4 classes of antiretrovirals received fostemsavir with an optimised regimen. After 48 weeks, 54% of those with 1–2 additional active drugs achieved viral where can i get carafate load suppression <40 copies/mL.

Response rates were 38% among patients lacking other active agents. Drug-related adverse events included nausea (4%) and diarrhoea where can i get carafate (3%). As gp120 substitutions reduced fostemsavir susceptibility in up to 70% of patients with virological failure, fostemsavir offers the most valuable salvage option in partnership with other active drugs.Kozal M, Aberg J, Pialoux G, et al. Fostemsavir in adults with multidrug-resistant where can i get carafate HIV-1 infection.

N Engl J Med 2020;382:1232–43. Doi. 10.1056/NEJMoa1902493Novel tools to aid identification of hepatitis C in primary careHepatitis C can now be cured with oral antiviral treatment, and improving diagnosis is a key element of elimination strategies.1 A cluster randomised controlled trial in South West England tested performance and cost-effectiveness of an electronic algorithm that identified at-risk patients in primary care according to national recommendations,2 coupled with educational activities and interventions to increase patients’ awareness. Outcomes were testing uptake, diagnosis and referral to specialist care.

Practices in the intervention arm had an increase in all outcome measures, with adjusted risk ratios of 1.59 (1.21–2.08) for uptake, 2.24 (1.47–3.42) for diagnosis and 5.78 (1.60–21.6) for referral. The intervention was highly cost-effective. Electronic algorithms applied to practice systems could enhance testing and diagnosis of hepatitis C in primary care, contributing to global elimination goals.Roberts K, Macleod J, Metcalfe C, et al. Cost-effectiveness of an intervention to increase uptake of hepatitis C virus testing and treatment (HepCATT).

Cluster randomised controlled trial in primary care. BMJ 2020;368:m322. Doi:10.1136/bmj.m322Low completion rates for antiretroviral postexposure prophylaxis (PEP) after sexual assaultA 4-week course of triple-agent postexposure prophylaxis (PEP) is recommended following a high-risk sexual assault.3 4 A retrospective study in Barcelona identified 1695 victims attending an emergency room (ER) between 2006 and 2015. Overall, 883 (52%) started prophylaxis in ER, which was mostly (43%) lopinavir/ritonavir based.

Follow-up appointments were arranged for those living in Catalonia (631, 71.5%), and of these, only 183 (29%) completed treatment. Loss to follow-up was more prevalent in those residing outside Barcelona. PEP non-completion was associated with a low perceived risk, previous assaults, a known aggressor and a positive cocaine test. Side effects were common, occurring in up to 65% of those taking lopinavir/ritonavir and accounting for 15% of all discontinuations.

More tolerable PEP regimens, accessible follow-up and provision of 1-month supply may improve completion rates.Inciarte A, Leal L, Masfarre L, et al. Postexposure prophylaxis for HIV infection in sexual assault victims. HIV Med 2020;21:43–52. Doi:10.1111/hiv.12797.Effective antiretroviral therapy reduces anal high-risk HPV infection and cancer riskAmong people with HIV, effective antiretroviral therapy (ART) is expected to improve control of anal infection with high-risk human papillomavirus (HR-HPV) and reduce the progression of HPV-associated anal lesions.

The magnitude of the effect is not well established. By meta-analysis, people on established ART (vs ART-naive) had a 35% lower prevalence of HR-HPV infection, and those with undetectable viral load (vs detectable viral load) had a 27% and 16% reduced risk of low and high-grade anal lesions, respectively. Sustained virological suppression on ART reduced by 44% the risk of anal cancer. The role of effective ART in reducing anal HR-HPV infection and cancer risks is especially salient given current limitations in anal cancer screening, high rates of anal lesion recurrence and access to vaccination.Kelly H, Chikandiwa A, Alemany Vilches L, et al.

Association of antiretroviral therapy with anal high-risk human papillomavirus, anal intraepithelial neoplasia and anal cancer in people living with HIV. A systematic review and meta-analysis. Lancet HIV. 2020;7:e262–78.

Doi:10.1016/S2352-3018(19)30434-5.The impact of sex work laws and stigma on HIV prevention among female sex workersSex work laws and stigma have been established as structural risk factors for HIV acquisition among female sex workers (FSWs). However, individual-level data assessing these relationships are limited. A study examined individual-level data collected in 2011–2018 from 7259 FSWs across 10 sub-Saharan African countries. An association emerged between HIV prevalence and increasingly punitive and non-protective laws.

HIV prevalence among FSWs was 11.6%, 19.6% and 39.4% in contexts where sex work was partly legalised, not recognised or criminalised, respectively. Stigma measures such as fear of seeking health services, mistreatment in healthcare settings, lack of police protection, blackmail and violence were associated with higher HIV prevalence and more punitive settings. Sex work laws that protect sex workers and reduce structural risks are needed.Lyons CE, Schwartz SR, Murray SM, et al. The role of sex work laws and stigmas in increasing HIV risks among sex workers.

Nat Commun 2020;11:773. Doi:10.1038/s41467-020-14593-6.BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a COVID-19 contact tracing pathway for Cumbria. The local system was live 10 days prior to the national system on 18 May 2020. It was designed to interface and dovetail with the government’s track and trace programme.Our involvement in this initiative was due to a chance meeting between Professor Matt Phillips, Consultant in Sexual Health and HIV, and the Director of Public Health Cumbria, Colin Cox.

Colin knew that Cumbria needed to act fast to prevent the transmission of COVID-19 and Matt knew that sexual health had the skills to help.ProcessDespite over 90% of the staff from CSHS being redeployed in March 2020, CSHS maintained urgent sexual healthcare for the county and a phone line for advice and guidance. As staff began to return to the service in May 2020 we had capacity to spare seven staff members, whose hours were the equivalent of four full-time staff. We had one system administrator, three healthcare assistants, one nurse, Health Advisor Helen Musker and myself.CSHS were paramount to the speed with which the local system began. Following approval from the Trust’s chief executive officer we had adapted our electronic patient records (EPR) system, developed a standard operating procedure and trained staff, using a stepwise competency model, within just 1 day.In collaboration with the local laboratories we developed methods for the input of positive COVID-19 results into our EPR derivative.

We ensured that labs would be able to cope with the increase in testing and that testing hubs had additional capacity. Testing sites and occupational health were asked to inform patients that if they tested positive they would be contacted by our teams.This initiative involved a multiagency system including local public health (PH) teams, local authority, North Cumbria and Morecambe Bay CCGs, Public Health England (PHE) and the military. If CSHS recognise more than one positive result in the same area/organisation, they flag this with PH at the daily incident management meeting and environmental health officers (EHOs) provide advice and guidance for the organisation. We have had an active role in the contact tracing for clusters in local general practices, providing essential information to PH to enable them to initiate outbreak control and provide accurate advice to the practices.

We are an integral part in recognising cases in large organisations and ensuring prompt action is taken to stem the spread of the disease. The team have provided out-of-hours work to ensure timely and efficient action is taken for all contacts.The local contact tracing pilot has evolved and a database was established by local authorities. Our data fed directly into this from the end of May 2020. This enables the multiagency team to record data in one place, improving recognition of patterns of transmission.DiscussionCumbria is covered by three National Health Service Trusts, which meant accessing data outside of our Trust was challenging and took more time to establish.

There are two CCGs for Cumbria, which meant discussions regarding testing were needed with both North and South CCGs and variations in provision had to be accounted for. There are six boroughs in Cumbria with different teams of EHOs working in each. With so many people involved, not only is there need for large-scale frequent communication across a multisystem team, there is also inevitable duplication of work.Lockdown is easing and sexual health clinics are increasing capacity in a new world of virtual appointments and reduced face-to-face consultations. Staff within the contact tracing team are now balancing their commitments across both teams to maintain their skills and keep abreast of the rapid developments within our service due to COVID-19.

We are currently applying for funding from PH in order to second staff and backfill posts in sexual health.ConclusionCSHS have been able to lend our skills effectively to the local contact tracing efforts. We have expedited the contact tracing in Cumbria and provided crucial information to help contain outbreaks. It has had a positive effect on staff morale within the service and we have gained national recognition for our work. We have developed excellent relationships with our local PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of COVID-19.

The beauty of this model is that if we are faced with a second lockdown, sexual health staff will inevitably be available to help with the increased demand for contact tracing. Our ambition is that this model will be replicated nationally..

High burden of antibiotic-resistant Mycoplasma genitalium in carafate best price symptomatic urethritisMycoplasma genitalium is an aetiological agent of sexually transmitted urethritis. A cohort study investigated M. Genitalium prevalence, antibiotic resistance and association with previous macrolide exposure among 1816 Chinese men who presented carafate best price with symptomatic urethritis between 2011 and 2015. Infection was diagnosed by PCR, and sequencing was used to detect mutations that confer resistance to macrolides and fluoroquinolones.

In 11% carafate best price of men, M. Genitalium was the sole pathogen identified. Nearly 90% of infections carafate best price were resistant to macrolides and fluoroquinolones. Previous macrolide exposure was associated with higher prevalence of resistance (97%).

The findings carafate best price point to the need for routine screening for M. Genitalium in symptomatic men with urethritis. Treatment strategies to overcome antibiotic resistance carafate best price in M. Genitalium are needed.Yang L, Xiaohong S, Wenjing L, et al.

Mycoplasma genitalium in symptomatic carafate best price male urethritis. Macrolide use is associated with increased resistance. Clin Infect Dis 2020;5:805–10. Doi:10.1093/cid/ciz294.A new entry inhibitor offers promise for treatment-experienced patients with multidrug-resistant HIVFostemsavir, the prodrug of carafate best price temsavir, is an attachment inhibitor.

By targeting the gp120 protein on the HIV-1 envelope, it prevents viral interaction with the CD4 receptor. No cross-resistance has been described carafate best price with other antiretroviral agents, including those that target viral entry by other modalities. In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who had exhausted ≥4 classes of antiretrovirals received fostemsavir with an optimised regimen. After 48 weeks, 54% of those with carafate best price 1–2 additional active drugs achieved viral load suppression <40 copies/mL.

Response rates were 38% among patients lacking other active agents. Drug-related adverse events included nausea (4%) carafate best price and diarrhoea (3%). As gp120 substitutions reduced fostemsavir susceptibility in up to 70% of patients with virological failure, fostemsavir offers the most valuable salvage option in partnership with other active drugs.Kozal M, Aberg J, Pialoux G, et al. Fostemsavir in adults with multidrug-resistant HIV-1 carafate best price infection.

N Engl J Med 2020;382:1232–43. Doi. 10.1056/NEJMoa1902493Novel tools to aid identification of hepatitis C in primary careHepatitis C can now be cured with oral antiviral treatment, and improving diagnosis is a key element of elimination strategies.1 A cluster randomised controlled trial in South West England tested performance and cost-effectiveness of an electronic algorithm that identified at-risk patients in primary care according to national recommendations,2 coupled with educational activities and interventions to increase patients’ awareness. Outcomes were testing uptake, diagnosis and referral to specialist care.

Practices in the intervention arm had an increase in all outcome measures, with adjusted risk ratios of 1.59 (1.21–2.08) for uptake, 2.24 (1.47–3.42) for diagnosis and 5.78 (1.60–21.6) for referral. The intervention was highly cost-effective. Electronic algorithms applied to practice systems could enhance testing and diagnosis of hepatitis C in primary care, contributing to global elimination goals.Roberts K, Macleod J, Metcalfe C, et al. Cost-effectiveness of an intervention to increase uptake of hepatitis C virus testing and treatment (HepCATT).

Cluster randomised controlled trial in primary care. BMJ 2020;368:m322. Doi:10.1136/bmj.m322Low completion rates for antiretroviral postexposure prophylaxis (PEP) after sexual assaultA 4-week course of triple-agent postexposure prophylaxis (PEP) is recommended following a high-risk sexual assault.3 4 A retrospective study in Barcelona identified 1695 victims attending an emergency room (ER) between 2006 and 2015. Overall, 883 (52%) started prophylaxis in ER, which was mostly (43%) lopinavir/ritonavir based.

Follow-up appointments were arranged for those living in Catalonia (631, 71.5%), and of these, only 183 (29%) completed treatment. Loss to follow-up was more prevalent in those residing outside Barcelona. PEP non-completion was associated with a low perceived risk, previous assaults, a known aggressor and a positive cocaine test. Side effects were common, occurring in up to 65% of those taking lopinavir/ritonavir and accounting for 15% of all discontinuations.

More tolerable PEP regimens, accessible follow-up and provision of 1-month supply may improve completion rates.Inciarte A, Leal L, Masfarre L, et al. Postexposure prophylaxis for HIV infection in sexual assault victims. HIV Med 2020;21:43–52. Doi:10.1111/hiv.12797.Effective antiretroviral therapy reduces anal high-risk HPV infection and cancer riskAmong people with HIV, effective antiretroviral therapy (ART) is expected to improve control of anal infection with high-risk human papillomavirus (HR-HPV) and reduce the progression of HPV-associated anal lesions.

The magnitude of the effect is not well established. By meta-analysis, people on established ART (vs ART-naive) had a 35% lower prevalence of HR-HPV infection, and those with undetectable viral load (vs detectable viral load) had a 27% and 16% reduced risk of low and high-grade anal lesions, respectively. Sustained virological suppression on ART reduced by 44% the risk of anal cancer. The role of effective ART in reducing anal HR-HPV infection and cancer risks is especially salient given current limitations in anal cancer screening, high rates of anal lesion recurrence and access to vaccination.Kelly H, Chikandiwa A, Alemany Vilches L, et al.

Association of antiretroviral therapy with anal high-risk human papillomavirus, anal intraepithelial neoplasia and anal cancer in people living with HIV. A systematic review and meta-analysis. Lancet HIV. 2020;7:e262–78.

Doi:10.1016/S2352-3018(19)30434-5.The impact of sex work laws and stigma on HIV prevention among female sex workersSex work laws and stigma have been established as structural risk factors for HIV acquisition among female sex workers (FSWs). However, individual-level data assessing these relationships are limited. A study examined individual-level data collected in 2011–2018 from 7259 FSWs across 10 sub-Saharan African countries. An association emerged between HIV prevalence and increasingly punitive and non-protective laws.

HIV prevalence among FSWs was 11.6%, 19.6% and 39.4% in contexts where sex work was partly legalised, not recognised or criminalised, respectively. Stigma measures such as fear of seeking health services, mistreatment in healthcare settings, lack of police protection, blackmail and violence were associated with higher HIV prevalence and more punitive settings. Sex work laws that protect sex workers and reduce structural risks are needed.Lyons CE, Schwartz SR, Murray SM, et al. The role of sex work laws and stigmas in increasing HIV risks among sex workers.

Nat Commun 2020;11:773. Doi:10.1038/s41467-020-14593-6.BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a COVID-19 contact tracing pathway for Cumbria. The local system was live 10 days prior to the national system on 18 May 2020. It was designed to interface and dovetail with the government’s track and trace programme.Our involvement in this initiative was due to a chance meeting between Professor Matt Phillips, Consultant in Sexual Health and HIV, and the Director of Public Health Cumbria, Colin Cox.

Colin knew that Cumbria needed to act fast to prevent the transmission of COVID-19 and Matt knew that sexual health had the skills to help.ProcessDespite over 90% of the staff from CSHS being redeployed in March 2020, CSHS maintained urgent sexual healthcare for the county and a phone line for advice and guidance. As staff began to return to the service in May 2020 we had capacity to spare seven staff members, whose hours were the equivalent of four full-time staff. We had one system administrator, three healthcare assistants, one nurse, Health Advisor Helen Musker and myself.CSHS were paramount to the speed with which the local system began. Following approval from the Trust’s chief executive officer we had adapted our electronic patient records (EPR) system, developed a standard operating procedure and trained staff, using a stepwise competency model, within just 1 day.In collaboration with the local laboratories we developed methods for the input of positive COVID-19 results into our EPR derivative.

We ensured that labs would be able to cope with the increase in testing and that testing hubs had additional capacity. Testing sites and occupational health were asked to inform patients that if they tested positive they would be contacted by our teams.This initiative involved a multiagency system including local public health (PH) teams, local authority, North Cumbria and Morecambe Bay CCGs, Public Health England (PHE) and the military. If CSHS recognise more than one positive result in the same area/organisation, they flag this with PH at the daily incident management meeting and environmental health officers (EHOs) provide advice and guidance for the organisation. We have had an active role in the contact tracing for clusters in local general practices, providing essential information to PH to enable them to initiate outbreak control and provide accurate advice to the practices.

We are an integral part in recognising cases in large organisations and ensuring prompt action is taken to stem the spread of the disease. The team have provided out-of-hours work to ensure timely and efficient action is taken for all contacts.The local contact tracing pilot has evolved and a database was established by local authorities. Our data fed directly into this from the end of May 2020. This enables the multiagency team to record data in one place, improving recognition of patterns of transmission.DiscussionCumbria is covered by three National Health Service Trusts, which meant accessing data outside of our Trust was challenging and took more time to establish.

There are two CCGs for Cumbria, which meant discussions regarding testing were needed with both North and South CCGs and variations in provision had to be accounted for. There are six boroughs in Cumbria with different teams of EHOs working in each. With so many people involved, not only is there need for large-scale frequent communication across a multisystem team, there is also inevitable duplication of work.Lockdown is easing and sexual health clinics are increasing capacity in a new world of virtual appointments and reduced face-to-face consultations. Staff within the contact tracing team are now balancing their commitments across both teams to maintain their skills and keep abreast of the rapid developments within our service due to COVID-19.

We are currently applying for funding from PH in order to second staff and backfill posts in sexual health.ConclusionCSHS have been able to lend our skills effectively to the local contact tracing efforts. We have expedited the contact tracing in Cumbria and provided crucial information to help contain outbreaks. It has had a positive effect on staff morale within the service and we have gained national recognition for our work. We have developed excellent relationships with our local PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of COVID-19.

The beauty of this model is that if we are faced with a second lockdown, sexual health staff will inevitably be available to help with the increased demand for contact tracing. Our ambition is that this model will be replicated nationally..

Carafate other names

In this edition Welcome back to carafate other names The Scoop!. Open enrollment for individual (non-group) health insurance plans is just around the carafate other names corner, and will be underway nationwide as of November 1. For those interested in open enrollment and individual-market coverage, there’s plenty of encouraging news this week regarding open enrollment extensions, new state enrollment platforms, the availability of plan browsing, and new insurers joining many states’ marketplaces.If you’ve got questions about open enrollment, check out our comprehensive 2021 Open Enrollment Guide, which addresses all aspects of the OEP that starts November 1. (And although carafate other names this site is all about individual market health coverage, you can also check out our guide to the Medicare open enrollment period – which starts today.)There’s a lot of news to cover.

Let’s get started!. Eleven carafate other names state-run exchanges extend open enrollment periods for 2021 coverageAlthough open enrollment is still a few weeks away, more than two-thirds of the fully state-run exchanges have already committed to extended open enrollment periods during which people can enroll in 2021 health coverage. Some of these are permanent extensions, while others only apply to the upcoming open enrollment period:Minnesota. November 1 to carafate other names December 22, 2020.Colorado.

November 1 to January 15, 2021Nevada. November 1, carafate other names 2020, to January 15, 2021.Pennsylvania. November 1, 2020, to January 15, 2021.Washington. November 1, 2020, carafate other names to January 15, 2021.Massachusetts.

November 1, 2020, to January 23, 2021.Rhode Island. November 1, carafate other names 2020, to January 23, 2021.California. November 1 to January 31, 2021.District of Columbia. November 1 carafate other names to January 31, 2021.New Jersey.

November 1, 2020, to January 31, 2021.New York. November 1, 2020, to January 31, 2021.The other state-run exchanges are Connecticut, Idaho, carafate other names Maryland, and Vermont. They all have the option to use the standard November 1 – December 15 enrollment window or issue an extension. And although they’ve currently all scheduled open enrollment to end on December 15, carafate other names it’s possible that we could see additional extensions as the year goes on.Two states move to state-run exchange platforms this fallMost states in the U.S.

Use the federally run HealthCare.gov platform for individual and family health coverage enrollment. But there were already 13 carafate other names fully state-run exchange platforms as of this year, and two more have joined them for the upcoming open enrollment season and future plan years.Residents in Pennsylvania will use Pennie to sign up for coverage this fall, and New Jersey residents will use GetCoveredNJ. (In previous years, residents in both states used HealthCare.gov.) Window shopping for 2021 health plans available in DC and eight statesIn states that use HealthCare.gov and most of the state-run exchanges, window shopping for 2021 coverage will be enabled by late October. But plan browsing carafate other names is currently available on some state-run exchange websites.

Residents in California, DC, Idaho, Maryland, Minnesota, Nevada, New Jersey, New York, and Vermont can already see the available plans and pricing for 2021. And in California, current enrollees can even renew their coverage now, without having to wait for the official start carafate other names of open enrollment.Mostly modest rate changes for 2021. Increases in some states, decreases in othersFor the last several months, we’ve been tracking proposed premiums for individual-market health insurance across the country. The rate review carafate other names process has been finalized and approved rate changes made public in many states.

As he does each year, Charles Gaba is tracking the proposed and approved rate changes in an at-a-glance spreadsheet. Thus far, the average approved rate change stands at an increase of just under half a percent carafate other names. Although that’s not yet a complete picture, it is indicative of a fourth consecutive year of fairly stable rates in the individual market, with prices in many areas of the country fairly similar in 2021 to what they were in 2018.We’ve got detailed overviews of numerous states’ approved rate changes for 2021, including some states where overall average rates are increasing. (See Florida, Idaho, Massachusetts, Nevada, New York, and Rhode Island) In other state, overall average rates carafate other names are actually decreasing.

(See Colorado, Delaware, Hawaii, Iowa, Maine, Maryland, and Washington.)For 2021, Pennsylvania and New Hampshire are joining a dozen other states that have reinsurance programs, and average premiums are expected to decrease in both states as a result of the new reinsurance programs.Insurers join marketplaces or expand coverage areas in more than 20 statesIn many states across the country, new insurers are joining the exchanges for 2021, and existing insurers are expanding their coverage areas within the states where carafate other names they offer coverage. We’re seeing this in numerous states, including Arkansas, California, Colorado, Florida, Illinois, Idaho, Indiana, Iowa, Maryland, Minnesota, Mississippi, Missouri, Nevada, New Mexico, North Carolina, Oklahoma, Oregon, Tennessee, Texas, Utah, Virginia, and Washington.There are a few states where existing insurers will no longer offer plans in the marketplace after 2020. New Mexico Health Connections will shut down at the end of 2020, Virginia Premier is leaving the individual market, and Highmark Choice Company is leaving Pennsylvania’s market carafate other names (but several other Highmark affiliates will remain, and Highmark Choice Company had very low enrollment).But overall, the trend is overwhelmingly towards increasing insurer participation and expanding coverage areas. This is the same trend we saw for 2019 and 2020.

And it’s a reversal of the trend we saw in 2017 and 2018, when insurers were fleeing the exchanges and the individual market.Wisconsin asks Trump administration to extend open enrollmentLate last month, numerous Wisconsin stakeholders — including the insurance commissioner, the Department of Health Services, numerous health insurance companies, and consumer advocates — sent a letter to the carafate other names Trump administration, asking for an extension of the upcoming open enrollment period through the end of January, instead of having it end on December 15.Wisconsin uses the federally run marketplace (HealthCare.gov), so the state does not have the option of extending open enrollment itself, the way several of the state-based exchanges have done. The letter points out how an extended open enrollment period would give the state more time to help people affected by the pandemic who need to select an individual market health plan for 2021.An extension would also give those individuals – many of whom are not accustomed to buying their own health insurance – more time to carefully consider their options. The letter concludes by pointedly noting that along with those practical benefits, carafate other names “an extension would signal that the federal government understands the plight of the newly uninsured, values their welfare and is prepared to do all in its power to protect our health system and economy.”Nearly two years after voters approved it, Medicaid expansion is in effect in NebraskaIn November 2018, voters in Nebraska approved a Medicaid expansion ballot measure. After an implementation process that lasted nearly two years, Medicaid expansion took effect this month in Nebraska.

Nebraska residents were able to start enrolling in expanded Medicaid in August, but enrollment will continue year-round for eligible residents.Now that Nebraska has expanded coverage, there are only 14 carafate other names states that still have not accepted federal funding to expand Medicaid, and two of them (Oklahoma and Missouri) will expand coverage by mid-2021 under the terms of ballot measures approved by voters this past summer.CMS report. Unsubsidized individual market enrollment declined 45% from 2016 to 2019The Centers for Medicare and Medicaid Services published a new enrollment trends report last week, with data updated to include the 2019 plan year. The CMS totals are based on risk adjustment data, but they do not carafate other names include enrollments in Massachusetts and Vermont, since both states have merged individual and small group markets for risk adjustment.Enrollment in the health insurance marketplaces/exchanges has remained fairly steady over the last few years, due mainly to the premium subsidies that keep coverage affordable for most exchange enrollees. But enrollment has declined sharply among people who don’t receive premium subsidies – which includes everyone who enrolls outside the exchange, as well as about 15 percent of on-exchange enrollees.

Across 48 states and Washington, DC, total unsubsidized enrollment in ACA-compliant individual market plans has dropped from 6.3 million in 2016 to 3.4 carafate other names million in 2019.KFF employer survey. Average cost of family premiums now exceeds $21,000The Kaiser Family Foundation’s annual employer health insurance survey report was published last week. As usual, it contains a wealth of information about the current state of employer-sponsored health insurance in the United carafate other names States. Among the interesting data points:67 percent of employees with employer-sponsored health coverage are enrolled in self-insured health plans.

This is up from 61 percent carafate other names last year (state health insurance regulations do not apply to self-insured plans, as they are instead regulated at the federal level).The average cost of employer-sponsored family health coverage has grown to $21,342 in annual premiums this year, up from $20,576 last year. The uninsured rate continues to rise, and is rising particularly fast among childrenLast month, the U.S. Census Bureau published its annual health carafate other names insurance report, with data about health coverage during 2019. About 8 percent of the population had no health coverage at all during 2019, and about 9.2 percent had no health coverage at the time they were surveyed.

This is an increase from 8.9 percent in carafate other names 2018, but it’s also the continuation of a steady upward trend in the uninsured rate since the Trump administration took office. It had been 8.7 percent in 2017 and 8.6 percent in 2016. The uninsured carafate other names rate is still well below where it was prior to the ACA. 15.5 percent of the population was uninsured as of 2010.In addition to the continued increase in the overall uninsured rate in recent years, Georgetown University’s Health Policy Institute published a sobering report last week, indicating that the uninsured rate among children in the U.S.

Increased more carafate other names in 2019 than it had in any other year over the last decade. In 2016, just 4.7 percent of children in the U.S. Were uninsured, which carafate other names was a historic low. But by 2019, it had increased to 5.7 percent.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable carafate other names Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Minnesota marketplace highlights and updatesOpen enrollment for 2021 health plans. November 1, 2020 through carafate other names December 22, 2020. Residents with carafate other names qualifying events can still enroll or make changes to their 2020 coverage.Insurers implementing modest rate increases for 2021, after three straight years of average rate decreases.

Quartz has joined the exchange for 2021, bringing total number of insurers to five.117,520 people enrolled for 2020, a new record for MNsure.Insurer participation in MNsure. 2014 to 2021.Reinsurance program received federal approval, began operation in 2018.With reinsurance, rates decreased for 2018 and again, even more carafate other names significantly, for 2019. But reinsurance also reduced funding for MinnesotaCare.The elimination of CSR funding further reduced MinnesotaCare funding, but this has been partly restored by a court ruling.MN provided premium relief for non-subsidy-eligible enrollees for 2017 only.Governor vetoed a proposed 2019 switch to HealthCare.gov.MNsure’s small business exchange no longer has any participating insurers.Minnesota health exchange overviewMinnesota’s one of the states fighting the hardest to preserve the Affordable Care Act’s gains. See actions Minnesota has taken.Minnesota’s state-run exchange, MNsure, has five participating insurers for 2021, up carafate other names from four in 2020.

The exchange has more than 117,000 individual market enrollees as of 2020.As a result of the COVID-19 pandemic, MNsure joined most of the other state-run exchanges in offering a special enrollment period during which people who were uninsured could enroll in a health plan. MNsure’s special enrollment period carafate other names began March 23, and continued through April 21. Nearly 9,500 Minnesota residents enrolled in private plans through MNsure during this window, as well as another 13,700 who enrolled in MinnesotaCare or Medicaid (enrollment in those programs is open year-round for eligible residents).Allison O’Toole, who led MNsure as CEO for three years, announced her resignation in March 2018, and the exchange named Nate Clark, the MNsure COO, as acting CEO. A few months later, the MNsure board named Clark as the permanent CEO carafate other names.

O’Toole left MNsure to work as director of state affairs for United States of Care, a non-profit created by Andy Slavitt, who was the acting administrator of CMS under the Obama Administration.Throughout 2017, Minnesotans who bought their own health insurance (on or off-exchange) and weren’t eligible for ACA subsidies were provided with 25 percent premium rebates from the state as a result of S.F.1, signed into law by Governor Dayton in early 2017. The subsidies helped to offset the large premium increases that applied in Minnesota in 2017, and helped to stabilize the individual health insurance market in carafate other names 2017. But the premium rebate program expired at the end of 2017.Thanks in large part to the new reinsurance program that Minnesota created (details below), premiums decreased in Minnesota’s individual market in 2018, 2019, and again in 2020, although rates are increasing modestly for 2021. In May 2019, Minnesota leaders reached an agreement on a budget that included an extension of the reinsurance program through 2020 and 2021 (it has already been granted federal approval through the end of 2022, but the state has to continue to cover its share of carafate other names the cost.

Minnesota Governor Tim Walz had hoped to implement a premium subsidy program and a new tax credit in Minnesota starting in 2020. But a compromise in the budget ended up with the state opting to continue the existing reinsurance program for two more years instead.).But the waiver that provides federal pass-through funding for reinsurance also resulted in a sharp and unexpected decrease in federal funding for MinnesotaCare, the Basic Health Program that provides coverage for people with income between 138 percent and 200 percent of the poverty level (between carafate other names $16,642 and $24,120 for a single person).In addition, the elimination of federal funding for cost-sharing reductions (CSR) in October 2018 resulted in a funding cut for MinnesotaCare, since the program is funded in large part by federal funds that would otherwise have been used to pay for premium subsidies and cost-sharing reductions in the exchange for the population that is instead eligible for MinnesotaCare. After an ensuing legal battle, a judge ordered HHS to restore funding for MinnesotaCare, although a resolution of the situation is ongoing, and the amount that HHS agreed to pay was still less than MinnesotaCare would have received if CSR funding had continued.Open enrollment for 2021 health plans extended through December 22, 2020. Insurers implementing modest rate increases for 2021, after three years of overall rate decreasesMNsure enabled window shopping carafate other names for 2021 health plans as of October 12, 2020.

This gives residents a few weeks to browse the available plans before open enrollment starts on November 1, 2020. And MNsure has announced that open enrollment will continue through carafate other names December 22, 2020. That’s a week longer than the open enrollment period that will apply in states that use the federally-run exchange. The flexibility to extend open enrollment is often cited as one of the benefits carafate other names of having a fully state-run exchange.

(MNsure had a similar extension last December, for 2020 health plans).For 2021, Quartz is joining the Minnesota marketplace. Quartz currently offers plans in Illinois and carafate other names Wisconsin, and is expanding into Minnesota for 2021. And two of the existing insurers — HealthPartners and UCare — are expanding their coverage areas for 2021 (BluePlus and Medica offer coverage statewide, and will continue to do so in 2021).The following average rate changes have been approved for MNsure’s insurers:Blue Plus. 4.21 percent increase (down from an initially proposed 7.12 percent increase)Group Health/Health Partners (GHI) carafate other names.

0.67 percent increase (down from an initially proposed 4.15 percent increase)Medica. 2.42 percent increase carafate other names (down from an initially proposed 7.06 percent increase)UCare. 1.6 percent increase (up from an initially proposed 1.39 percent decrease)Quartz. New for 2021, so no applicable rate changePreferredOne Insurance Company, which offers plans outside the exchange, is increasing carafate other names premiums by 1.05 percent (down from an initially proposed average increase of 5.09 percent).

Rate changes in previous years2015. Average increase of 4.5 percent carafate other names. MNsure critics characterized the official announcement as misleading as it failed to take into account low-cost carafate other names 2014 plans from PreferredOne. Consumers who bought a PreferredOne plan through MNsure for 2014 could only renew their policies for 2015 by working directly with the insurer, since PreferredOne stopped offering plans in the exchange at the end of 2014.

However, PreferredOne rates went up an average of 63 percent, and consumers didn’t qualify for subsidies carafate other names if they shopped outside the exchange. 2016. Average increase of 41.4 percent for the individual market, and about 38.5 for plans sold in MNsure carafate other names (ie, not counting PreferredOne). Rates increased significantly in 2016 across the entire individual market in Minnesota — including plans sold through MNsure, the state-run exchange.Approved rates for 2016 were announced on October 1, 2015, ranging from about 15 percent for Medica to 49 percent for Blue Cross Blue Shield of Minnesota.

In general, carafate other names the carriers cited higher-than-expected claims costs over the past year, along with the impending phase-out of the ACA’s reinsurance program as justification for their 2016 rate requests. But Governor Mark Dayton called some of the higher proposed increases “outrageous,” and promised a rigorous review of the filed rate changes and justifications. Ultimately, regulators were able to limit the highest rate increases to 49 percent — as opposed to the 54 percent that carafate other names had been requested by Blue Plus and BCBS of MN — but the final weighted average rate increase in the individual market in Minnesota still ended up being the highest in the nation. But Minnesota still had the lowest overall premiums in the upper midwest (although Minnesota had the highest average rate increase in the country for 2016, they had the lowest overall rates in the country in 2014 and 2015).Minnesota Commerce Commissioner Mike Rothman called the rate increases “unacceptably high,” and Gov.

Dayton noted that he was “extremely unhappy” carafate other names with the rate changes. But Rothman noted that his office “objected to all of the rates across the board,” and “squeezed out everything we could that was not actuarial justified.” In other words, the final rates, although much higher than officials and policyholders would have liked, were justified based on medical claims costs — the population enrolled in individual health plans in Minnesota was sicker than expected, and drug costs had been particularly onerous.Only about 55 percent of people who had 2015 coverage through MNsure received premium subsidies. But due to the sharp premium increases, that carafate other names had increased to about 63 percent for the people who had purchased or renewed coverage as of June 2016.2017. When the Minnesota Department of Commerce announced health insurance rates for 2017 for the individual and small group markets, the rate hikes were somewhat reasonable in the small group market (ranging from a decrease of 1 percent to an increase of 17.8 percent), but the individual market was “experiencing serious disruptions in 2017” and “on the verge of collapse.” The four carriers that offered plans through MNsure had the following average rate increases in 2017:Blue Plus = 55 percentHealthPartners/Group Health (GHI) = 50 percent (HealthPartners is only offering plans in 10 of the 67 counties where they offered plans in 2016.

Their enrollment cap is 72,000 for 2017)Medica = 57.5 percent (enrollment cap is 50,000 for 2017)UCare = 66.8 percent (UCare capped enrollment at 30,000 for 2017, but only had 16,000 enrollees in 2016)The enrollment caps that HealthPartners, Medica, and UCare employed for 2017 were approved as part of the rate review process, and are designed to protect carriers from further financial losses as they absorb BCBSMN’s enrollees who are shopping for new coverage during open carafate other names enrollment.In a news release relating to the rate announcement for 2017, the Minnesota Department of Commerce didn’t mince words. They noted that the individual market in the state was on the brink of collapse, and that they did everything in their power to save the market. While they succeeded in keeping the state’s individual market viable for 2017, with only one carrier exiting (BCBSMN, although their HMO affiliate, Blue Plus, remained in the carafate other names exchange), they reiterated very clearly that substantial reforms would be needed to keep the market stable in future years, and highlighted the fact that rates would be sharply higher and that carriers would limit enrollment in 2017.2018. Final rates for 2018 were approved in October 2017 (comprehensive information about the approved rates is here), based on the Minnesota Premium Security Plan (MSPS) being implemented but cost-sharing reductions (CSR) not being funded by the federal government (the cost of CSRs was added to on-exchange Silver plans).

Average approved rate changes for MNsure carafate other names insurers ranged from a 13.3 percent decrease for UCare to a 2.8 percent increase for Blue Plus. Three of the four MNsure insurers decreased their average premiums for 2018.On September 21, MNsure had posted a notice indicating that if the reinsurance program were not approved, rates would be about 20 percent higher than they would otherwise be in 2018. Fortunately for Minnesota residents, the reinsurance program did receive federal approval, and average rates declined slightly for 2018.But some enrollees who don’t get ACA premium subsidies still experienced a rate increase, due to the termination of the one-year, state-funded 25 percent premium rebates at the end of 2017.PreferredOne, which exited MNsure at carafate other names the end of 2014 and only offers coverage in the off-exchange market, proposed dramatically lower rates for 2018. A 38 percent average decrease if MSPS were to be approved, and a 23 percent average decrease if not.

The 38 percent decrease was implemented, and no adjustments were necessary to account for CSR funding, since PreferredOne does not offer plans in carafate other names the exchange, and CSRs are only available on silver exchange plans.2019. Average premium decrease of 12.4 percent. Average premiums carafate other names dropped for all five insurers in the individual market in 2019. This was the second year in a row of declining rates in Minnesota, but Blue Plus had a small rate increase for 2018, so 2019 was the first year that all five insurers decreased their average rates.

Minnesota insurance regulators noted that rates in 2019 were about 20 percent lower than they would have been without the reinsurance program.But most of Minnesota’s insurers charged higher rates in 2019 than they would have if the individual mandate penalty hadn’t been carafate other names eliminated, and if access to short-term plans and association health plans hadn’t been expanded by the Trump administration. For example, UCare’s rate filing notes that while average rates were decreasing by about 10 percent, the rate decrease would have been nearly 15 percent if the individual mandate penalty had remained in place.At ACA Signups, Charles Gaba calculated a weighted average rate decrease of 12.4 percent for 2019 in Minnesota, but noted that the average decrease would have been nearly 19 percent without those changes at the federal level.2020. Average premium carafate other names decrease of 1 percent. Four of the five insurers (including PreferredOne, which only offers coverage off-exchange) in Minnesota’s individual market decreased their average premiums for 2020.

This was the third year in a row that average individual market premiums dropped in Minnesota’s individual market, due in large part to the carafate other names reinsurance program that the state has established.The following average rate changes were implemented for 2020:Blue Plus. 1.5 percent decrease (Blue Plus had originally proposed carafate other names a 4.8 percent increase)Group Health/Health Partners (GHI). 1.26 percent decrease (GHI had originally proposed a 2.1 percent increase)Medica. 1.01 percent decrease (Medica had originally proposed an average decrease of carafate other names 1.4 percent)UCare.

0.18 percent increase (UCare originally proposed a 0.3 percent increase)PreferredOne, which only offers off-exchange coverage, reduced their rates by an average of 20 percent, on the heels of an 11 percent decrease in 2019. MNsure enrollment carafate other names exceeded 116k in 2018, dropped to 113k for 2019, but grew to more than 1117k in 2020From 2014 through 2018, enrollment in MNsure’s individual market plans increased every year, reaching 116,358 people by 2018. That was the highest open enrollment total in MNsure’s history, despite the shorter enrollment period, which ended in mid-January instead of the end of January (open enrollment for 2018 coverage ended on December 15, 2017 in states that use HealthCare.gov, but MNsure opted to extend their enrollment window that year, and have also extended subsequent enrollment windows).Enrollment dropped for the first time in 2019, when 113,552 people enrolled in individual market plans through MNsure. In most carafate other names states that use HealthCare.gov, enrollment peaked in 2016 and has been dropping since then.

But MNsure’s drop-off in 2019, which amounted to only a 2.4 percent reduction in enrollment, is the only time year-over-year enrollment has declined. Notably, the ACA’s individual mandate penalty was eliminated as of 2019, and regulations that the Trump administration implemented in late 2018 now make it more feasible for healthy people to use short-term plans instead of ACA-compliant plans (Minnesota has its own rules for short-term plans, but they’re more relaxed than the Obama-era federal rules carafate other names that applied in 2017 and most of 2018).And for 2020, enrollment grew again, reaching a record high of 117,520 enrollees.Here’s a look at the number of people who have signed up for individual market plans through MNsure during each year’s open enrollment period. These numbers all represent total enrollment at the end of open enrollment. Effectuated enrollment is always lower, and MNsure provides periodic effectuated enrollment data on their carafate other names board meeting materials page.

Insurer participation in MNsure. 2014-20212014. Five insurers offered individual policies through MNsure for 2014. Blue Cross Blue Shield of Minnesota, HealthPartners/Group Health, Medica, PreferredOne, and UCare.

Kaiser Health News reported that Minnesota offered some of the lowest premiums for silver (mid-level) plans in the U.S. Four of Minnesota’s nine regions made Kaiser’s list of the 10 least expensive places to buy health insurance.2015. But PreferredOne, which offered the lowest rates in the nation in 2014 and captured a large portion of 2014 enrollees, withdrew from MNsure for 2015. PreferredOne said remaining on the exchange was “not administratively and financially sustainable.” A Star Tribune business writer attributed PreferredOne’s departure as a market dynamics issue rather than a problem with MNsure.However, Blue Plus (an affiliate of Blue Cross Blue Shield of MN, offering HMO plans) joined the exchange for 2015, so there were still five insurers offering plans for 2015.

Blue Cross Blue Shield of Minnesota, Blue Plus, Health Partners/Group Health, Medica, and UCare. MNsure offered 84 plans statewide, up from 78 for 2014.2016. BCBSMN, Blue Plus, Health Partners/Group Health, Medica, and UCare offered individual market plans through MNsure for 2016.2017. In an effort to recruit more carriers to offer plans through MNsure for 2017 — particularly outside the Twin Cities metro area — state regulators sent out a request for proposals from health insurers on August 15, 2016.

Regulators noted that insurers could propose waivers of regulations in order to make it feasible for them to offer coverage through MNsure, although any such waiver requests would have to be approved by regulators.Steven Parente, a health insurance expert at the University of Minnesota, called the state’s effort to recruit insurers to MNsure a “distress call” and noted that August 15 is awfully late in the year to be putting out a request for insurer participation, given that open enrollment begins November 1. And ultimately, no new insurers opted to join MNsure for 2017.Blue Cross Blue Shield of MN dropped their individual market PPO plans at the end of 2016 due to significant financial losses. That left Blue Plus (which offered HMOs and covered roughly 13,000 people in 2016 in the individual market) as the only BCBSMN affiliate in the exchange. Roughly 103,000 people had to select new plans during open enrollment.Most of those BCBSMN enrollees had off-exchange coverage, though.

There were only about 20,400 MNsure enrollees (a little more than one in five MNsure enrollees) with coverage under BCBSMN who needed to switch to another plan during open enrollment. BCBSMN had individual PPO options available in all 87 counties in Minnesota through MNsure in 2016, while the Blue Plus coverage area — comprised of four separate HMO networks — was available in 77 of the state’s counties.Nationwide, carriers have been shifting away from PPOs and towards HMOs and EPOs. In Colorado, Anthem Blue Cross Blue Shield also dropped their PPOs at the end of 2016. In Indiana, there were no PPOs available in the individual market by 2017.

Blue Cross Blue Shield of New Mexico dropped all of their individual market plans at the end of 2015 except one off-exchange HMO. Blue Cross Blue Shield of Texas dropped their individual market PPO plans at the end of 2015.The broad network offered by PPOs tends to be attractive to enrollees who have health problems. They’re often willing to pay higher premiums in trade for access to broad network of hospitals and specialists. But PPOs are expensive for carriers, as enrollees don’t need primary care referrals to see specialists, and it’s more challenging for carriers to hold down costs when there are more providers in the network.All of the MNsure carriers except Blue Plus are also limiting their total enrollment for 2017.

By November 11, 2016, less than two weeks into open enrollment for 2017 coverage, Medica had hit their 50,000 member enrollment cap for 2017 (including on and off-exchange enrollments, and also accounting for expected renewals of 2016 Medica plans), and their policies were no longer available in the individual market in Minnesota, on or off-exchange. The only exception was five counties (Benton, Crow Wing, Mille Lacs, Morrison, and Stearns) where Medica agreed not to limit enrollment, as all of the other available carriers in those counties have imposed enrollment caps too. In those five counties, Medica plans continued to be available.At that point, Medica’s market share in MNsure for 2017 stood at 34.2 percent. By December 14, Medica’s market share had dropped to 27.7 percent, as enrollments had continued to climb for the remaining carriers.On January 31, Medica re-opened enrollment for 2017.

This was because a smaller-than-expected number of 2016 Medica enrollees renewed their plans for 2017, meaning that the carrier still had some wiggle room under their 50,000 member cap. At that point, they had room for about 7,000 more enrollees. Medica plans were thus available throughout the duration of the special enrollment period that was added on at the end of open enrollment, and continue to be available for people with qualifying events.2018. Plans continued to be available from Blue Plus, Health Partners/Group Health (GHI), Medica, UCare.

In the months before a decision was reached regarding an extension of the open enrollment window for 2018 plans (the first year that the federal government imposed a shorter, month-and-a-half enrollment window), two of MNsure’s participating insurers had differing positions. UCare believed the exchange should add an additional two-week special enrollment period, while Medica did not want the exchange to have the option to extend the newly-scheduled six-week enrollment window. Notably, Medica capped their enrollment very early during the 2017 open enrollment period, and while UCare also had an enrollment cap, it was set with a target of nearly doubling their 2016 enrollment. But Medica is the only MNsure insurer that didn’t set an enrollment cap for 2018.As was the case for 2017, enrollment caps were used in the individual market in Minnesota for 2018 by all insurers other than Medica (Medica did have an enrollment cap for 2017, which they hit very early in open enrollment.

However, they resumed enrollments at the end of January 2017). Details about the insurers’ enrollment caps are in the plan binders in SERFF. For 2018, MNsure insurers implemented the following enrollment caps:Blue Plus. 55,000 member cap (aiming for a target of 50,000 effectuated enrollees, but effectuated enrollment is always lower than the number of people who initially enroll)Health Partners/Group Health (GHI).

73,400 member cap (aiming for a target of 70,000 effectuated enrollees)Medica. No enrollment capUCare. 35,000 member cap (aiming for a target of 30,000 effectuated enrollees)MNsure confirmed in May 2018 that none of their insurers had hit their enrollment caps for 2018.Outside the exchange, PreferredOne had an enrollment cap of 3,000 members, although their 2017 membership was only about 300 people.2019 and 2020. Blue Plus, Health Partners/Group Health, UCare, and Medica have continued to offer plans through MNsure, and all of them continued to participate in 2020 as well.

Blue Plus expanded to once again offer statewide coverage in 2020, for the first time since 2016.2021. Quartz joined the exchange for 2021, joining the four existing insurers. HealthPartners and UCare are both expanding their coverage areas for 2021.Minnesota Premium Security Plan. 1332 waiver proposal approved by CMS, but with a significant funding cut for MinnesotaCareIn May 2017, Minnesota Governor Mark Dayton submitted a 1332 waiver proposal to CMS.

The 1332 waiver was based on H.F.5, which was enacted without Dayton’s signature in April 2017 (Dayton had proposed an alternative measure that would have allowed people in Minnesota to buy into MinnesotaCare. That measure was not able to pass the state’s Republican-dominated legislature).[For more than two decades, MinnesotaCare was a state program subsidizing health insurance for low-income residents. As of January 1, 2015, it transitioned to a Basic Health Program under the ACA, becoming the first BHP in the nation.]H.F.5 created the Minnesota Premium Security Plan (MPSP), which is a state-based reinsurance program (similar to the one the ACA implemented on a temporary basis through 2016, and that Alaska created for 2017. Several other states have since implemented reinsurance programs).

The reinsurance program, which took effect in Minnesota in 2018, covers a portion of the claims that insurers face, resulting in lower total claims costs for the insurers, and thus lower premiums (average individual market premiums in Minnesota decreased from 2017 to 2018 as a result of the reinsurance program). The reinsurance kicks in once claims reach $50,000, and covers them at 80 percent up to $250,000 (this is similar to the coverage under the transitional reinsurance program that the ACA provided from 2014 through 2016).H.F.5 was contingent upon approval of the 1332 waiver, because it relies partially on federal funding, in addition to state funding. Under the federal approval that was granted in September 2017, the federal government is giving Minnesota the money that they save on premium tax credits, and that money is combined with state funds to implement the reinsurance program (lower premiums — as a result of the reinsurance program — result in the federal government having to pay a smaller total amount of premium tax credits, since the tax credits are smaller when premiums are smaller).It was expected that CMS would approve the state’s 1332 waiver proposal, and Governor Dayton requested that the approval process be swift so that the state could move forward with the implementation of the Minnesota Premium Security Plan in time for the 2018 plan year. Dayton indicated that his office had been told that approval would come in August 2017, but CMS didn’t approve the waiver until September 22.

And the waiver approval letter noted that the federal savings for MinnesotaCare (the state’s Basic Health Program, or BHP) resulting from the reinsurance program would not be eligible to be passed along to the state — in other words, CMS would keep those savings instead.[Federal BHP funding is equal to 95 percent of the amount that the federal government would have otherwise spent on premium subsidies and cost-sharing reductions for the population that ends up being eligible for the BHP. So lower premiums — as a result of reinsurance — for qualified health plans in the exchange means that the amount the federal government would have had to spend on premium subsidies for that population is lower. That translates into a smaller amount of funding for the state’s BHP, according to the approach that HHS took for Minnesota’s waiver approval.]And based on the scathing letter that Dayton sent CMS a few days earlier, it appeared at that point that Minnesota could actually lose money on the deal — losing more in federal funding for MinnesotaCare than they gain in reinsurance funding. Dayton noted in his letter that the 1332 waiver approval process had been “nightmarish,” and that Minnesota went to great lengths to follow instructions from CMS at every turn, throughout the process of drafting H.F.5 and the 1332 waiver proposal.

He explains that CMS provided Minnesota with explicit guidance in terms of how to draft the reinsurance program while maintaining full federal funding for MinnesotaCare, and highlighted the fact that the state never deviated from the instructions that were provided.The StarTribune editorial board called out then-Secretary of HHS, Tom Price and the Trump Administration for their lack of clarity on the issue, for apparently misleading the state during the 1332 waiver drafting process, and for effectively punishing the state of Minnesota for taking an innovative approach to ensuring that as many people as possible have health insurance.Insurers filed rates based on reinsurance being available. And by the time the waiver was approved, there was very little time to evaluate the potential impacts of the funding changes, as rates had to be finalized by October 2 in Minnesota. The finalized rates did incorporate the reinsurance program. The state has accepted the approved waiver, but Gov.

Dayton sent a letter to HHS on October 3, asking them to reconsider the MinnesotaCare funding cuts, but the issue has remained unresolved.Elimination of CSR funding results in additional funding cut for MinnesotaCare, but a lawsuit has partially restored that fundingNationwide, 54 percent of exchange enrollees benefit from cost-sharing subsidies. But in Minnesota, only 13 percent of exchange enrollees are receiving cost-sharing subsidies. This is because of MinnesotaCare, which covers all enrollees with income up to 200 percent of the poverty level. That’s the same group that would otherwise benefit the most from cost-sharing subsidies, so the fact that MinnesotaCare is available means that most of the people who would otherwise be enrolled in cost-sharing subsidy plans are instead enrolled in MinnesotaCare.At first glance, this would appear to have made the uncertainty surrounding cost-sharing subsidy funding in 2017 a little less of a pressing issue in Minnesota than it was in many other states, since private insurers weren’t facing the sort of losses that insurers in other states were facing without federal funding for CSR.

But when the Trump Administration eliminated federal funding for CSR in October 2017, HHS took the position tha t since CSR funding had been eliminated, the CSR portion of the federal funding for the BHPs in New York and Minnesota would be reduced to $0. This was not a cut-and-dried conclusion, however, as explained earlier in 2017 by Michael Kalina.In January 2018, the Attorneys General for New York and Minnesota filed a lawsuit against the US Department of Health and Human Services, seeking to restore funding for their Basic Health Programs. A judge ruled in favor of the states in May 2018, ensuring that MinnesotaCare would continue to receive at least some CSR-based funding. The amount awarded to the state for the first quarter of 2018 was just over half of what the state had initially expected in CSR-related funding, but a larger chuck of the funding was restored later in 2018.

According to the Star Tribune, however, Minnesota still ended up losing $161 million in federal funding for MinnesotaCare due to the CSR funding cuts.In early 2019, the Trump administration proposed yet another funding cut (a third, after the cuts imposed by the reinsurance program and the elimination of CSR funding) as part of a new methodology for calculating BHP funding. This one was much smaller than the other two cuts, but taken together the funding reductions are pushing MinnesotaCare towards a looming budget shortfall. SHOP exchange. Down to one carrier as of 2016, zero by 2018 (and still zero in 2019)In 2015, there were two carriers in MNsure’s SHOP exchange for small businesses.

Blue Cross Blue Shield of Minnesota, and Medica. But Medica announced in 2015 that they would exit the SHOP exchange in Minnesota, North Dakota, and Wisconsin at the end of the year. That left BCBS as the only small group carrier available through MNsure in 2016, but it didn’t change much from a practical standpoint, since 83 percent of MNsure’s small groups were enrolled in plans through BCBS in 2015. Indeed, Medica’s reason for exiting the small business exchange was based on low enrollment in the first two years.Blue Cross Blue Shield of Minnesota continued to be the only insurer offering SHOP coverage via MNsure in 2017, but announced in July 2017 that they would no longer offer SHOP coverage in 2018, and would instead transition their SHOP enrollees to small business coverage outside the exchange.

At that point, there were only 3,287 people enrolled in SHOP coverage in Minnesota — far below the 155,000 people that were originally projected to have coverage through MNsure’s SHOP program by 2016 (this much lower-than-anticipated enrollment has been the case in nearly every state’s SHOP exchange. This situation is not unique to Minnesota). State law provided 25% premium rebate in 2017. Amendment to allow plans without essential benefits was cut from final legislationThroughout 2016, then-Governor Dayton called for a state-funded premium rebate for people who buy their own insurance but aren’t eligible for the ACA’s premium subsidies (those are only available for people with income up to 400 percent of the poverty level, or $100,400 for a family of four in 2019).Governor Dayton also noted that the government needed to act quickly to stabilize the individual market in Minnesota, and by late November 2016, his patience with lawmakers was wearing thin.

In a November 23 press conference, Dayton said that House Republicans needed to “stop dilly-dallying” and decide whether to move forward with Dayton’s rebate proposal.Dayton had also indicated that he was considering calling a special session of the legislature after election day to address the situation, and that was being negotiated for December 20. But the talks fell through when Dayton and Republican House Speaker Kurt Daudt couldn’t agree on the three bills that would have been addressed in the special session. As a result, there was no special session.Instead, the issue was taken up by lawmakers as soon as the 2017 legislative session began. On January 5, Minnesota Senators Michelle Benson (R, 31st District) and Gary Dahms (R, 16th District) introduced S.F.1.

The bill called for using $300 million in state funding to provide a 25 percent rebate to roughly 125,000 people in Minnesota.S.F.1 passed the Minnesota Senate by a 35-31 vote on January 12. Only one DFL Senator (Melisa Franzen, from Edina) voted with Republicans in favor of the legislation. It was then sent to the House, where an amendment was added that stripped out the requirement that health plans provide various mandated benefits (see “Journal of the Day” section “Top of page 154” in this version of the bill. Under the terms of the amendment, as long as a carrier offered at least one plan with all the mandated benefits, they would have been allowed to offer others without mandated benefits).The amended bill was sent back to the Senate on January 23.

Differences between the bills that the two chambers passed had to be reconciled before being sent to Governor Dayton for his signature. By that point, the amendment to allow less-robust plans to be sold had garnered national attention, and public outrage helped to push lawmakers away from the provision. S.F.1 had also called for $150 million to be appropriated for fiscal year 2018 (through June 30, 2019) from the state general fund to a state-based reinsurance program to stabilize the individual market (Alaska did something similar in 2016, preventing a market collapse), but that provision was also removed in the final version (Minnesota did ultimately set up a reinsurance program, effective in 2018, which has served to stabilize the market and reduce premiums).A Conference Committee in the Senate recommended that the House “recede from its amendments” and the Conference Committee report passed the Senate on a 47-19 vote. The House passed the bill a few hours later, 108-19.

It was sent to Governor Dayton, who immediately signed it into law. DFLers did have to compromise on one issue during the process. S.F.1 allows for-profit HMOs to begin operating in Minnesota’s individual market, which had long been limited to non-profit HMOs.Consumers were told to expect the premium rebates to show up by April 2017, but they were retroactively effective to January 2017. So a person who had been paying full price for a plan since January 2017 saw a substantial premium reduction on the April or May invoice.

Going forward, for the remainder of the year, a 25 percent rebate applied each month.Since S.F.1 was signed into law with only a few days remaining in open enrollment (it ended January 31 that year), Governor Dayton and exchange officials were worried that there wouldn’t be enough time for people to learn about the rebate and apply for coverage before January 31. In December, Dayton had asked HHS to allow MNsure to extend its enrollment deadline to February 28 (instead of January 31) in order to allow lawmakers more time to work out the details of a state-based premium rebate while still allowing people to enroll after the legislative process is complete.HHS denied the request for a blanket extension, but MNsure used their own authority on January 28 to grant a one-week special enrollment period (February 1 to February 8) due to exceptional circumstances. Although the state-based 25 percent premium rebate was available on or off the exchange, the one-week extension was only valid through MNsure. Health insurers did not have to accept off-exchange enrollments without a qualifying event after January 31.The 25 percent premium rebate program in Minnesota was only authorized for one year, so the rebates did not continue into 2018.

And although almost 100,000 people received premium relief through the program in 2017, it ended up costing less than the legislature had allocated, and about $100 million was returned to the state’s budget at the end of 2017.Protecting Medicaid enrollees from estate liensIn every state, Medicaid is jointly funded by the state and the federal government. Longstanding federal regulations, which predate the ACA, require states to “seek recovery of payments from the individual’s estate for nursing facility services, home and community-based services, and related hospital and prescription drug services” for any Medicaid enrollee over the age of 55. This applies essentially to long-term care services, but states also have the option to go after the individual’s estate to recover costs for other care that was provided by Medicaid after age 55.Prior to 2014, this wasn’t typically an issue, as Medicaid eligibility was generally restricted by asset tests or requirements that applicants be disabled or pregnant (although Minnesota did have much more generous Medicaid eligibility guidelines than most states prior to 2014). But as of 2014, in states that expanded Medicaid under the ACA, the only eligibility guideline is income.

Applicants with income that doesn’t exceed 138 percent of the poverty level are directed to Medicaid, regardless of any assets they might have.When applicants use the health insurance exchange — MNsure in Minnesota — they’re automatically funneled into Medical Assistance (Medicaid) if their income is under 138 percent of the poverty level. But what these enrollees didn’t know was that the state also had a program in place to put liens on estates for Medicaid-provided services for people age 55 and older.The combination of these systems caught numerous residents off guard. They were enrolled in Medical Assistance through MNsure based on their income, but were not aware that liens were being placed on their homes so that the state could recoup the costs upon their deaths.State Senator Tony Lourey (DFL, District 11) addressed the issue with language included in HF2749, the Omnibus supplemental budget bill, which was signed into law by Governor Dayton on June 1, 2016. The legislation limits estate recovery to just what’s required under federal Medicaid rules (ie, essentially, long-term care costs for people age 55 or older), and makes the provision retroactive to January 1, 2014.Early tech strugglesMNsure opened for business in the fall of 2013, but technological issues persisted well into 2015, despite numerous improvements throughout 2014.

Given MNsure’s difficult launch, the state conducted a series of audits and reviews. The first audit reviewed how MNsure spent state and federal money. Auditors concluded that the exchange has generally adequate internal controls and found no fraud or abuse. The review was conducted by the state Office of the Legislative Auditor, and the report was published in October 2014.Another audit, also conducted by the Office of the Legislative Auditor and released in November 2014, found that the MNsure system in some cases incorrectly determined who qualified for public health benefits.

The errors occurred during the first open enrollment period, before a series of system fixes were implemented. The audit did not quantify the total financial impact of the errors. The state Human Services commissioner said a consultant working on technical fixes to MNsure concluded that the eligibility functionality was working correctly as of June 2014.A third audit, a performance evaluation report released in February 2015, said “MNsure’s failures outweighed its achievements.” Among other criticisms, auditors said MNsure staff withheld information from the board of directors and state officials, the enrollment website was seriously flawed and launched without adequate testing, and the first-year enrollment target was unrealistically low.In April 2014, MNsure hired Deloitte Consulting to audit MNsure’s technology and improve the website to make enrolling in coverage and updating life events easier and more streamlined. Deloitte has been involved in successful state-run marketplaces for Connecticut, Kentucky, Rhode Island and Washington.Software upgrades were installed in August 2014, and system testing continued right up until the start of open enrollment.

To reduce wait times for consumers and insurance professionals, MNsure increased its call center and support staff and launched a dedicated service line for agents and brokers.More in-person assisters were available in Minnesota for the 2015 open enrollment period. MNsure encourages residents to utilize the exchange’s assister directory to find local navigators and brokers who can help with the enrollment process.MNsure has improved dramatically in terms of its technology since the early days of ACA implementation, and enrollment increased every year from 2014 through 2019.Lawmakers approved switching to HealthCare.gov as of 2019, but governor vetoedOn May 9, 2017, lawmakers in Minnesota passed SF800, an omnibus health and human services bill. Among many other things, the legislation called for switching from MNsure to the federally-run marketplace (HealthCare.gov) starting in 2019 (see Section 5). But Governor Dayton vetoed it.Gov.

Dayton has long been supportive of MNsure, and had previously clarified that he would veto the bill. In noting his plans to veto the legislation, Dayton made no mention of the transition to HealthCare.gov that was included in the legislation, but focused instead on the sharp budget cuts in the bill. But his veto ensured that MNsure would remain in place, at least for the time being.The Senate’s original version of SF800 did not call for scrapping MNsure, but the bill went through considerable back-and-forth between the two chambers, and the version that passed was the 4th engrossment of the bill.In March 2015, Dayton had asked the legislature to create a Task Force on Health Care Financing that would study MNsure along with possible future alternatives. Dayton noted in his letter that he supported making MNsure “directly accountable to the governor and subject to the same legislative oversight as other state agencies” and his budget included half a million dollars devoted to the task force.

The spending bill was approved by the legislature in May, and the 29-member task force was appointed in the summer.One of the possibilities that the task force considered was the possibility of switching to Healthcare.gov, but it’s clear that there was no cut-and-dried answer to the question of whether Minnesota is better served by having a state-run exchange, switching to a federally-run exchange, or teaming up with the federal government on either a supported state-based marketplace or partnership exchange.In a December 2015 meeting of the task force, the MN Department of Human Services presented a financial analysis of the alternatives available to MNsure. They determined that switching entirely to Healthcare.gov would cost the state an additional $5.1 million in one-time costs from June 2016 to June 2017. And switching to a supported state-based marketplace would cost an additional $6.6 million during that same time frame. If the state had opted to switch to Healthcare.gov, the soonest it could have happened was 2018, since HHS requires a year’s notice from states wishing to transition to Healthcare.gov, and Minnesota wouldn’t have been in a position to make a decision until sometime in 2016.There were significant reservations about making that switch prior to the Supreme Court’s ruling on King v.

Burwell. The Court ruled in June 2015 that subsidies are legal in every state, including those that use Healthcare.gov. Prior to the decision, a switch to Healthcare.gov could have jeopardized subsidies for tens of thousands of Minnesota residents. But once it was clear that Healthcare.gov’s subsidies are safe, some stakeholders began calling for Minnesota to scrap its state-run exchange and use Healthcare.gov instead.

Because the MNsure task force was included in the 2016 budget, no hasty decisions were made.In January 2016, the task force submitted their recommendations to the legislature. They covered a broad range of issues, but did not recommend that MNsure transition to the federal enrollment platform. Lawmakers essentially left the exchange alone during the 2016 legislative session.The magnitude of the 2016 rate increases that were announced in October resulted in MNsure opponents renewing their calls to switch to Healthcare.gov. But it’s important to keep in mind that the 41 percent weighted average rate hike in Minnesota was market-wide, and did not just apply to MNsure enrollees.

In fact, the off-exchange carrier (PreferredOne) had among the highest rate hikes in the state for 2016, at 39 percent, and the exchange’s weighted average rate increase (38.5 percent) was lower than the weighted average rate increase for the whole individual market (41 percent).Minnesota health insurance exchange linksMNsure855-3MNSURE (855-366-7873)State Exchange Profile. MinnesotaThe Henry J. Kaiser Family Foundation overview of Minnesota’s progress toward creating a state health insurance exchange.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

In this carafate best price edition Welcome back to The Scoop!. Open enrollment for individual (non-group) health insurance plans is carafate best price just around the corner, and will be underway nationwide as of November 1. For those interested in open enrollment and individual-market coverage, there’s plenty of encouraging news this week regarding open enrollment extensions, new state enrollment platforms, the availability of plan browsing, and new insurers joining many states’ marketplaces.If you’ve got questions about open enrollment, check out our comprehensive 2021 Open Enrollment Guide, which addresses all aspects of the OEP that starts November 1. (And although this site is all about individual market health coverage, you can also check out our guide to the carafate best price Medicare open enrollment period – which starts today.)There’s a lot of news to cover. Let’s get started!.

Eleven state-run exchanges extend open enrollment periods for 2021 coverageAlthough open enrollment is still a few weeks carafate best price away, more than two-thirds of the fully state-run exchanges have already committed to extended open enrollment periods during which people can enroll in 2021 health coverage. Some of these are permanent extensions, while others only apply to the upcoming open enrollment period:Minnesota. November 1 to December carafate best price 22, 2020.Colorado. November 1 to January 15, 2021Nevada. November 1, 2020, to carafate best price January 15, 2021.Pennsylvania.

November 1, 2020, to January 15, 2021.Washington. November 1, 2020, carafate best price to January 15, 2021.Massachusetts. November 1, 2020, to January 23, 2021.Rhode Island. November 1, 2020, to January 23, 2021.California carafate best price. November 1 to January 31, 2021.District of Columbia.

November 1 to carafate best price January 31, 2021.New Jersey. November 1, 2020, to January 31, 2021.New York. November 1, 2020, to January 31, 2021.The carafate best price other state-run exchanges are Connecticut, Idaho, Maryland, and Vermont. They all have the option to use the standard November 1 – December 15 enrollment window or issue an extension. And although they’ve currently all scheduled open enrollment to end on carafate best price December 15, it’s possible that we could see additional extensions as the year goes on.Two states move to state-run exchange platforms this fallMost states in the U.S.

Use the federally run HealthCare.gov platform for individual and family health coverage enrollment. But there were already 13 fully state-run exchange platforms as of this year, and two more have joined them for the upcoming open enrollment season and future plan years.Residents in Pennsylvania will use Pennie to sign up for coverage this fall, and New Jersey residents will carafate best price use GetCoveredNJ. (In previous years, residents in both states used HealthCare.gov.) Window shopping for 2021 health plans available in DC and eight statesIn states that use HealthCare.gov and most of the state-run exchanges, window shopping for 2021 coverage will be enabled by late October. But plan browsing is currently available on carafate best price some state-run exchange websites. Residents in California, DC, Idaho, Maryland, Minnesota, Nevada, New Jersey, New York, and Vermont can already see the available plans and pricing for 2021.

And in California, current carafate best price enrollees can even renew their coverage now, without having to wait for the official start of open enrollment.Mostly modest rate changes for 2021. Increases in some states, decreases in othersFor the last several months, we’ve been tracking proposed premiums for individual-market health insurance across the country. The rate review process has been finalized carafate best price and approved rate changes made public in many states. As he does each year, Charles Gaba is tracking the proposed and approved rate changes in an at-a-glance spreadsheet. Thus far, carafate best price the average approved rate change stands at an increase of just under half a percent.

Although that’s not yet a complete picture, it is indicative of a fourth consecutive year of fairly stable rates in the individual market, with prices in many areas of the country fairly similar in 2021 to what they were in 2018.We’ve got detailed overviews of numerous states’ approved rate changes for 2021, including some states where overall average rates are increasing. (See Florida, Idaho, Massachusetts, Nevada, New York, and carafate best price Rhode Island) In other state, overall average rates are actually decreasing. (See Colorado, Delaware, Hawaii, Iowa, Maine, Maryland, and Washington.)For 2021, Pennsylvania and New Hampshire carafate best price are joining a dozen other states that have reinsurance programs, and average premiums are expected to decrease in both states as a result of the new reinsurance programs.Insurers join marketplaces or expand coverage areas in more than 20 statesIn many states across the country, new insurers are joining the exchanges for 2021, and existing insurers are expanding their coverage areas within the states where they offer coverage. We’re seeing this in numerous states, including Arkansas, California, Colorado, Florida, Illinois, Idaho, Indiana, Iowa, Maryland, Minnesota, Mississippi, Missouri, Nevada, New Mexico, North Carolina, Oklahoma, Oregon, Tennessee, Texas, Utah, Virginia, and Washington.There are a few states where existing insurers will no longer offer plans in the marketplace after 2020. New Mexico Health Connections will shut down at the end of 2020, Virginia Premier is leaving the individual market, and Highmark Choice Company is leaving Pennsylvania’s market (but several other Highmark carafate best price affiliates will remain, and Highmark Choice Company had very low enrollment).But overall, the trend is overwhelmingly towards increasing insurer participation and expanding coverage areas.

This is the same trend we saw for 2019 and 2020. And it’s a reversal of the trend we saw in 2017 and 2018, when insurers were fleeing the exchanges and the individual market.Wisconsin asks Trump administration to extend open enrollmentLate last month, numerous Wisconsin stakeholders — including the insurance commissioner, the Department of Health Services, numerous health insurance companies, and consumer advocates — sent a letter to the Trump administration, asking for an extension of the upcoming open enrollment period through the end of January, instead of having it carafate best price end on December 15.Wisconsin uses the federally run marketplace (HealthCare.gov), so the state does not have the option of extending open enrollment itself, the way several of the state-based exchanges have done. The letter points out how an extended open enrollment period would give the state more time to help people affected by the pandemic who need to select an individual market health plan for 2021.An extension would also give those individuals – many of whom are not accustomed to buying their own health insurance – more time to carefully consider their options. The letter concludes by pointedly noting that along with those practical benefits, “an extension would signal that the federal government understands the plight of the newly uninsured, values their welfare and is prepared to do all in its power to protect our health system and economy.”Nearly two years after voters approved it, Medicaid expansion is in effect in NebraskaIn carafate best price November 2018, voters in Nebraska approved a Medicaid expansion ballot measure. After an implementation process that lasted nearly two years, Medicaid expansion took effect this month in Nebraska.

Nebraska residents were able to start enrolling in expanded Medicaid in August, but enrollment will continue year-round for eligible residents.Now that Nebraska has expanded coverage, there are only 14 states that still have not accepted federal funding to expand Medicaid, and two of carafate best price them (Oklahoma and Missouri) will expand coverage by mid-2021 under the terms of ballot measures approved by voters this past summer.CMS report. Unsubsidized individual market enrollment declined 45% from 2016 to 2019The Centers for Medicare and Medicaid Services published a new enrollment trends report last week, with data updated to include the 2019 plan year. The CMS totals are based on risk adjustment data, but they do not include enrollments in Massachusetts and Vermont, since both states have merged individual and small group markets for risk adjustment.Enrollment in the health insurance marketplaces/exchanges has carafate best price remained fairly steady over the last few years, due mainly to the premium subsidies that keep coverage affordable for most exchange enrollees. But enrollment has declined sharply among people who don’t receive premium subsidies – which includes everyone who enrolls outside the exchange, as well as about 15 percent of on-exchange enrollees. Across 48 states and Washington, DC, total unsubsidized enrollment in carafate best price ACA-compliant individual market plans has dropped from 6.3 million in 2016 to 3.4 million in 2019.KFF employer survey.

Average cost of family premiums now exceeds $21,000The Kaiser Family Foundation’s annual employer health insurance survey report was published last week. As usual, it contains a wealth of information about carafate best price the current state of employer-sponsored health insurance in the United States. Among the interesting data points:67 percent of employees with employer-sponsored health coverage are enrolled in self-insured health plans. This is up from 61 percent last year (state health insurance regulations do not apply to self-insured plans, as they are instead regulated at the federal level).The average cost of employer-sponsored family health coverage has grown to $21,342 in annual premiums this year, carafate best price up from $20,576 last year. The uninsured rate continues to rise, and is rising particularly fast among childrenLast month, the U.S.

Census Bureau published its annual health insurance report, with data about health coverage carafate best price during 2019. About 8 percent of the population had no health coverage at all during 2019, and about 9.2 percent had no health coverage at the time they were surveyed. This is carafate best price an increase from 8.9 percent in 2018, but it’s also the continuation of a steady upward trend in the uninsured rate since the Trump administration took office. It had been 8.7 percent in 2017 and 8.6 percent in 2016. The uninsured rate is still well below where it was prior carafate best price to the ACA.

15.5 percent of the population was uninsured as of 2010.In addition to the continued increase in the overall uninsured rate in recent years, Georgetown University’s Health Policy Institute published a sobering report last week, indicating that the uninsured rate among children in the U.S. Increased more in 2019 than it carafate best price had in any other year over the last decade. In 2016, just 4.7 percent of children in the U.S. Were uninsured, carafate best price which was a historic low. But by 2019, it had increased to 5.7 percent.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org carafate best price. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Minnesota marketplace highlights and updatesOpen enrollment for 2021 health plans. November 1, carafate best price 2020 through December 22, 2020. Residents with qualifying events can still enroll or make changes to their 2020 coverage.Insurers implementing modest carafate best price rate increases for 2021, after three straight years of average rate decreases. Quartz has joined the exchange for 2021, bringing total number of insurers to five.117,520 people enrolled for 2020, a new record for MNsure.Insurer participation in MNsure.

2014 to carafate best price 2021.Reinsurance program received federal approval, began operation in 2018.With reinsurance, rates decreased for 2018 and again, even more significantly, for 2019. But reinsurance also reduced funding for MinnesotaCare.The elimination of CSR funding further reduced MinnesotaCare funding, but this has been partly restored by a court ruling.MN provided premium relief for non-subsidy-eligible enrollees for 2017 only.Governor vetoed a proposed 2019 switch to HealthCare.gov.MNsure’s small business exchange no longer has any participating insurers.Minnesota health exchange overviewMinnesota’s one of the states fighting the hardest to preserve the Affordable Care Act’s gains. See actions carafate best price Minnesota has taken.Minnesota’s state-run exchange, MNsure, has five participating insurers for 2021, up from four in 2020. The exchange has more than 117,000 individual market enrollees as of 2020.As a result of the COVID-19 pandemic, MNsure joined most of the other state-run exchanges in offering a special enrollment period during which people who were uninsured could enroll in a health plan. MNsure’s special enrollment period began March 23, carafate best price and continued through April 21.

Nearly 9,500 Minnesota residents enrolled in private plans through MNsure during this window, as well as another 13,700 who enrolled in MinnesotaCare or Medicaid (enrollment in those programs is open year-round for eligible residents).Allison O’Toole, who led MNsure as CEO for three years, announced her resignation in March 2018, and the exchange named Nate Clark, the MNsure COO, as acting CEO. A few months later, the MNsure carafate best price board named Clark as the permanent CEO. O’Toole left MNsure to work as director of state affairs for United States of Care, a non-profit created by Andy Slavitt, who was the acting administrator of CMS under the Obama Administration.Throughout 2017, Minnesotans who bought their own health insurance (on or off-exchange) and weren’t eligible for ACA subsidies were provided with 25 percent premium rebates from the state as a result of S.F.1, signed into law by Governor Dayton in early 2017. The subsidies helped to offset the carafate best price large premium increases that applied in Minnesota in 2017, and helped to stabilize the individual health insurance market in 2017. But the premium rebate program expired at the end of 2017.Thanks in large part to the new reinsurance program that Minnesota created (details below), premiums decreased in Minnesota’s individual market in 2018, 2019, and again in 2020, although rates are increasing modestly for 2021.

In May 2019, Minnesota leaders reached an agreement on a budget that included an extension of the reinsurance program through 2020 and 2021 (it has already been granted federal approval through the end of 2022, but the state has to continue to cover carafate best price its share of the cost. Minnesota Governor Tim Walz had hoped to implement a premium subsidy program and a new tax credit in Minnesota starting in 2020. But a compromise in the budget ended up with the state opting to continue the existing reinsurance program for two more years instead.).But the waiver that provides federal pass-through funding for reinsurance also resulted in a sharp and unexpected decrease in federal funding for MinnesotaCare, the Basic Health Program carafate best price that provides coverage for people with income between 138 percent and 200 percent of the poverty level (between $16,642 and $24,120 for a single person).In addition, the elimination of federal funding for cost-sharing reductions (CSR) in October 2018 resulted in a funding cut for MinnesotaCare, since the program is funded in large part by federal funds that would otherwise have been used to pay for premium subsidies and cost-sharing reductions in the exchange for the population that is instead eligible for MinnesotaCare. After an ensuing legal battle, a judge ordered HHS to restore funding for MinnesotaCare, although a resolution of the situation is ongoing, and the amount that HHS agreed to pay was still less than MinnesotaCare would have received if CSR funding had continued.Open enrollment for 2021 health plans extended through December 22, 2020. Insurers implementing modest rate increases for 2021, after three years of overall rate decreasesMNsure enabled window shopping for 2021 health plans carafate best price as of October 12, 2020.

This gives residents a few weeks to browse the available plans before open enrollment starts on November 1, 2020. And MNsure has announced that open enrollment will carafate best price continue through December 22, 2020. That’s a week longer than the open enrollment period that will apply in states that use the federally-run exchange. The flexibility to extend open enrollment is often cited as one of the benefits of having a carafate best price fully state-run exchange. (MNsure had a similar extension last December, for 2020 health plans).For 2021, Quartz is joining the Minnesota marketplace.

Quartz currently offers plans in Illinois and Wisconsin, and is carafate best price expanding into Minnesota for 2021. And two of the existing insurers — HealthPartners and UCare — are expanding their coverage areas for 2021 (BluePlus and Medica offer coverage statewide, and will continue to do so in 2021).The following average rate changes have been approved for MNsure’s insurers:Blue Plus. 4.21 percent increase (down from an initially carafate best price proposed 7.12 percent increase)Group Health/Health Partners (GHI). 0.67 percent increase (down from an initially proposed 4.15 percent increase)Medica. 2.42 percent increase (down from an carafate best price initially proposed 7.06 percent increase)UCare.

1.6 percent increase (up from an initially proposed 1.39 percent decrease)Quartz. New for 2021, so no applicable rate changePreferredOne Insurance Company, which offers plans outside the carafate best price exchange, is increasing premiums by 1.05 percent (down from an initially proposed average increase of 5.09 percent). Rate changes in previous years2015. Average increase of 4.5 carafate best price percent. MNsure critics characterized carafate best price the official announcement as misleading as it failed to take into account low-cost 2014 plans from PreferredOne.

Consumers who bought a PreferredOne plan through MNsure for 2014 could only renew their policies for 2015 by working directly with the insurer, since PreferredOne stopped offering plans in the exchange at the end of 2014. However, PreferredOne rates went up an average of 63 percent, carafate best price and consumers didn’t qualify for subsidies if they shopped outside the exchange. 2016. Average increase of 41.4 percent carafate best price for the individual market, and about 38.5 for plans sold in MNsure (ie, not counting PreferredOne). Rates increased significantly in 2016 across the entire individual market in Minnesota — including plans sold through MNsure, the state-run exchange.Approved rates for 2016 were announced on October 1, 2015, ranging from about 15 percent for Medica to 49 percent for Blue Cross Blue Shield of Minnesota.

In general, the carriers cited higher-than-expected claims costs over the past year, along with carafate best price the impending phase-out of the ACA’s reinsurance program as justification for their 2016 rate requests. But Governor Mark Dayton called some of the higher proposed increases “outrageous,” and promised a rigorous review of the filed rate changes and justifications. Ultimately, regulators were able to limit the highest rate increases to 49 percent — as opposed to the 54 percent that had been requested by Blue Plus and BCBS of MN — but the final weighted average rate increase in the individual market in Minnesota still ended carafate best price up being the highest in the nation. But Minnesota still had the lowest overall premiums in the upper midwest (although Minnesota had the highest average rate increase in the country for 2016, they had the lowest overall rates in the country in 2014 and 2015).Minnesota Commerce Commissioner Mike Rothman called the rate increases “unacceptably high,” and Gov. Dayton noted carafate best price that he was “extremely unhappy” with the rate changes.

But Rothman noted that his office “objected to all of the rates across the board,” and “squeezed out everything we could that was not actuarial justified.” In other words, the final rates, although much higher than officials and policyholders would have liked, were justified based on medical claims costs — the population enrolled in individual health plans in Minnesota was sicker than expected, and drug costs had been particularly onerous.Only about 55 percent of people who had 2015 coverage through MNsure received premium subsidies. But due to the sharp premium increases, that had increased to about 63 percent for the people who had purchased or renewed coverage as of carafate best price June 2016.2017. When the Minnesota Department of Commerce announced health insurance rates for 2017 for the individual and small group markets, the rate hikes were somewhat reasonable in the small group market (ranging from a decrease of 1 percent to an increase of 17.8 percent), but the individual market was “experiencing serious disruptions in 2017” and “on the verge of collapse.” The four carriers that offered plans through MNsure had the following average rate increases in 2017:Blue Plus = 55 percentHealthPartners/Group Health (GHI) = 50 percent (HealthPartners is only offering plans in 10 of the 67 counties where they offered plans in 2016. Their enrollment cap is 72,000 for 2017)Medica = 57.5 percent (enrollment cap is 50,000 for 2017)UCare = 66.8 percent (UCare capped enrollment at 30,000 for 2017, but only had 16,000 enrollees in 2016)The enrollment caps that HealthPartners, Medica, and UCare employed for 2017 were approved as part of the rate review process, and are designed to protect carriers from further financial losses as they absorb BCBSMN’s enrollees who are shopping for new carafate best price coverage during open enrollment.In a news release relating to the rate announcement for 2017, the Minnesota Department of Commerce didn’t mince words. They noted that the individual market in the state was on the brink of collapse, and that they did everything in their power to save the market.

While they succeeded in keeping the state’s individual market viable for 2017, with only one carrier exiting (BCBSMN, although their HMO affiliate, Blue Plus, remained in the exchange), they reiterated very clearly that substantial reforms would be needed to keep the market stable in future years, and highlighted the fact that rates would be sharply higher and that carafate best price carriers would limit enrollment in 2017.2018. Final rates for 2018 were approved in October 2017 (comprehensive information about the approved rates is here), based on the Minnesota Premium Security Plan (MSPS) being implemented but cost-sharing reductions (CSR) not being funded by the federal government (the cost of CSRs was added to on-exchange Silver plans). Average approved rate changes for MNsure insurers ranged from a 13.3 percent decrease for UCare to a 2.8 percent increase for Blue carafate best price Plus. Three of the four MNsure insurers decreased their average premiums for 2018.On September 21, MNsure had posted a notice indicating that if the reinsurance program were not approved, rates would be about 20 percent higher than they would otherwise be in 2018. Fortunately for Minnesota residents, the reinsurance program did receive federal approval, and average rates declined slightly for 2018.But some enrollees who don’t get ACA premium subsidies still experienced a rate increase, due to the termination carafate best price of the one-year, state-funded 25 percent premium rebates at the end of 2017.PreferredOne, which exited MNsure at the end of 2014 and only offers coverage in the off-exchange market, proposed dramatically lower rates for 2018.

A 38 percent average decrease if MSPS were to be approved, and a 23 percent average decrease if not. The 38 percent decrease was implemented, and no adjustments carafate best price were necessary to account for CSR funding, since PreferredOne does not offer plans in the exchange, and CSRs are only available on silver exchange plans.2019. Average premium decrease of 12.4 percent. Average premiums carafate best price dropped for all five insurers in the individual market in 2019. This was the second year in a row of declining rates in Minnesota, but Blue Plus had a small rate increase for 2018, so 2019 was the first year that all five insurers decreased their average rates.

Minnesota insurance regulators noted that rates in 2019 were about 20 percent lower than they would have been without the reinsurance program.But most of Minnesota’s insurers charged higher carafate best price rates in 2019 than they would have if the individual mandate penalty hadn’t been eliminated, and if access to short-term plans and association health plans hadn’t been expanded by the Trump administration. For example, UCare’s rate filing notes that while average rates were decreasing by about 10 percent, the rate decrease would have been nearly 15 percent if the individual mandate penalty had remained in place.At ACA Signups, Charles Gaba calculated a weighted average rate decrease of 12.4 percent for 2019 in Minnesota, but noted that the average decrease would have been nearly 19 percent without those changes at the federal level.2020. Average premium carafate best price decrease of 1 percent. Four of the five insurers (including PreferredOne, which only offers coverage off-exchange) in Minnesota’s individual market decreased their average premiums for 2020. This was the third year in a row that average individual market premiums dropped in Minnesota’s individual market, due in large part to the reinsurance program carafate best price that the state has established.The following average rate changes were implemented for 2020:Blue Plus.

1.5 percent decrease (Blue Plus had originally proposed carafate best price a 4.8 percent increase)Group Health/Health Partners (GHI). 1.26 percent decrease (GHI had originally proposed a 2.1 percent increase)Medica. 1.01 percent decrease (Medica carafate best price had originally proposed an average decrease of 1.4 percent)UCare. 0.18 percent increase (UCare originally proposed a 0.3 percent increase)PreferredOne, which only offers off-exchange coverage, reduced their rates by an average of 20 percent, on the heels of an 11 percent decrease in 2019. MNsure enrollment exceeded 116k in 2018, dropped carafate best price to 113k for 2019, but grew to more than 1117k in 2020From 2014 through 2018, enrollment in MNsure’s individual market plans increased every year, reaching 116,358 people by 2018.

That was the highest open enrollment total in MNsure’s history, despite the shorter enrollment period, which ended in mid-January instead of the end of January (open enrollment for 2018 coverage ended on December 15, 2017 in states that use HealthCare.gov, but MNsure opted to extend their enrollment window that year, and have also extended subsequent enrollment windows).Enrollment dropped for the first time in 2019, when 113,552 people enrolled in individual market plans through MNsure. In most states that use HealthCare.gov, enrollment peaked in 2016 and has been dropping since then carafate best price. But MNsure’s drop-off in 2019, which amounted to only a 2.4 percent reduction in enrollment, is the only time year-over-year enrollment has declined. Notably, the ACA’s individual mandate penalty was eliminated as of 2019, and regulations that the Trump administration implemented in late 2018 now make it more feasible for healthy people to use short-term plans instead of ACA-compliant plans (Minnesota has its own rules for short-term plans, but they’re more relaxed than the Obama-era carafate best price federal rules that applied in 2017 and most of 2018).And for 2020, enrollment grew again, reaching a record high of 117,520 enrollees.Here’s a look at the number of people who have signed up for individual market plans through MNsure during each year’s open enrollment period. These numbers all represent total enrollment at the end of open enrollment.

Effectuated enrollment carafate best price is always lower, and MNsure provides periodic effectuated enrollment data on their board meeting materials page. Insurer participation in MNsure. 2014-20212014. Five insurers offered individual policies through MNsure for 2014. Blue Cross Blue Shield of Minnesota, HealthPartners/Group Health, Medica, PreferredOne, and UCare.

Kaiser Health News reported that Minnesota offered some of the lowest premiums for silver (mid-level) plans in the U.S. Four of Minnesota’s nine regions made Kaiser’s list of the 10 least expensive places to buy health insurance.2015. But PreferredOne, which offered the lowest rates in the nation in 2014 and captured a large portion of 2014 enrollees, withdrew from MNsure for 2015. PreferredOne said remaining on the exchange was “not administratively and financially sustainable.” A Star Tribune business writer attributed PreferredOne’s departure as a market dynamics issue rather than a problem with MNsure.However, Blue Plus (an affiliate of Blue Cross Blue Shield of MN, offering HMO plans) joined the exchange for 2015, so there were still five insurers offering plans for 2015. Blue Cross Blue Shield of Minnesota, Blue Plus, Health Partners/Group Health, Medica, and UCare.

MNsure offered 84 plans statewide, up from 78 for 2014.2016. BCBSMN, Blue Plus, Health Partners/Group Health, Medica, and UCare offered individual market plans through MNsure for 2016.2017. In an effort to recruit more carriers to offer plans through MNsure for 2017 — particularly outside the Twin Cities metro area — state regulators sent out a request for proposals from health insurers on August 15, 2016. Regulators noted that insurers could propose waivers of regulations in order to make it feasible for them to offer coverage through MNsure, although any such waiver requests would have to be approved by regulators.Steven Parente, a health insurance expert at the University of Minnesota, called the state’s effort to recruit insurers to MNsure a “distress call” and noted that August 15 is awfully late in the year to be putting out a request for insurer participation, given that open enrollment begins November 1. And ultimately, no new insurers opted to join MNsure for 2017.Blue Cross Blue Shield of MN dropped their individual market PPO plans at the end of 2016 due to significant financial losses.

That left Blue Plus (which offered HMOs and covered roughly 13,000 people in 2016 in the individual market) as the only BCBSMN affiliate in the exchange. Roughly 103,000 people had to select new plans during open enrollment.Most of those BCBSMN enrollees had off-exchange coverage, though. There were only about 20,400 MNsure enrollees (a little more than one in five MNsure enrollees) with coverage under BCBSMN who needed to switch to another plan during open enrollment. BCBSMN had individual PPO options available in all 87 counties in Minnesota through MNsure in 2016, while the Blue Plus coverage area — comprised of four separate HMO networks — was available in 77 of the state’s counties.Nationwide, carriers have been shifting away from PPOs and towards HMOs and EPOs. In Colorado, Anthem Blue Cross Blue Shield also dropped their PPOs at the end of 2016.

In Indiana, there were no PPOs available in the individual market by 2017. Blue Cross Blue Shield of New Mexico dropped all of their individual market plans at the end of 2015 except one off-exchange HMO. Blue Cross Blue Shield of Texas dropped their individual market PPO plans at the end of 2015.The broad network offered by PPOs tends to be attractive to enrollees who have health problems. They’re often willing to pay higher premiums in trade for access to broad network of hospitals and specialists. But PPOs are expensive for carriers, as enrollees don’t need primary care referrals to see specialists, and it’s more challenging for carriers to hold down costs when there are more providers in the network.All of the MNsure carriers except Blue Plus are also limiting their total enrollment for 2017.

By November 11, 2016, less than two weeks into open enrollment for 2017 coverage, Medica had hit their 50,000 member enrollment cap for 2017 (including on and off-exchange enrollments, and also accounting for expected renewals of 2016 Medica plans), and their policies were no longer available in the individual market in Minnesota, on or off-exchange. The only exception was five counties (Benton, Crow Wing, Mille Lacs, Morrison, and Stearns) where Medica agreed not to limit enrollment, as all of the other available carriers in those counties have imposed enrollment caps too. In those five counties, Medica plans continued to be available.At that point, Medica’s market share in MNsure for 2017 stood at 34.2 percent. By December 14, Medica’s market share had dropped to 27.7 percent, as enrollments had continued to climb for the remaining carriers.On January 31, Medica re-opened enrollment for 2017. This was because a smaller-than-expected number of 2016 Medica enrollees renewed their plans for 2017, meaning that the carrier still had some wiggle room under their 50,000 member cap.

At that point, they had room for about 7,000 more enrollees. Medica plans were thus available throughout the duration of the special enrollment period that was added on at the end of open enrollment, and continue to be available for people with qualifying events.2018. Plans continued to be available from Blue Plus, Health Partners/Group Health (GHI), Medica, UCare. In the months before a decision was reached regarding an extension of the open enrollment window for 2018 plans (the first year that the federal government imposed a shorter, month-and-a-half enrollment window), two of MNsure’s participating insurers had differing positions. UCare believed the exchange should add an additional two-week special enrollment period, while Medica did not want the exchange to have the option to extend the newly-scheduled six-week enrollment window.

Notably, Medica capped their enrollment very early during the 2017 open enrollment period, and while UCare also had an enrollment cap, it was set with a target of nearly doubling their 2016 enrollment. But Medica is the only MNsure insurer that didn’t set an enrollment cap for 2018.As was the case for 2017, enrollment caps were used in the individual market in Minnesota for 2018 by all insurers other than Medica (Medica did have an enrollment cap for 2017, which they hit very early in open enrollment. However, they resumed enrollments at the end of January 2017). Details about the insurers’ enrollment caps are in the plan binders in SERFF. For 2018, MNsure insurers implemented the following enrollment caps:Blue Plus.

55,000 member cap (aiming for a target of 50,000 effectuated enrollees, but effectuated enrollment is always lower than the number of people who initially enroll)Health Partners/Group Health (GHI). 73,400 member cap (aiming for a target of 70,000 effectuated enrollees)Medica. No enrollment capUCare. 35,000 member cap (aiming for a target of 30,000 effectuated enrollees)MNsure confirmed in May 2018 that none of their insurers had hit their enrollment caps for 2018.Outside the exchange, PreferredOne had an enrollment cap of 3,000 members, although their 2017 membership was only about 300 people.2019 and 2020. Blue Plus, Health Partners/Group Health, UCare, and Medica have continued to offer plans through MNsure, and all of them continued to participate in 2020 as well.

Blue Plus expanded to once again offer statewide coverage in 2020, for the first time since 2016.2021. Quartz joined the exchange for 2021, joining the four existing insurers. HealthPartners and UCare are both expanding their coverage areas for 2021.Minnesota Premium Security Plan. 1332 waiver proposal approved by CMS, but with a significant funding cut for MinnesotaCareIn May 2017, Minnesota Governor Mark Dayton submitted a 1332 waiver proposal to CMS. The 1332 waiver was based on H.F.5, which was enacted without Dayton’s signature in April 2017 (Dayton had proposed an alternative measure that would have allowed people in Minnesota to buy into MinnesotaCare.

That measure was not able to pass the state’s Republican-dominated legislature).[For more than two decades, MinnesotaCare was a state program subsidizing health insurance for low-income residents. As of January 1, 2015, it transitioned to a Basic Health Program under the ACA, becoming the first BHP in the nation.]H.F.5 created the Minnesota Premium Security Plan (MPSP), which is a state-based reinsurance program (similar to the one the ACA implemented on a temporary basis through 2016, and that Alaska created for 2017. Several other states have since implemented reinsurance programs). The reinsurance program, which took effect in Minnesota in 2018, covers a portion of the claims that insurers face, resulting in lower total claims costs for the insurers, and thus lower premiums (average individual market premiums in Minnesota decreased from 2017 to 2018 as a result of the reinsurance program). The reinsurance kicks in once claims reach $50,000, and covers them at 80 percent up to $250,000 (this is similar to the coverage under the transitional reinsurance program that the ACA provided from 2014 through 2016).H.F.5 was contingent upon approval of the 1332 waiver, because it relies partially on federal funding, in addition to state funding.

Under the federal approval that was granted in September 2017, the federal government is giving Minnesota the money that they save on premium tax credits, and that money is combined with state funds to implement the reinsurance program (lower premiums — as a result of the reinsurance program — result in the federal government having to pay a smaller total amount of premium tax credits, since the tax credits are smaller when premiums are smaller).It was expected that CMS would approve the state’s 1332 waiver proposal, and Governor Dayton requested that the approval process be swift so that the state could move forward with the implementation of the Minnesota Premium Security Plan in time for the 2018 plan year. Dayton indicated that his office had been told that approval would come in August 2017, but CMS didn’t approve the waiver until September 22. And the waiver approval letter noted that the federal savings for MinnesotaCare (the state’s Basic Health Program, or BHP) resulting from the reinsurance program would not be eligible to be passed along to the state — in other words, CMS would keep those savings instead.[Federal BHP funding is equal to 95 percent of the amount that the federal government would have otherwise spent on premium subsidies and cost-sharing reductions for the population that ends up being eligible for the BHP. So lower premiums — as a result of reinsurance — for qualified health plans in the exchange means that the amount the federal government would have had to spend on premium subsidies for that population is lower. That translates into a smaller amount of funding for the state’s BHP, according to the approach that HHS took for Minnesota’s waiver approval.]And based on the scathing letter that Dayton sent CMS a few days earlier, it appeared at that point that Minnesota could actually lose money on the deal — losing more in federal funding for MinnesotaCare than they gain in reinsurance funding.

Dayton noted in his letter that the 1332 waiver approval process had been “nightmarish,” and that Minnesota went to great lengths to follow instructions from CMS at every turn, throughout the process of drafting H.F.5 and the 1332 waiver proposal. He explains that CMS provided Minnesota with explicit guidance in terms of how to draft the reinsurance program while maintaining full federal funding for MinnesotaCare, and highlighted the fact that the state never deviated from the instructions that were provided.The StarTribune editorial board called out then-Secretary of HHS, Tom Price and the Trump Administration for their lack of clarity on the issue, for apparently misleading the state during the 1332 waiver drafting process, and for effectively punishing the state of Minnesota for taking an innovative approach to ensuring that as many people as possible have health insurance.Insurers filed rates based on reinsurance being available. And by the time the waiver was approved, there was very little time to evaluate the potential impacts of the funding changes, as rates had to be finalized by October 2 in Minnesota. The finalized rates did incorporate the reinsurance program. The state has accepted the approved waiver, but Gov.

Dayton sent a letter to HHS on October 3, asking them to reconsider the MinnesotaCare funding cuts, but the issue has remained unresolved.Elimination of CSR funding results in additional funding cut for MinnesotaCare, but a lawsuit has partially restored that fundingNationwide, 54 percent of exchange enrollees benefit from cost-sharing subsidies. But in Minnesota, only 13 percent of exchange enrollees are receiving cost-sharing subsidies. This is because of MinnesotaCare, which covers all enrollees with income up to 200 percent of the poverty level. That’s the same group that would otherwise benefit the most from cost-sharing subsidies, so the fact that MinnesotaCare is available means that most of the people who would otherwise be enrolled in cost-sharing subsidy plans are instead enrolled in MinnesotaCare.At first glance, this would appear to have made the uncertainty surrounding cost-sharing subsidy funding in 2017 a little less of a pressing issue in Minnesota than it was in many other states, since private insurers weren’t facing the sort of losses that insurers in other states were facing without federal funding for CSR. But when the Trump Administration eliminated federal funding for CSR in October 2017, HHS took the position tha t since CSR funding had been eliminated, the CSR portion of the federal funding for the BHPs in New York and Minnesota would be reduced to $0.

This was not a cut-and-dried conclusion, however, as explained earlier in 2017 by Michael Kalina.In January 2018, the Attorneys General for New York and Minnesota filed a lawsuit against the US Department of Health and Human Services, seeking to restore funding for their Basic Health Programs. A judge ruled in favor of the states in May 2018, ensuring that MinnesotaCare would continue to receive at least some CSR-based funding. The amount awarded to the state for the first quarter of 2018 was just over half of what the state had initially expected in CSR-related funding, but a larger chuck of the funding was restored later in 2018. According to the Star Tribune, however, Minnesota still ended up losing $161 million in federal funding for MinnesotaCare due to the CSR funding cuts.In early 2019, the Trump administration proposed yet another funding cut (a third, after the cuts imposed by the reinsurance program and the elimination of CSR funding) as part of a new methodology for calculating BHP funding. This one was much smaller than the other two cuts, but taken together the funding reductions are pushing MinnesotaCare towards a looming budget shortfall.

SHOP exchange. Down to one carrier as of 2016, zero by 2018 (and still zero in 2019)In 2015, there were two carriers in MNsure’s SHOP exchange for small businesses. Blue Cross Blue Shield of Minnesota, and Medica. But Medica announced in 2015 that they would exit the SHOP exchange in Minnesota, North Dakota, and Wisconsin at the end of the year. That left BCBS as the only small group carrier available through MNsure in 2016, but it didn’t change much from a practical standpoint, since 83 percent of MNsure’s small groups were enrolled in plans through BCBS in 2015.

Indeed, Medica’s reason for exiting the small business exchange was based on low enrollment in the first two years.Blue Cross Blue Shield of Minnesota continued to be the only insurer offering SHOP coverage via MNsure in 2017, but announced in July 2017 that they would no longer offer SHOP coverage in 2018, and would instead transition their SHOP enrollees to small business coverage outside the exchange. At that point, there were only 3,287 people enrolled in SHOP coverage in Minnesota — far below the 155,000 people that were originally projected to have coverage through MNsure’s SHOP program by 2016 (this much lower-than-anticipated enrollment has been the case in nearly every state’s SHOP exchange. This situation is not unique to Minnesota). State law provided 25% premium rebate in 2017. Amendment to allow plans without essential benefits was cut from final legislationThroughout 2016, then-Governor Dayton called for a state-funded premium rebate for people who buy their own insurance but aren’t eligible for the ACA’s premium subsidies (those are only available for people with income up to 400 percent of the poverty level, or $100,400 for a family of four in 2019).Governor Dayton also noted that the government needed to act quickly to stabilize the individual market in Minnesota, and by late November 2016, his patience with lawmakers was wearing thin.

In a November 23 press conference, Dayton said that House Republicans needed to “stop dilly-dallying” and decide whether to move forward with Dayton’s rebate proposal.Dayton had also indicated that he was considering calling a special session of the legislature after election day to address the situation, and that was being negotiated for December 20. But the talks fell through when Dayton and Republican House Speaker Kurt Daudt couldn’t agree on the three bills that would have been addressed in the special session. As a result, there was no special session.Instead, the issue was taken up by lawmakers as soon as the 2017 legislative session began. On January 5, Minnesota Senators Michelle Benson (R, 31st District) and Gary Dahms (R, 16th District) introduced S.F.1. The bill called for using $300 million in state funding to provide a 25 percent rebate to roughly 125,000 people in Minnesota.S.F.1 passed the Minnesota Senate by a 35-31 vote on January 12.

Only one DFL Senator (Melisa Franzen, from Edina) voted with Republicans in favor of the legislation. It was then sent to the House, where an amendment was added that stripped out the requirement that health plans provide various mandated benefits (see “Journal of the Day” section “Top of page 154” in this version of the bill. Under the terms of the amendment, as long as a carrier offered at least one plan with all the mandated benefits, they would have been allowed to offer others without mandated benefits).The amended bill was sent back to the Senate on January 23. Differences between the bills that the two chambers passed had to be reconciled before being sent to Governor Dayton for his signature. By that point, the amendment to allow less-robust plans to be sold had garnered national attention, and public outrage helped to push lawmakers away from the provision.

S.F.1 had also called for $150 million to be appropriated for fiscal year 2018 (through June 30, 2019) from the state general fund to a state-based reinsurance program to stabilize the individual market (Alaska did something similar in 2016, preventing a market collapse), but that provision was also removed in the final version (Minnesota did ultimately set up a reinsurance program, effective in 2018, which has served to stabilize the market and reduce premiums).A Conference Committee in the Senate recommended that the House “recede from its amendments” and the Conference Committee report passed the Senate on a 47-19 vote. The House passed the bill a few hours later, 108-19. It was sent to Governor Dayton, who immediately signed it into law. DFLers did have to compromise on one issue during the process. S.F.1 allows for-profit HMOs to begin operating in Minnesota’s individual market, which had long been limited to non-profit HMOs.Consumers were told to expect the premium rebates to show up by April 2017, but they were retroactively effective to January 2017.

So a person who had been paying full price for a plan since January 2017 saw a substantial premium reduction on the April or May invoice. Going forward, for the remainder of the year, a 25 percent rebate applied each month.Since S.F.1 was signed into law with only a few days remaining in open enrollment (it ended January 31 that year), Governor Dayton and exchange officials were worried that there wouldn’t be enough time for people to learn about the rebate and apply for coverage before January 31. In December, Dayton had asked HHS to allow MNsure to extend its enrollment deadline to February 28 (instead of January 31) in order to allow lawmakers more time to work out the details of a state-based premium rebate while still allowing people to enroll after the legislative process is complete.HHS denied the request for a blanket extension, but MNsure used their own authority on January 28 to grant a one-week special enrollment period (February 1 to February 8) due to exceptional circumstances. Although the state-based 25 percent premium rebate was available on or off the exchange, the one-week extension was only valid through MNsure. Health insurers did not have to accept off-exchange enrollments without a qualifying event after January 31.The 25 percent premium rebate program in Minnesota was only authorized for one year, so the rebates did not continue into 2018.

And although almost 100,000 people received premium relief through the program in 2017, it ended up costing less than the legislature had allocated, and about $100 million was returned to the state’s budget at the end of 2017.Protecting Medicaid enrollees from estate liensIn every state, Medicaid is jointly funded by the state and the federal government. Longstanding federal regulations, which predate the ACA, require states to “seek recovery of payments from the individual’s estate for nursing facility services, home and community-based services, and related hospital and prescription drug services” for any Medicaid enrollee over the age of 55. This applies essentially to long-term care services, but states also have the option to go after the individual’s estate to recover costs for other care that was provided by Medicaid after age 55.Prior to 2014, this wasn’t typically an issue, as Medicaid eligibility was generally restricted by asset tests or requirements that applicants be disabled or pregnant (although Minnesota did have much more generous Medicaid eligibility guidelines than most states prior to 2014). But as of 2014, in states that expanded Medicaid under the ACA, the only eligibility guideline is income. Applicants with income that doesn’t exceed 138 percent of the poverty level are directed to Medicaid, regardless of any assets they might have.When applicants use the health insurance exchange — MNsure in Minnesota — they’re automatically funneled into Medical Assistance (Medicaid) if their income is under 138 percent of the poverty level.

But what these enrollees didn’t know was that the state also had a program in place to put liens on estates for Medicaid-provided services for people age 55 and older.The combination of these systems caught numerous residents off guard. They were enrolled in Medical Assistance through MNsure based on their income, but were not aware that liens were being placed on their homes so that the state could recoup the costs upon their deaths.State Senator Tony Lourey (DFL, District 11) addressed the issue with language included in HF2749, the Omnibus supplemental budget bill, which was signed into law by Governor Dayton on June 1, 2016. The legislation limits estate recovery to just what’s required under federal Medicaid rules (ie, essentially, long-term care costs for people age 55 or older), and makes the provision retroactive to January 1, 2014.Early tech strugglesMNsure opened for business in the fall of 2013, but technological issues persisted well into 2015, despite numerous improvements throughout 2014. Given MNsure’s difficult launch, the state conducted a series of audits and reviews. The first audit reviewed how MNsure spent state and federal money.

Auditors concluded that the exchange has generally adequate internal controls and found no fraud or abuse. The review was conducted by the state Office of the Legislative Auditor, and the report was published in October 2014.Another audit, also conducted by the Office of the Legislative Auditor and released in November 2014, found that the MNsure system in some cases incorrectly determined who qualified for public health benefits. The errors occurred during the first open enrollment period, before a series of system fixes were implemented. The audit did not quantify the total financial impact of the errors. The state Human Services commissioner said a consultant working on technical fixes to MNsure concluded that the eligibility functionality was working correctly as of June 2014.A third audit, a performance evaluation report released in February 2015, said “MNsure’s failures outweighed its achievements.” Among other criticisms, auditors said MNsure staff withheld information from the board of directors and state officials, the enrollment website was seriously flawed and launched without adequate testing, and the first-year enrollment target was unrealistically low.In April 2014, MNsure hired Deloitte Consulting to audit MNsure’s technology and improve the website to make enrolling in coverage and updating life events easier and more streamlined.

Deloitte has been involved in successful state-run marketplaces for Connecticut, Kentucky, Rhode Island and Washington.Software upgrades were installed in August 2014, and system testing continued right up until the start of open enrollment. To reduce wait times for consumers and insurance professionals, MNsure increased its call center and support staff and launched a dedicated service line for agents and brokers.More in-person assisters were available in Minnesota for the 2015 open enrollment period. MNsure encourages residents to utilize the exchange’s assister directory to find local navigators and brokers who can help with the enrollment process.MNsure has improved dramatically in terms of its technology since the early days of ACA implementation, and enrollment increased every year from 2014 through 2019.Lawmakers approved switching to HealthCare.gov as of 2019, but governor vetoedOn May 9, 2017, lawmakers in Minnesota passed SF800, an omnibus health and human services bill. Among many other things, the legislation called for switching from MNsure to the federally-run marketplace (HealthCare.gov) starting in 2019 (see Section 5). But Governor Dayton vetoed it.Gov.

Dayton has long been supportive of MNsure, and had previously clarified that he would veto the bill. In noting his plans to veto the legislation, Dayton made no mention of the transition to HealthCare.gov that was included in the legislation, but focused instead on the sharp budget cuts in the bill. But his veto ensured that MNsure would remain in place, at least for the time being.The Senate’s original version of SF800 did not call for scrapping MNsure, but the bill went through considerable back-and-forth between the two chambers, and the version that passed was the 4th engrossment of the bill.In March 2015, Dayton had asked the legislature to create a Task Force on Health Care Financing that would study MNsure along with possible future alternatives. Dayton noted in his letter that he supported making MNsure “directly accountable to the governor and subject to the same legislative oversight as other state agencies” and his budget included half a million dollars devoted to the task force. The spending bill was approved by the legislature in May, and the 29-member task force was appointed in the summer.One of the possibilities that the task force considered was the possibility of switching to Healthcare.gov, but it’s clear that there was no cut-and-dried answer to the question of whether Minnesota is better served by having a state-run exchange, switching to a federally-run exchange, or teaming up with the federal government on either a supported state-based marketplace or partnership exchange.In a December 2015 meeting of the task force, the MN Department of Human Services presented a financial analysis of the alternatives available to MNsure.

They determined that switching entirely to Healthcare.gov would cost the state an additional $5.1 million in one-time costs from June 2016 to June 2017. And switching to a supported state-based marketplace would cost an additional $6.6 million during that same time frame. If the state had opted to switch to Healthcare.gov, the soonest it could have happened was 2018, since HHS requires a year’s notice from states wishing to transition to Healthcare.gov, and Minnesota wouldn’t have been in a position to make a decision until sometime in 2016.There were significant reservations about making that switch prior to the Supreme Court’s ruling on King v. Burwell. The Court ruled in June 2015 that subsidies are legal in every state, including those that use Healthcare.gov.

Prior to the decision, a switch to Healthcare.gov could have jeopardized subsidies for tens of thousands of Minnesota residents. But once it was clear that Healthcare.gov’s subsidies are safe, some stakeholders began calling for Minnesota to scrap its state-run exchange and use Healthcare.gov instead. Because the MNsure task force was included in the 2016 budget, no hasty decisions were made.In January 2016, the task force submitted their recommendations to the legislature. They covered a broad range of issues, but did not recommend that MNsure transition to the federal enrollment platform. Lawmakers essentially left the exchange alone during the 2016 legislative session.The magnitude of the 2016 rate increases that were announced in October resulted in MNsure opponents renewing their calls to switch to Healthcare.gov.

But it’s important to keep in mind that the 41 percent weighted average rate hike in Minnesota was market-wide, and did not just apply to MNsure enrollees. In fact, the off-exchange carrier (PreferredOne) had among the highest rate hikes in the state for 2016, at 39 percent, and the exchange’s weighted average rate increase (38.5 percent) was lower than the weighted average rate increase for the whole individual market (41 percent).Minnesota health insurance exchange linksMNsure855-3MNSURE (855-366-7873)State Exchange Profile. MinnesotaThe Henry J. Kaiser Family Foundation overview of Minnesota’s progress toward creating a state health insurance exchange.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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Convalescent plasma from a recovered coronavirus disease (COVID-19) patient is seen at the Central Seattle Donor Center of Bloodworks Northwest during the outbreak in Seattle, Washington, April 17, 2020.Lindsey Wasson | ReutersA panel of experts convened by the National Institutes of Health said Tuesday there is "insufficient data" to show convalescent plasma works against the coronavirus, refuting claims made by President Donald Trump buy carafate online usa and the head of the Food and Drug Administration.The panel said it reviewed available data on the treatment and found no data from "well-controlled, adequately powered randomized clinical trials that demonstrate the efficacy and safety of convalescent plasma" for the treatment of Covid-19. It also said buy carafate online usa "there was no difference in 7-day survival" for patients, contradicting FDA Commissioner Dr. Stephen Hahn, who said the treatment resulted in a 35% improvement in survival. "There are insufficient data to recommend either for or against the use of convalescent plasma for buy carafate online usa the treatment of COVID-19," the panel said in a statement.

"Convalescent plasma should not be considered standard of care for the treatment of patients with COVID-19."The FDA buy carafate online usa granted the treatment emergency authorization on Aug 23., allowing U.S. Health-care providers to use the plasma to treat suspected or confirmed infections in hospitalized patients.Results of a study by the Mayo Clinic that the FDA cited in its authorization of the plasma treatment indicates that patients below age 80 who were not on a respirator and received plasma with a high level of antibodies within three days of diagnosis fared better than patients who received plasma with a low level of antibodies. A weakness of the Mayo study was that it did not include a controlled group of patients receiving a placebo.The FDA's decision to authorize emergency use came a day after Trump accused buy carafate online usa the FDA of delaying enrollment in clinical trials for Covid-19 vaccines or therapeutics. The criticism from Trump and action from the FDA led some scientists to say the emergency use was politically motivated, especially since it was announced on the eve of the Republican National Convention.Hahn, under intense criticism, later walked back comments he made on the benefits of convalescent plasma, saying he could have done buy carafate online usa a better job of explaining the data on its effectiveness.He also said he wasn't bowing to pressure from Trump.

"The decision was made by FDA career scientists based on data submitted a few weeks ago," Hahn tweeted last week. This is a developing buy carafate online usa story. Please check back for updates..

Convalescent plasma from a recovered coronavirus disease (COVID-19) patient is seen at the Central Seattle Donor Center of Bloodworks Northwest during the outbreak in Seattle, Washington, April 17, 2020.Lindsey Wasson | ReutersA panel of experts convened by the National Institutes of Health said Tuesday there is "insufficient data" to show convalescent plasma works against the coronavirus, refuting claims made by President Donald Trump and the head of the Food and Drug Administration.The panel said it reviewed available data on carafate best price the treatment and found no data from "well-controlled, adequately powered randomized clinical trials that demonstrate the efficacy and safety of convalescent plasma" for the treatment of Covid-19. It also said "there was no difference carafate best price in 7-day survival" for patients, contradicting FDA Commissioner Dr. Stephen Hahn, who said the treatment resulted in a 35% improvement in survival. "There are insufficient carafate best price data to recommend either for or against the use of convalescent plasma for the treatment of COVID-19," the panel said in a statement. "Convalescent plasma should not be considered standard of care for the treatment of patients with COVID-19."The FDA granted the treatment emergency authorization on Aug carafate best price 23., allowing U.S.

Health-care providers to use the plasma to treat suspected or confirmed infections in hospitalized patients.Results of a study by the Mayo Clinic that the FDA cited in its authorization of the plasma treatment indicates that patients below age 80 who were not on a respirator and received plasma with a high level of antibodies within three days of diagnosis fared better than patients who received plasma with a low level of antibodies. A weakness of the Mayo study was that it did not include a carafate best price controlled group of patients receiving a placebo.The FDA's decision to authorize emergency use came a day after Trump accused the FDA of delaying enrollment in clinical trials for Covid-19 vaccines or therapeutics. The criticism from Trump and action from the FDA led some scientists to say the emergency use was politically motivated, especially since it was announced on the eve of the Republican carafate best price National Convention.Hahn, under intense criticism, later walked back comments he made on the benefits of convalescent plasma, saying he could have done a better job of explaining the data on its effectiveness.He also said he wasn't bowing to pressure from Trump. "The decision was made by FDA career scientists based on data submitted a few weeks ago," Hahn tweeted last week. This is carafate best price a developing story.

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October is Mental Health Awareness Month and is carafate over the counter medication World Mental Health Day takes place on 10 October 2020. This year, the COVID-19 pandemic has added a new dimension to concerns regarding mental health in our communities. Across the globe stories continue to emerge of people’s experiences of anxiety, fear and depression due to the uncertainty and stress brought on by the virus.1–3 Job losses, financial and housing insecurity, the challenges of is carafate over the counter medication working from home, home schooling, restricted access to health and social care services and social isolation coupled with reduced support and contact with family and friends have all impacted people’s well-being. There is particular concern about the mental health of healthcare workers during this difficult time.While most healthcare workers are resilient to the long-term effects of this period of stress and anxiety, there is the added worry about scarce resources, lack of cure or effective treatment options, isolation from family, coping with patient suffering and deaths and the moral and ethical impact of decisions as to who will receive acute care. These factors have significant potential for negative repercussions on the mental health and well-being of healthcare staff.4 5 is carafate over the counter medication There have been reports of high levels of stress, depression and even suicides,6 and long-term effects include a higher risk for post-traumatic stress disorder or moral injury.5Healthcare organisations need to plan for the inevitable consequence of this pandemic and ensure that resources are in place for their workers.

Screening for mental health issues and treatment, including counselling, should be made available. In addition, nurses and other healthcare staff should be encouraged to reflect on their experiences and consider how is carafate over the counter medication to implement self-care strategies that will enhance their well-being. This includes staying informed of the current data and information and being aware of the risks to themselves and others while caring for patients with the virus. By monitoring and enacting strategies to reduce stress and develop support systems, staff can minimise longer-term impacts.4Whether organisational support and self-care monitoring have achieved better mental health outcomes for healthcare workers is, as yet, unknown. Research across the is carafate over the counter medication globe is underway not only related to the virus itself but also to the mental health consequences of the pandemic.

We do not yet know the extent of the issues or how best to support healthcare providers. In order to better understand the issues and to support nurses at this time, evidence-based nursing will focus our social media to mental health is carafate over the counter medication issues during the month of October. We will highlight and share relevant resources and information and encourage discussion of the key challenges facing healthcare workers.During October, we will showcase the experiences of four key groups—patients, nurses, students and informal carers and families. Be sure is carafate over the counter medication to log into evidence-based nursing each week for the following blogs:October 4. Impact of COVID-19 on patient mental health.October 11.

Impact of COVID-19 on nurses’ is carafate over the counter medication mental health and.Twitter Chat on Wednesday October 14 at 20:00 UK time.Oct. 18. Impact of COVID-19 on student nursing.Oct. 25. Impact of COVID-19 on informal carers and families.A PhD is a globally recognised postgraduate degree and typically the highest degree programme awarded by a University, with students usually required to expand the boundaries of knowledge by undertaking original research.

The purpose of PhD programmes of study is to nurture, support and facilitate doctoral students to undertake independent research to expected academic and research standards, culminating in a substantial thesis and examined by viva voce. In this paper—the first of two linked Research Made Simple articles—we explore what the foundations of a high-quality PhD are, and how a Doctoral candidate can develop a study which is successful, original and impactful.Foundations of a ‘good’ PhD studySupervision and supportCentral to the development and completion of a good PhD is the supervisory relationship between the student and supervisor. The supervisor guides the student by directing them to resources and training to ensure continuous learning, provides opportunity to engage with experts in the field, and facilitates the development of critical thinking through questioning and providing constructive criticism.1The support needs of students will be different, so a flexible yet quality assured approach to PhD research training is required. A good supervisory team (usually includes at least two postdoctoral academics) provide experienced guidance and mentorship and will offer students academic support, with regular meetings and timely feedback on written submissions, will assist the student to develop a peer network and help them access research communities relative to their field. Effective supervision has beneficial outcomes for students, including encouraging a positive work ethic and influencing engagement in a stimulating environment, allowing students to pursue their own ideas with educated encouragement.

The quality of the supervisory relationship can impact greatly on the PhD experience and ultimately sets the student on the road to producing excellent Doctoral work.1An environment that promotes personal and professional development is further aided by positive peer interactions. If students feel part of a community and have contact with others also working on doctoral studies, there is the scope for peer compassion and understanding during both challenging and rewarding periods. Students who access personal and professional support and guidance through mentoring models during their studies are more likely to succeed. These models include one-to-one peer mentoring or activities for example journal discussion or methods learning groups. Often, groups of students naturally come together and give each other support and advice about research process expectations and challenges, and offer friendship, and guidance.2 Given the usefulness of different types of mentoring models, all can create a supportive and collaborative environment within a PhD programme of study, to minimise working in isolation and enable students to achieve their greatest potential.Characteristics of a good study.

Originality and theoretical underpinningA PhD should make an original contribution to knowledge. Originality can be achieved through the study design, the nature or outcomes of the knowledge synthesis, or the implications for research and/or practice.3 Disciplinary variation, however, influences the assessment of originality. For example, originality in science, technology, engineering and mathematics subjects is often inferred if the work is published/publishable, in comparison to intellectual originality in the social sciences.4 Although PhD originality assumes different nuances in different contexts, there is a general acceptance across disciplines that there should be evidence of the following within the thesis:An interplay between old and new—any claims of originality are developed from existing knowledge and practices.There are degrees of originality, relating to more than one aspect of the thesis.Any claims for originality are accompanied by clear articulation of significance.A good PhD should be also underpinned by theoretical and/or conceptual frameworks (that include philosophical and methodological models) that give clarity to the approach, structure and vision of the study.5 These theoretical and conceptual frameworks can explain why the study is pertinent and how the research addresses gaps in the literature.6 Table 1 provides a distinction of what construes theoretical and conceptual frameworks.View this table:Table 1 Characteristics of theoretical and conceptual frameworks7Theoretical/conceptual frameworks must align with the research question/aims, and the student must be able to articulate how conceptual/theoretical framework were chosen. Key points for consideration include:Are the research questions/aim and objectives well defined?. What theory/theories/concepts are being operationalised?.

How are the theories/concepts related?. Are the ontological and epistemological perspectives clearly conveyed and how do they relate to theories and concepts outlined?. What are the potential benefits and limitations of the theories and concepts outlined?. Are the ways the theories/concepts are outlined and being used original?. A PhD thesis (and demonstrable in viva) must be able to offer cohesion between the choice of research methods that stems from the conceptual/theoretical framework, the related ontological and epistemological decisions, the theoretical perspective and the chosen methodology (table 2).

PhD students must be able to articulate the methodological decisions made and be critical of methods employed to answer their research questions.View this table:Table 2 Relationship between research paradigms, perspectives, methodologies and methods.8 9ConclusionIn summary, we offer considerations of what the foundations of a good PhD should be. We have considered some of the key ingredients of quality PhD supervision, support and research processes and explored how these will contribute to the development of a study that leads to student success and which makes a valuable contribution to the evidence base. In the next paper, we will look in more detail at the assessment of the PhD through the submission of a thesis and an oral viva..

October is Mental Health Awareness Month and World carafate best price Mental Health Day takes place on 10 October 2020. This year, the COVID-19 pandemic has added a new dimension to concerns regarding mental health in our communities. Across the globe stories continue to emerge of people’s experiences of anxiety, fear and depression due to carafate best price the uncertainty and stress brought on by the virus.1–3 Job losses, financial and housing insecurity, the challenges of working from home, home schooling, restricted access to health and social care services and social isolation coupled with reduced support and contact with family and friends have all impacted people’s well-being. There is particular concern about the mental health of healthcare workers during this difficult time.While most healthcare workers are resilient to the long-term effects of this period of stress and anxiety, there is the added worry about scarce resources, lack of cure or effective treatment options, isolation from family, coping with patient suffering and deaths and the moral and ethical impact of decisions as to who will receive acute care. These factors have carafate best price significant potential for negative repercussions on the mental health and well-being of healthcare staff.4 5 There have been reports of high levels of stress, depression and even suicides,6 and long-term effects include a higher risk for post-traumatic stress disorder or moral injury.5Healthcare organisations need to plan for the inevitable consequence of this pandemic and ensure that resources are in place for their workers.

Screening for mental health issues and treatment, including counselling, should be made available. In addition, nurses and other healthcare carafate best price staff should be encouraged to reflect on their experiences and consider how to implement self-care strategies that will enhance their well-being. This includes staying informed of the current data and information and being aware of the risks to themselves and others while caring for patients with the virus. By monitoring and enacting strategies to reduce stress and develop support systems, staff can minimise longer-term impacts.4Whether organisational support and self-care monitoring have achieved better mental health outcomes for healthcare workers is, as yet, unknown. Research across the globe is underway not only related to the virus itself but also to the mental health consequences carafate best price of the pandemic.

We do not yet know the extent of the issues or how best to support healthcare providers. In order to better understand the issues and to support nurses at this time, evidence-based nursing will focus our social media to mental health issues during the carafate best price month of October. We will highlight and share relevant resources and information and encourage discussion of the key challenges facing healthcare workers.During October, we will showcase the experiences of four key groups—patients, nurses, students and informal carers and families. Be sure to log into evidence-based nursing carafate best price each week for the following blogs:October 4. Impact of COVID-19 on patient mental health.October 11.

Impact of COVID-19 on nurses’ mental health carafate best price and.Twitter Chat on Wednesday October 14 at 20:00 UK time.Oct. 18. Impact of COVID-19 on student nursing.Oct. 25. Impact of COVID-19 on informal carers and families.A PhD is a globally recognised postgraduate degree and typically the highest degree programme awarded by a University, with students usually required to expand the boundaries of knowledge by undertaking original research.

The purpose of PhD programmes of study is to nurture, support and facilitate doctoral students to undertake independent research to expected academic and research standards, culminating in a substantial thesis and examined by viva voce. In this paper—the first of two linked Research Made Simple articles—we explore what the foundations of a high-quality PhD are, and how a Doctoral candidate can develop a study which is successful, original and impactful.Foundations of a ‘good’ PhD studySupervision and supportCentral to the development and completion of a good PhD is the supervisory relationship between the student and supervisor. The supervisor guides the student by directing them to resources and training to ensure continuous learning, provides opportunity to engage with experts in the field, and facilitates the development of critical thinking through questioning and providing constructive criticism.1The support needs of students will be different, so a flexible yet quality assured approach to PhD research training is required. A good supervisory team (usually includes at least two postdoctoral academics) provide experienced guidance and mentorship and will offer students academic support, with regular meetings and timely feedback on written submissions, will assist the student to develop a peer network and help them access research communities relative to their field. Effective supervision has beneficial outcomes for students, including encouraging a positive work ethic and influencing engagement in a stimulating environment, allowing students to pursue their own ideas with educated encouragement.

The quality of the supervisory relationship can impact greatly on the PhD experience and ultimately sets the student on the road to producing excellent Doctoral work.1An environment that promotes personal and professional development is further aided by positive peer interactions. If students feel part of a community and have contact with others also working on doctoral studies, there is the scope for peer compassion and understanding during both challenging and rewarding periods. Students who access personal and professional support and guidance through mentoring models during their studies are more likely to succeed. These models include one-to-one peer mentoring or activities for example journal discussion or methods learning groups. Often, groups of students naturally come together and give each other support and advice about research process expectations and challenges, and offer friendship, and guidance.2 Given the usefulness of different types of mentoring models, all can create a supportive and collaborative environment within a PhD programme of study, to minimise working in isolation and enable students to achieve their greatest potential.Characteristics of a good study.

Originality and theoretical underpinningA PhD should make an original contribution to knowledge. Originality can be achieved through the study design, the nature or outcomes of the knowledge synthesis, or the implications for research and/or practice.3 Disciplinary variation, however, influences the assessment of originality. For example, originality in science, technology, engineering and mathematics subjects is often inferred if the work is published/publishable, in comparison to intellectual originality in the social sciences.4 Although PhD originality assumes different nuances in different contexts, there is a general acceptance across disciplines that there should be evidence of the following within the thesis:An interplay between old and new—any claims of originality are developed from existing knowledge and practices.There are degrees of originality, relating to more than one aspect of the thesis.Any claims for originality are accompanied by clear articulation of significance.A good PhD should be also underpinned by theoretical and/or conceptual frameworks (that include philosophical and methodological models) that give clarity to the approach, structure and vision of the study.5 These theoretical and conceptual frameworks can explain why the study is pertinent and how the research addresses gaps in the literature.6 Table 1 provides a distinction of what construes theoretical and conceptual frameworks.View this table:Table 1 Characteristics of theoretical and conceptual frameworks7Theoretical/conceptual frameworks must align with the research question/aims, and the student must be able to articulate how conceptual/theoretical framework were chosen. Key points for consideration include:Are the research questions/aim and objectives well defined?. What theory/theories/concepts are being operationalised?.

How are the theories/concepts related?. Are the ontological and epistemological perspectives clearly conveyed and how do they relate to theories and concepts outlined?. What are the potential benefits and limitations of the theories and concepts outlined?. Are the ways the theories/concepts are outlined and being used original?. A PhD thesis (and demonstrable in viva) must be able to offer cohesion between the choice of research methods that stems from the conceptual/theoretical framework, the related ontological and epistemological decisions, the theoretical perspective and the chosen methodology (table 2).

PhD students must be able to articulate the methodological decisions made and be critical of methods employed to answer their research questions.View this table:Table 2 Relationship between research paradigms, perspectives, methodologies and methods.8 9ConclusionIn summary, we offer considerations of what the foundations of a good PhD should be. We have considered some of the key ingredients of quality PhD supervision, support and research processes and explored how these will contribute to the development of a study that leads to student success and which makes a valuable contribution to the evidence base. In the next paper, we will look in more detail at the assessment of the PhD through the submission of a thesis and an oral viva..