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MidMichigan Health’s buy lasix 100mg Medical Centers recently received annual safety grades for fall 2021 from The Leapfrog Group, an independent national watchdog organization committed to health care quality and safety. The Leapfrog Hospital Safety Grade assigns an “A,” “B,” “C,” “D,” or “F” letter grade to general hospitals across the country based on over thirty national performance measures reflecting errors, injuries, accidents and s, as well as systems hospitals have in place to prevent harm.For the fall 2021 Leapfrog Hospital Safety Grade, MidMichigan Medical Center in Midland earned a fourth consecutive ‘A’ grade. MidMichigan Medical Center – Gratiot buy lasix 100mg its fifth ‘B’ in a row, and the Medical Center in West Branch a second ‘B’ ‘in a row. MidMichigan Medical Center – Alpena received a ‘C’ grade.

MidMichigan Medical Centers in Clare and Gladwin are not graded as they buy lasix 100mg do not meet volume thresholds for scoring or are critical access hospitals.“While scoring and weight calculations for the Leapfrog Hospital Safety Grade change from one grade period to the next, we continually review best practices in patient safety to strengthen our quality and performance measures,” said Diane Postler-Slattery, Ph.D., FACHE, president and CEO, MidMichigan Health. €œEach scoring period allows us to learn through Leapfrog on how our performance compares to the best in the nation, giving us opportunity to reflect on adjustments we can be make for the betterment of our patients.”With quality and patient experience an ongoing focus at MidMichigan Health, all areas of care are reviewed daily for opportunities for improvement. According to the Leapfrog safety survey, since the spring 2021 grading period, several areas buy lasix 100mg of progress has been made across MidMichigan Health Medical Centers. These include improvements in c-difficile, including testing protocol revisions, case reviews, antibiotic use and duration.

Improvements continue to also be made in patient experience scores, hand hygiene and falls.“MidMichigan Health continues to be laser focused on zero harm and reducing falls and preventing falls with injury,” stated Postler-Slattery. €œWe have a culture buy lasix 100mg that supports zero falls and we take a number of steps to ensure it remains a top priority. Among those efforts include consistently measuring and analyzing specific contributing factors that may lead to patient’s fall. In addition, we hold unit buy lasix 100mg quality and safety huddles once a shift to address observations and make necessary changes.

Our patients remain the focus of all that we do.”The Leapfrog Hospital Safety Grade is the only hospital ratings program based exclusively on hospital prevention of medical errors and harms to patients. The grading system is peer-reviewed, fully transparent and free buy lasix 100mg to the public. Grades are updated twice annually, in the fall and spring.Those interested in viewing the full grades may visit www.hospitalsafetygrade.org. About The Leapfrog GroupFounded in 2000 by large employers and other purchasers, The Leapfrog Group is buy lasix 100mg a national nonprofit organization driving a movement for giant leaps forward in the quality and safety of American health care.

The flagship Leapfrog Hospital Survey and new Leapfrog Ambulatory Surgery Center (ASC) Survey collect and transparently report hospital and ASC performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog's other main initiative, assigns letter grades to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents, and s.The MidMichigan Health – West Branch Maternity Unit celebrated its 50th birth on October 29, 2021, since reopening March of 2021. Lyla Jane was buy lasix 100mg born at 8:38 a.m., weighing 6 pounds 11 ounces. The new Maternity Unit received more than $2 million of improvements and equipment purchases, creating a comfortable, state-of the-art, family-focused place for women to give birth.

The unit offers four labor, delivery, recovery, post-partum (LDRP) buy lasix 100mg suites. Three private care rooms. A renovated buy lasix 100mg and newly equipped cesarean-section delivery suite. Upgraded nursery, and a new advanced security system for mom and baby.

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Start Preamble Centers for how to administer lasix Medicare &. Medicaid Services (CMS), how to administer lasix HHS. Notice. This notice announces the monthly actuarial rates for aged (age 65 and over) and disabled (under age 65) beneficiaries enrolled in Part B of the Medicare Supplementary Medical Insurance (SMI) program beginning January 1, 2021. In addition, this notice announces the monthly premium for aged and disabled beneficiaries, the deductible for 2021, and the income-related monthly adjustment amounts to be paid by beneficiaries with modified adjusted gross income above certain threshold amounts.

The monthly actuarial rates for 2021 are $291.00 for aged enrollees and $349.90 for disabled enrollees. The standard monthly Part B premium rate for all enrollees for 2021 is $148.50, which is equal to 50 percent of the monthly actuarial rate for aged enrollees (or approximately 25 percent of the expected average total cost of Part B coverage for aged enrollees) plus the $3.00 repayment amount required under current law. (The 2020 standard premium rate was $144.60, which included the $3.00 repayment amount.) The Part B deductible for 2021 is $203.00 for all Part B beneficiaries. If a beneficiary has to pay an income-related monthly adjustment, he or she will have to pay a total monthly premium of about 35, 50, 65, 80 or 85 percent of the total cost of Part B coverage plus a repayment amount of $4.20, $6.00, $7.80, $9.60 or $10.20, respectively. The premium and related amounts announced in this notice are effective on January 1, 2021.

Start Further Info M. Kent Clemens, (410) 786-6391. End Further Info End Preamble Start Supplemental Information I. Background Part B is the voluntary portion of the Medicare program that pays all or part of the costs for physicians' services. Outpatient hospital services.

Certain home health services. Services furnished by rural health clinics, ambulatory surgical centers, and comprehensive outpatient rehabilitation facilities. And certain other medical and health services not covered by Medicare Part A, Hospital Insurance. Medicare Part B is available to individuals who are entitled to Medicare Part A, as well as to U.S. Residents who have attained age 65 and are citizens and to aliens who were lawfully admitted for permanent residence and have resided in the United States for 5 consecutive years.

Part B requires enrollment and payment of monthly premiums, as described in 42 CFR part 407, subpart B, and part 408, respectively. The premiums paid by (or on behalf of) all enrollees fund approximately one-fourth of the total incurred costs, and transfers from the general fund of the Treasury pay approximately three-fourths of these costs. The Secretary of the Department of Health and Human Services (the Secretary) is required by section 1839 of the Social Security Act (the Act) to announce the Part B monthly actuarial rates for aged and disabled beneficiaries as well as the monthly Part B premium. The Part B annual deductible is included because its determination is directly linked to the aged actuarial rate. The monthly actuarial rates for aged and disabled enrollees are used to determine the correct amount of general revenue financing per beneficiary each month.

These amounts, according to actuarial estimates, will equal, respectively, one-half of the expected average monthly cost of Part B for each aged enrollee (age 65 or over) and one-half of the expected average monthly cost of Part B for each disabled enrollee (under age 65). The Part B deductible to be paid by enrollees is also announced. Prior to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173), the Part B deductible was set in statute.

After setting the 2005 deductible amount at $110, section 629 of the MMA (amending section 1833(b) of the Act) required that the Part B deductible be indexed beginning in 2006. The inflation factor to be used each year is the annual percentage increase in the Part B actuarial rate for enrollees age 65 and over. Specifically, the 2021 Part B deductible is calculated by multiplying the 2020 deductible by the ratio of the 2021 aged actuarial rate to the 2020 aged actuarial rate. The amount determined under this formula is then rounded to the nearest $1. The monthly Part B premium rate to be paid by aged and disabled enrollees is also announced.

(Although the costs to the program per disabled enrollee are different than for the aged, the statute provides that the two groups pay the same premium amount.) Beginning with the passage of section 203 of the Social Security Amendments of 1972 (Pub. L. 92-603), the premium rate, which was determined on a fiscal-year basis, was limited to the lesser of the actuarial rate for aged enrollees, or the current monthly premium rate increased by the same percentage as the most recent general increase in monthly Title II Social Security benefits. However, the passage of section 124 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) (Pub. L.

97-248) suspended this premium determination process. Section 124 of TEFRA changed the premium basis to 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees). Section 606 of the Social Security Amendments of 1983 (Pub. L. 98-21), section 2302 of the Deficit Reduction Act of 1984 (DEFRA 84) (Pub.

L. 98-369), section 9313 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA 85) (Pub. L. 99-272), section 4080 of the Omnibus Budget Reconciliation Act of Start Printed Page 719051987 (OBRA 87) (Pub. L.

100-203), and section 6301 of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) (Pub. L. 101-239) extended the provision that the premium be based on 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees). This extension expired at the end of 1990. The premium rate for 1991 through 1995 was legislated by section 1839(e)(1)(B) of the Act, as added by section 4301 of the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) (Pub.

L. 101-508). In January 1996, the premium determination basis would have reverted to the method established by the 1972 Social Security Act Amendments. However, section 13571 of the Omnibus Budget Reconciliation Act of 1993 (OBRA 93) (Pub. L.

103-66) changed the premium basis to 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees) for 1996 through 1998. Section 4571 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33) permanently extended the provision that the premium be based on 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees). The BBA included a further provision affecting the calculation of the Part B actuarial rates and premiums for 1998 through 2003.

Section 4611 of the BBA modified the home health benefit payable under Part A for individuals enrolled in Part B. Under this section, beginning in 1998, expenditures for home health services not considered “post-institutional” are payable under Part B rather than Part A. However, section 4611(e)(1) of the BBA required that there be a transition from 1998 through 2002 for the aggregate amount of the expenditures transferred from Part A to Part B. Section 4611(e)(2) of the BBA also provided a specific yearly proportion for the transferred funds. The proportions were one-sixth for 1998, one-third for 1999, one-half for 2000, two-thirds for 2001, and five-sixths for 2002.

For the purpose of determining the correct amount of financing from general revenues of the Federal Government, it was necessary to include only these transitional amounts in the monthly actuarial rates for both aged and disabled enrollees, rather than the total cost of the home health services being transferred. Section 4611(e)(3) of the BBA also specified, for the purpose of determining the premium, that the monthly actuarial rate for enrollees age 65 and over be computed as though the transition would occur for 1998 through 2003 and that one-seventh of the cost be transferred in 1998, two-sevenths in 1999, three-sevenths in 2000, four-sevenths in 2001, five-sevenths in 2002, and six-sevenths in 2003. Therefore, the transition period for incorporating this home health transfer into the premium was 7 years while the transition period for including these services in the actuarial rate was 6 years. Section 811 of the MMA, which amended section 1839 of the Act, requires that, starting on January 1, 2007, the Part B premium a beneficiary pays each month be based on his or her annual income. Specifically, if a beneficiary's modified adjusted gross income is greater than the legislated threshold amounts (for 2021, $88,000 for a beneficiary filing an individual income tax return and $176,000 for a beneficiary filing a joint tax return), the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage.

In addition to the standard 25-percent premium, these beneficiaries now have to pay an income-related monthly adjustment amount. The MMA made no change to the actuarial rate calculation, and the standard premium, which will continue to be paid by beneficiaries whose modified adjusted gross income is below the applicable thresholds, still represents 25 percent of the estimated total cost to the program of Part B coverage for an aged enrollee. However, depending on income and tax filing status, a beneficiary can now be responsible for 35, 50, 65, 80, or 85 percent of the estimated total cost of Part B coverage, rather than 25 percent. Section 402 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L.

114-10) modified the income thresholds beginning in 2018, and section 53114 of the Bipartisan Budget Act of 2018 (BBA of 2018) (Pub. L. 115-123) further modified the income thresholds beginning in 2019. For years beginning in 2019, the BBA of 2018 established a new income threshold. If a beneficiary's modified adjusted gross income is greater than or equal to $500,000 for a beneficiary filing an individual income tax return and $750,000 for a beneficiary filing a joint tax return, the beneficiary is responsible for 85 percent of the estimated total cost of Part B coverage.

The BBA of 2018 specified that these new income threshold levels be inflation-adjusted beginning in 2028. The end result of the higher premium is that the Part B premium subsidy is reduced, and less general revenue financing is required, for beneficiaries with higher income because they are paying a larger share of the total cost with their premium. That is, the premium subsidy continues to be approximately 75 percent for beneficiaries with income below the applicable income thresholds, but it will be reduced for beneficiaries with income above these thresholds. The MMA specified that there be a 5-year transition period to reach full implementation of this provision. However, section 5111 of the Deficit Reduction Act of 2005 (DRA) (Pub.

L. 109-171) modified the transition to a 3-year period. Section 4732(c) of the BBA added section 1933(c) of the Act, which required the Secretary to allocate money from the Part B trust fund to the state Medicaid programs for the purpose of providing Medicare Part B premium assistance from 1998 through 2002 for the low-income Medicaid beneficiaries who qualify under section 1933 of the Act. This allocation, while not a benefit expenditure, was an expenditure of the trust fund and was included in calculating the Part B actuarial rates through 2002. For 2003 through 2015, the expenditure was made from the trust fund because the allocation was temporarily extended.

However, because the extension occurred after the financing was determined, the allocation was not included in the calculation of the financing rates for these years. Section 211 of MACRA permanently extended this expenditure, which is included in the calculation of the Part B actuarial rates for 2016 and subsequent years. Another provision affecting the calculation of the Part B premium is section 1839(f) of the Act, as amended by section 211 of the Medicare Catastrophic Coverage Act of 1988 (MCCA 88) (Pub. L. 100-360).

(The Medicare Catastrophic Coverage Repeal Act of 1989 (Pub. L. 101-234) did not repeal the revisions to section 1839(f) of the Act made by MCCA 88.) Section 1839(f) of the Act, referred to as the “hold-harmless” provision, provides that, if an individual is entitled to benefits under section 202 or 223 of the Act (the Old-Age and Survivors Insurance Benefit and the Disability Insurance Benefit, respectively) and has the Part B premium deducted from these benefit payments, the premium increase will be reduced, if necessary, to avoid causing a decrease in the individual's net monthly payment. This decrease in payment occurs if the increase in the individual's Social Security benefit due to the cost-of-living adjustment under section 215(i) of the Act is less than the increase in the premium. Specifically, the reduction in the premium amount applies if the individual is entitled to Start Printed Page 71906benefits under section 202 or 223 of the Act for November and December of a particular year and the individual's Part B premiums for December and the following January are deducted from the respective month's section 202 or 223 benefits.

The hold-harmless provision does not apply to beneficiaries who are required to pay an income-related monthly adjustment amount. A check for benefits under section 202 or 223 of the Act is received in the month following the month for which the benefits are due. The Part B premium that is deducted from a particular check is the Part B payment for the month in which the check is received. Therefore, a benefit check for November is not received until December, but December's Part B premium has been deducted from it. Generally, if a beneficiary qualifies for hold-harmless protection, the reduced premium for the individual for that January and for each of the succeeding 11 months is the greater of either— The monthly premium for January reduced as necessary to make the December monthly benefits, after the deduction of the Part B premium for January, at least equal to the preceding November's monthly benefits, after the deduction of the Part B premium for December.

Or The monthly premium for that individual for that December. In determining the premium limitations under section 1839(f) of the Act, the monthly benefits to which an individual is entitled under section 202 or 223 of the Act do not include retroactive adjustments or payments and deductions on account of work. Also, once the monthly premium amount is established under section 1839(f) of the Act, it will not be changed during the year even if there are retroactive adjustments or payments and deductions on account of work that apply to the individual's monthly benefits. Individuals who have enrolled in Part B late or who have re-enrolled after the termination of a coverage period are subject to an increased premium under section 1839(b) of the Act. The increase is a percentage of the premium and is based on the new premium rate before any reductions under section 1839(f) of the Act are made.

Section 1839 of the Act, as amended by section 601(a) of the Bipartisan Budget Act of 2015 (Pub. L. 114-74), specified that the 2016 actuarial rate for enrollees age 65 and older be determined as if the hold-harmless provision did not apply. The premium revenue that was lost by using the resulting lower premium (excluding the forgone income-related premium revenue) was replaced by a transfer of general revenue from the Treasury, which will be repaid over time to the general fund. Similarly, section 1839 of the Act, as amended by section 2401 of the Continuing Appropriations Act, 2021 and Other Extensions Act (Pub.

L. 116-159), specifies that the 2021 actuarial rate for enrollees age 65 and older be determined as the sum of the 2020 actuarial rate for enrollees age 65 and older and one-fourth of the difference between the 2020 actuarial rate and the preliminary 2021 actuarial rate (as determined by the Secretary of HHS) for such enrollees. The premium revenue lost by using the resulting lower premium (excluding the forgone income-related premium revenue) will be replaced by a transfer of general revenue from the Treasury, which will be repaid over time. Starting in 2016, in order to repay the balance due (which includes the transfer amounts and the forgone income-related premium revenue from the Bipartisan Budget Act of 2015 and the Continuing Appropriations Act, 2021 and Other Extensions Act), the Part B premium otherwise determined will be increased by $3.00. These repayment amounts will be added to the Part B premium otherwise determined each year and will be paid back to the general fund of the Treasury, and they will continue until the balance due is paid back.

High-income enrollees pay the $3 repayment amount plus an additional $1.20, $3.00, $4.80, $6.60, or $7.20 in repayment as part of the income-related monthly adjustment amount (IRMAA) premium dollars, which reduce (dollar for dollar) the amount of general revenue received by Part B from the general fund of the Treasury. Because of this general revenue offset, the repayment IRMAA premium dollars are not included in the direct repayments made to the general fund of the Treasury from Part B in order to avoid a double repayment. (Only the $3.00 monthly repayment amounts are included in the direct repayments). These repayment amounts will continue until the balance due is zero. (In the final year of the repayment, the additional amounts may be modified to avoid an overpayment.) The repayment amounts (excluding those for high-income enrollees) are subject to the hold-harmless provision.

The original balance due was $9,066,409,000, consisting of $1,625,761,000 in forgone income-related premium revenue plus a transfer amount of $7,440,648,000 from the provisions of the Bipartisan Budget Act of 2015. The increase in the balance due in 2021 will be $8,799,829,000, consisting of $946,046,000 in forgone income-related premium income plus a transfer amount of $7,853,783,000 from the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act. An estimated $6,761,022,000 will have been collected for repayment to the general fund by the end of 2020. II. Provisions of the Notice A.

Notice of Medicare Part B Monthly Actuarial Rates, Monthly Premium Rates, and Annual Deductible The Medicare Part B monthly actuarial rates applicable for 2021 are $291.00 for enrollees age 65 and over and $349.90 for disabled enrollees under age 65. In section II.B. Of this notice, we present the actuarial assumptions and bases from which these rates are derived. The Part B standard monthly premium rate for all enrollees for 2021 is $148.50. The following are the 2021 Part B monthly premium rates to be paid by (or on behalf of) beneficiaries who file either individual tax returns (and are single individuals, heads of households, qualifying widows or widowers with dependent children, or married individuals filing separately who lived apart from their spouses for the entire taxable year), or joint tax returns.

Beneficiaries who file individual tax returns with income:Beneficiaries who file joint tax returns with income:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000Less than or equal to $176,000$0.00$148.50Greater than $88,000 and less than or equal to $111,000Greater than $176,000 and less than or equal to $222,00059.40207.90Start Printed Page 71907Greater than $111,000 and less than or equal to $138,000Greater than $222,000 and less than or equal to $276,000148.50297.00Greater than $138,000 and less than or equal to $165,000Greater than $276,000 and less than or equal to $330,000237.60386.10Greater than $165,000 and less than $500,000Greater than $330,000 and less than $750,000326.70475.20Greater than or equal to $500,000Greater than or equal to $750,000356.40504.90 In addition, the monthly premium rates to be paid by (or on behalf of) beneficiaries who are married and lived with their spouses at any time during the taxable year, but who file separate tax returns from their spouses, are as follows. Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000$0.00$148.50Greater than $88,000 and less than $412,000326.70475.20Greater than or equal to $412,000356.40504.90 The Part B annual deductible for 2021 is $203.00 for all beneficiaries. B. Statement of Actuarial Assumptions and Bases Employed in Determining the Monthly Actuarial Rates and the Monthly Premium Rate for Part B Beginning January 2021 The actuarial assumptions and bases used to determine the monthly actuarial rates and the monthly premium rates for Part B are established by the Centers for Medicare &. Medicaid Services' Office of the Actuary.

The estimates underlying these determinations are prepared by actuaries meeting the qualification standards and following the actuarial standards of practice established by the Actuarial Standards Board. 1. Actuarial Status of the Part B Account in the Supplementary Medical Insurance Trust Fund Under section 1839 of the Act, the starting point for determining the standard monthly premium is the amount that would be necessary to finance Part B on an incurred basis. This is the amount of income that would be sufficient to pay for services furnished during that year (including associated administrative costs) even though payment for some of these services will not be made until after the close of the year. The portion of income required to cover benefits not paid until after the close of the year is added to the trust fund and used when needed.

Because the premium rates are established prospectively, they are subject to projection error. Additionally, legislation enacted after the financing was established, but effective for the period in which the financing is set, may affect program costs. As a result, the income to the program may not equal incurred costs. Trust fund assets must therefore be maintained at a level that is adequate to cover an appropriate degree of variation between actual and projected costs, and the amount of incurred, but unpaid, expenses. Numerous factors determine what level of assets is appropriate to cover variation between actual and projected costs.

For 2021, the four most important of these factors are (1) the impact of the hypertension medications lasix on program spending. (2) the difference from prior years between the actual performance of the program and estimates made at the time financing was established. (3) the likelihood and potential magnitude of expenditure changes resulting from enactment of legislation affecting Part B costs in a year subsequent to the establishment of financing for that year. And (4) the expected relationship between incurred and cash expenditures. The first factor, the impact of the lasix on program spending, brings a higher-than-usual degree of uncertainty to projected costs for the 2021 Part B financing.

The other three factors are analyzed on an ongoing basis, as the trends can vary over time. Table 1 summarizes the estimated actuarial status of the trust fund as of the end of the financing period for 2019 and 2020. Table 1—Estimated Actuarial Status of the Part B Account in the Supplementary Medical Insurance Trust Fund as of the End of the Financing PeriodFinancing period endingAssets (in millions)Liabilities (in millions)Assets less liabilities (in millions)December 31, 2019$99,602$31,566$68,036December 31, 2020123,05132,88490,167 Start Printed Page 71908 2. Monthly Actuarial Rate for Enrollees Age 65 and Older The monthly actuarial rate for enrollees age 65 and older is one-half of the sum of monthly amounts for (1) the projected cost of benefits. And (2) administrative expenses for each enrollee age 65 and older, after adjustments to this sum to allow for interest earnings on assets in the trust fund and an adequate contingency margin.

The contingency margin is an amount appropriate to provide for possible variation between actual and projected costs and to amortize any surplus assets or unfunded liabilities. Section 1839 of the Act, as amended by section 2401 of the Continuing Appropriations Act, 2021 and Other Extensions Act (Pub. L. 116-159), specifies that the 2021 monthly actuarial rate for enrollees age 65 and older be determined as the sum of the 2020 monthly actuarial rate for enrollees age 65 and older and one-fourth of the difference between the 2020 monthly actuarial rate and the preliminary 2021 monthly actuarial rate (as determined by the Secretary of HHS) for such enrollees. The premium revenue lost by using the resulting lower premium (excluding the forgone income-related premium revenue) will be replaced by a transfer of general revenue from the Treasury, which will be repaid over time.

The preliminary monthly actuarial rate for enrollees age 65 and older for 2021 is determined by first establishing per enrollee costs by type of service from program data through 2020 and then projecting these costs for subsequent years. The projection factors used for financing periods from January 1, 2018 through December 31, 2021 are shown in Table 2. The 2020 monthly actuarial rate for enrollees age 65 and older is $283.20, and the preliminary 2021 monthly actuarial rate for enrollees age 65 and older is $314.30. In accordance with the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act, the 2021 monthly actuarial rate for enrollees age 65 and older is $291.00 ($283.20 + 0.25 × (314.30−283.20)). As indicated in Table 3, the projected per enrollee amount required to pay for one-half of the total of benefits and administrative costs for enrollees age 65 and over for 2021 is $307.52.

Based on current estimates, the assets at the end of 2020 are not sufficient to cover the amount of incurred, but unpaid, expenses, to provide for substantial variation between actual and projected costs, and to accommodate the unusually high degree of uncertainty due to the hypertension medications lasix. Thus, a positive contingency margin is needed to increase assets to a more appropriate level. The preliminary monthly actuarial rate of $314.30 provides an adjustment of $8.17 for a contingency margin and −$1.39 for interest earnings. The contingency margin for 2021 is affected by several factors. First, in response to the lasix, about $43 billion was paid out of the Part B account as part of the Accelerated and Advanced Payment (AAP) programs.

Providers are to repay their AAP payments to Part B over time through reduced Part B claims payments. However, until the AAP payments have been repaid, the Part B account would not have the roughly $43 billion in assets, and the financing for 2021 would need to be increased to restore the assets used to make these payments. The Continuing Appropriations Act, 2021 and Other Extensions Act requires that a transfer be made from the Treasury to Part B to restore the roughly $43 billion in AAP payments paid out and specifies that any future AAP provider repayments be transferred to the Treasury. Because the 2021 Part B financing includes the assumption that roughly $43 billion will be transferred from the Treasury to Part B before the end of calendar year 2020, the AAP payments do not impact contingency margin. Second, in order to take into account the uncertainty and potential impact of the hypertension medications lasix, assumptions were developed for testing and treatment for hypertension medications, utilization of non-hypertension medications-related care, potential costs for hypertension medications treatments, and possible paths of the lasix.

Several Part B lasix cost scenarios were developed based on these assumptions. The difference between the best-estimate lasix scenario and the highest-cost lasix scenario was used to establish the additional contingency margin needed to account for the potential costs and uncertainty from the lasix. Third, starting in 2011, manufacturers and importers of brand-name prescription drugs pay a fee that is allocated to the Part B account of the SMI trust. For 2021, the total of these brand-name drug fees is estimated to be $2.8 billion. The contingency margin for 2021 has been reduced to account for this additional revenue.

The traditional goal for the Part B reserve has been that assets minus liabilities at the end of a year should represent between 15 and 20 percent of the following year's total incurred expenditures. To accomplish this goal, a 17-percent reserve ratio, which is a fully adequate contingency reserve level, has been the normal target used to calculate the Part B premium. The financing rates for 2021 are set above the normal target due to the higher-than-usual uncertainty for 2021. The actuarial rate of $291.00 per month for aged beneficiaries, as announced in this notice for 2021, reflects the combined effect of the factors and legislation previously described and the projected assumptions listed in Table 2. 3.

Monthly Actuarial Rate for Disabled Enrollees Disabled enrollees are those persons under age 65 who are enrolled in Part B because of entitlement to Social Security disability benefits for more than 24 months or because of entitlement to Medicare under the end-stage renal disease (ESRD) program. Projected monthly costs for disabled enrollees (other than those with ESRD) are prepared in a manner parallel to the projection for the aged using appropriate actuarial assumptions (see Table 2). Costs for the ESRD program are projected differently because of the different nature of services offered by the program. As shown in Table 4, the projected per enrollee amount required to pay for one-half of the total of benefits and administrative costs for disabled enrollees for 2021 is $377.23. The monthly actuarial rate of $349.90 also provides an adjustment of −$1.61 for interest earnings and −$25.72 for a contingency margin, reflecting the same factors and legislation described previously for the aged actuarial rate at magnitudes appropriate to the disabled rate determination.

Based on current estimates, the assets associated with the disabled Medicare beneficiaries at the end of 2020 are sufficient to cover the amount of incurred, but unpaid, expenses and to provide for a significant degree of variation between actual and projected costs. As noted for the aged actuarial rate, the 2021 contingency margin is set above the normal target level in order to accommodate the higher uncertainty due to the hypertension medications lasix. The actuarial rate of $349.90 per month for disabled beneficiaries, as announced in this notice for 2021, reflects the combined net effect of the factors and legislation described previously for aged beneficiaries and the projection assumptions listed in Table 2. 4. Sensitivity Testing Several factors contribute to uncertainty about future trends in medical care costs.

It is appropriate to Start Printed Page 71909test the adequacy of the rates using alternative cost growth rate assumptions. The results of those assumptions are shown in Table 5. One set represents increases that are higher and, therefore, more pessimistic than the current estimate. The other set represents increases that are lower and, therefore, more optimistic than the current estimate. The values for the alternative assumptions were determined from a statistical analysis of the historical variation in the respective increase factors.

The historical variation may not be representative of the current level of uncertainty due to the hypertension medications lasix. As indicated in Table 5, the monthly actuarial rates would result in an excess of assets over liabilities of $101,796 million by the end of December 2021 under the cost growth rate assumptions shown in Table 2 and under the assumption that the provisions of current law are fully implemented. This result amounts to 21.6 percent of the estimated total incurred expenditures for the following year. Assumptions that are somewhat more pessimistic (and that therefore test the adequacy of the assets to accommodate projection errors) produce a surplus of $65,262 million by the end of December 2021 under current law, which amounts to 12.4 percent of the estimated total incurred expenditures for the following year. Under fairly optimistic assumptions, the monthly actuarial rates would result in a surplus of $176,475 million by the end of December 2021, or 34.2 percent of the estimated total incurred expenditures for the following year.

The sensitivity analysis indicates that, in a typical year, the premium and general revenue financing established for 2021, together with existing Part B account assets, would be adequate to cover estimated Part B costs for 2021 under current law, should actual costs prove to be somewhat greater than expected. However, the current level of uncertainty due to the lasix may differ from the historical variation included in this analysis. 5. Premium Rates and Deductible As determined in accordance with section 1839 of the Act, the following are the 2021 Part B monthly premium rates to be paid by beneficiaries who file either individual tax returns (and are single individuals, heads of households, qualifying widows or widowers with dependent children, or married individuals filing separately who lived apart from their spouses for the entire taxable year) or joint tax returns. Beneficiaries who file individual tax returns with income:Beneficiaries who file joint tax returns with income:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000Less than or equal to $176,000$0.00$148.50Greater than $88,000 and less than or equal to $111,000Greater than $176,000 and less than or equal to $222,00059.40207.90Greater than $111,000 and less than or equal to $138,000Greater than $222,000 and less than or equal to $276,000148.50297.00Greater than $138,000 and less than or equal to $165,000Greater than $276,000 and less than or equal to $330,000237.60386.10Greater than $165,000 and less than $500,000Greater than $330,000 and less than $750,000326.70475.20Greater than or equal to $500,000Greater than or equal to $750,000356.40504.90 In addition, the monthly premium rates to be paid by beneficiaries who are married and lived with their spouses at any time during the taxable year, but who file separate tax returns from their spouses, are as follows.

Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000$0.00$148.50Greater than $88,000 and less than $412,000326.70475.20Greater than or equal to $412,000356.40504.90 Table 2—Projection Factors 1 12-Month Periods Ending December 31 of 2018-2021[In percent]Calendar yearPhysicians' servicesDurable medical equipmentCarrier lab 2Physician- administered drugsOther carrier services 3Outpatient hospitalHome health agencyHospital lab 4Other intermediary services 5Managed careAged:20181.618.111.412.22.38.41.4−1.07.67.420193.87.34.311.02.25.63.9−3.65.58.42020−14.0−1.5−13.56.3−5.8−6.5−3.7−7.0−3.78.5202129.30.517.79.614.936.619.08.815.03.6Disabled:2018−0.613.53.77.91.94.80.5−1.35.37.620195.55.410.412.05.87.33.70.611.18.32020−9.30.3−15.211.51.6−3.7−1.5−3.8−0.69.5202124.71.523.08.98.834.922.46.822.23.01 All values for services other than managed care are per fee-for-service enrollee. Managed care values are per managed care enrollee.2 Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.3 Includes ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies, etc.Start Printed Page 719104 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.5 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals, etc. Table 3—Derivation of Monthly Actuarial Rate for Enrollees Age 65 and Over for Financing Periods Ending December 31, 2018 Through December 31, 2021 CY 2018CY 2019CY 2020Preliminary CY 2021CY 2021Covered services (at level recognized):Physician fee schedule$72.28$73.02$60.48$76.83$76.83Durable medical equipment6.056.325.995.935.93Carrier lab 14.284.353.614.194.19Physician-administered drugs16.0717.3717.7419.9219.92Other carrier services 29.339.288.419.529.52Outpatient hospital49.4650.8445.7161.5261.52Home health8.858.958.299.729.72Hospital lab 32.172.041.821.951.95Other intermediary services 418.6119.1317.7020.0620.06Managed care100.65113.46129.87137.11137.11Total services287.76304.75299.62346.77346.77Cost sharing:Deductible−6.40−6.32−6.74−6.94−6.94Coinsurance−28.62−28.79−26.02−30.36−30.36Sequestration of benefits−5.05−5.39−1.78−6.17−6.17HIT payment incentives0.160.000.000.000.00Total benefits247.85264.26265.07303.30303.30Administrative expenses3.904.114.714.214.21Incurred expenditures251.75268.36269.79307.52307.52Value of interest−1.80−1.88−1.09−1.39−1.39Contingency margin for projection error and to amortize the surplus or deficit 511.95−1.5814.508.17−15.13Monthly actuarial rate$261.90$264.90$283.20$314.30$291.001 Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.2 Includes ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies, etc.3 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.4 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals, etc.5 The significant negative margin included in the 2021 actuarial rate is attributable to the application of the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act. Table 4—Derivation of Monthly Actuarial Rate for Disabled Enrollees for Financing Periods Ending December 31, 2018 Through December 31, 2020 CY 2018CY 2019CY 2020CY 2021Covered services (at level recognized):Physician fee schedule$73.05$72.63$61.25$72.93Durable medical equipment12.0912.0211.0210.81Carrier lab 15.716.004.735.51Physician-administered drugs14.8015.5415.8417.51Other carrier services 212.3212.3811.7012.20Outpatient hospital65.1665.5357.8675.43Home health6.956.786.197.20Hospital lab 32.612.482.212.26Other intermediary services 450.7852.7951.6853.18Managed care103.40124.70154.31168.50Total services346.87370.84376.79425.52Cost sharing:Deductible−6.16−6.05−6.45−6.65Coinsurance−41.95−41.78−38.85−41.50Sequestration of benefits−5.97−6.45−2.21−7.53HIT payment incentives0.160.000.000.00Total benefits292.95316.56329.29369.85Administrative expenses4.604.927.897.38Incurred expenditures297.55321.48337.15377.23Value of interest−2.68−2.52−1.38−1.61Start Printed Page 71911Contingency margin for projection error and to amortize the surplus or deficit 50.13−3.567.83−25.72Monthly actuarial rate$295.00$315.40$343.60$349.901 Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.2 Includes ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies, etc.3 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.4 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals, etc.5 The significant negative margin included in the 2021 actuarial rate is attributable to the application of the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act. Table 5—Actuarial Status of the Part B Account in the SMI Trust Fund Under Three Sets of Assumptions for Financing Periods Through December 31, 2021As of December 31,201920202021Actuarial status (in millions):Assets$99,602$123,051$138,974Liabilities$31,566$32,884$37,178Assets less liabilities$68,036$90,167$101,796Ratio 117.7%20.2%21.6%Low-cost projection:Actuarial status (in millions):Assets$99,602$144,338$176,457Liabilities$31,566$30,519$35,245Assets less liabilities$68,036$113,819$141,212Ratio 118.9%28.2%34.2%High-cost projection:Actuarial status (in millions):Assets$99,602$101,797$104,088Liabilities$31,566$35,245$38,826Assets less liabilities$68,036$66,552$65,262Ratio 116.7%13.7%12.4%1 Ratio of assets less liabilities at the end of the year to the total incurred expenditures during the following year, expressed as a percent.

III. Collection of Information Requirements This document does not impose information collection requirements—that is, reporting, recordkeeping, or third-party disclosure requirements. Consequently, there is no need for review by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). IV.

Regulatory Impact Analysis A. Statement of Need Section 1839 of the Act requires us to annually announce (that is, by September 30th of each year) the Part B monthly actuarial rates for aged and disabled beneficiaries as well as the monthly Part B premium. We also announce the Part B annual deductible because its determination is directly linked to the aged actuarial rate. B. Overall Impact We have examined the impacts of this notice as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub.

L. 96-354), section 1102(b) of the Social Security Act, section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 1995, Pub. L. 104-4), Executive Order 13132 on Federalism (August 4, 1999), the Congressional Review Act (5 U.S.C. 804(2)), and Executive Order 13771 on Reducing and Controlling Regulatory Costs (January 30, 2017).

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major notices with economically significant effects ($100 million or more in any one year). The 2021 standard Part B premium of $148.50 is $3.90 higher than the 2020 premium of $144.60. We estimate that this premium increase, for the approximately 59 million Part B enrollees in 2021, will have an annual effect on the economy of $100 million or more. As a result, this notice is economically significant under section 3(f)(1) of Executive Order 12866 and is a major action as defined under the Congressional Review Act (5 U.S.C.

804(2)). As discussed earlier, this notice announces that the monthly actuarial rates applicable for 2021 are $291.00 for enrollees age 65 and over and $349.90 for disabled enrollees under age 65. It also announces the 2021 monthly Part B premium rates to be paid by Start Printed Page 71912beneficiaries who file either individual tax returns (and are single individuals, heads of households, qualifying widows or widowers with dependent children, or married individuals filing separately who lived apart from their spouses for the entire taxable year) or joint tax returns. Beneficiaries who file individual tax returns with income:Beneficiaries who file joint tax returns with income:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000Less than or equal to $176,000$0.00$148.50Greater than $88,000 and less than or equal to $111,000Greater than $176,000 and less than or equal to $222,00059.40207.90Greater than $111,000 and less than or equal to $138,000Greater than $222,000 and less than or equal to $276,000148.50297.00Greater than $138,000 and less than or equal to $165,000Greater than $276,000 and less than or equal to $330,000237.60386.10Greater than $165,000 and less than $500,000Greater than $330,000 and less than $750,000326.70475.20Greater than or equal to $500,000Greater than or equal to $750,000356.40504.90 In addition, the monthly premium rates to be paid by beneficiaries who are married and lived with their spouses at any time during the taxable year, but who file separate tax returns from their spouses, are also announced and listed in the following chart. Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000$0.00$148.50Greater than $88,000 and less than $412,000326.70475.20Greater than or equal to $412,000356.40504.90 The RFA requires agencies to analyze options for regulatory relief of small businesses, if a rule has a significant impact on a substantial number of small entities.

For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Individuals and states are not included in the definition of a small entity. This notice announces the monthly actuarial rates for aged (age 65 and over) and disabled (under 65) beneficiaries enrolled in Part B of the Medicare SMI program beginning January 1, 2021. Also, this notice announces the monthly premium for aged and disabled beneficiaries as well as the income-related monthly adjustment amounts to be paid by beneficiaries with modified adjusted gross income above certain threshold amounts. As a result, we are not preparing an analysis for the RFA because the Secretary has determined that this notice will not have a significant economic impact on a substantial number of small entities.

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds. As we discussed previously, we are not preparing an analysis for section 1102(b) of the Act because the Secretary has determined that this notice will not have a significant effect on a substantial number of small rural hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any one year of $100 million in 1995 dollars, updated annually for inflation.

In 2020, that threshold is approximately $156 million. Part B enrollees who are also enrolled in Medicaid have their monthly Part B premiums paid by Medicaid. The cost to each state Medicaid program from the 2021 premium increase is estimated to be less than the threshold. This notice does not impose mandates that will have a consequential effect of the threshold amount or more on state, local, or tribal governments or on the private sector. Executive Order 13132 establishes certain requirements that an agency must meet when it publishes a proposed rule (and subsequent final rule) that imposes substantial direct compliance costs on state and local governments, preempts state law, or otherwise has Federalism implications.

We have determined that this notice does not significantly affect the rights, roles, and responsibilities of states. Accordingly, the requirements of Executive Order 13132 do not apply to this notice. Executive Order 13771, titled “Reducing Regulation and Controlling Regulatory Costs,” was issued on January 30, 2017 (82 FR 9339, February 3, 2017). It has been determined that this notice is a transfer notice that does not impose more than de minimis costs and thus is not a regulatory action for the purposes of E.O. 13771.

In accordance with the provisions of Executive Order 12866, this notice was reviewed by the Office of Management and Budget. V. Waiver of Proposed Rulemaking We ordinarily publish a notice of proposed rulemaking in the Federal Register and invite public comment prior to a rule taking effect in accordance with section 1871 of the Act and section 553(b) of the Administrative Procedure Act (APA). Section 1871(a)(2) of the Act provides that no rule, requirement, or other statement of policy (other than a national coverage determination) that establishes or changes a substantive legal standard Start Printed Page 71913governing the scope of benefits, the payment for services, or the eligibility of individuals, entities, or organizations to furnish or receive services or benefits under Medicare shall take effect unless it is promulgated through notice and comment rulemaking. Unless there is a statutory exception, section 1871(b)(1) of the Act generally requires the Secretary of the Department of Health and Human Services (the Secretary) to provide for notice of a proposed rule in the Federal Register and provide a period of not less than 60 days for public comment before establishing or changing a substantive legal standard regarding the matters enumerated by the statute.

Similarly, under 5 U.S.C. 553(b) of the APA, the agency is required to publish a notice of proposed rulemaking in the Federal Register before a substantive rule takes effect. Section 553(d) of the APA and section 1871(e)(1)(B)(i) of the Act usually require a 30-day delay in effective date after issuance or publication of a rule, subject to exceptions. Sections 553(b)(B) and 553(d)(3) of the APA provide for exceptions from the advance notice and comment requirement and the delay in effective date requirements. Sections 1871(b)(2)(C) and 1871(e)(1)(B)(ii) of the Act also provide exceptions from the notice and 60-day comment period and the 30-day delay in effective date.

Section 553(b)(B) of the APA and section 1871(b)(2)(C) of the Act expressly authorize an agency to dispense with notice and comment rulemaking for good cause if the agency makes a finding that notice and comment procedures are impracticable, unnecessary, or contrary to the public interest. The annual updated amounts for the Part B monthly actuarial rates for aged and disabled beneficiaries, the Part B premium, and Part B deductible set forth in this notice do not establish or change a substantive legal standard regarding the matters enumerated by the statute or constitute a substantive rule that would be subject to the notice requirements in section 553(b) of the APA. However, to the extent that an opportunity for public notice and comment could be construed as required for this notice, we find good cause to waive this requirement. Section 1839 of the Act requires the Secretary to determine the monthly actuarial rates for aged and disabled beneficiaries, as well as the monthly Part B premium (including the income-related monthly adjustment amounts to be paid by beneficiaries with modified adjusted gross income above certain threshold amounts), for each calendar year in accordance with the statutory formulae, in September preceding the year to which they will apply. Further, the statute requires that the agency promulgate the Part B premium amount, in September preceding the year to which it will apply, and include a public statement setting forth the actuarial assumptions and bases employed by the Secretary in arriving at the amount of an adequate actuarial rate for enrollees age 65 and older.

We include the Part B annual deductible, which is established pursuant to a specific formula described in section 1833(b) of the Act, because the determination of the amount is directly linked to the rate of increase in actuarial rate under section 1839(a)(1) of the Act. We have calculated the monthly actuarial rates for aged and disabled beneficiaries, the Part B deductible, and the monthly Part B premium as directed by the statute. Since the statute establishes both when the monthly actuarial rates for aged and disabled beneficiaries and the monthly Part B premium must be published and the information that the Secretary must factor into those amounts, we do not have any discretion in that regard. We find notice and comment procedures to be unnecessary for this notice and we find good cause to waive such procedures under section 553(b)(B) of the APA and section 1871(b)(2)(C) of the Act, if such procedures may be construed to be required at all. Through this notice, we are simply notifying the public of the updates to the monthly actuarial rates for aged and disabled beneficiaries and the Part B deductible, as well as the monthly Part B premium amounts and the income-related monthly adjustment amounts to be paid by certain beneficiaries, in accordance with the statute, for CY 2021.

As such, we also note that even if notice and comment procedures were required for this notice, for the previously stated reason, we would find good cause to waive the delay in effective date of the notice, as additional delay would be contrary to the public interest under section 1871(e)(1)(B)(ii) of the Act. Publication of this notice is consistent with section 1839 of the Act, and we believe that any potential delay in the effective date of the notice, if such delay were required at all, could cause unnecessary confusion both for the agency and Medicare beneficiaries. Start Signature Dated. October 30, 2020. Seema Verma, Administrator, Centers for Medicare &.

Medicaid Services. Dated. November 2, 2020. Alex M. Azar II, Secretary, Department of Health and Human Services.

End Signature End Supplemental Information [FR Doc. 2020-25029 Filed 11-6-20. 4:15 pm]BILLING CODE 4120-01-P.

Start Preamble Kamagra canada wholesale Centers for buy lasix 100mg Medicare &. Medicaid Services buy lasix 100mg (CMS), HHS. Notice.

This notice announces the monthly actuarial rates for aged (age 65 and over) and disabled (under age 65) beneficiaries enrolled in Part B of the Medicare Supplementary Medical Insurance (SMI) program beginning January 1, 2021. In addition, this notice announces the monthly premium for aged and disabled beneficiaries, the deductible for 2021, and the income-related monthly adjustment amounts to be paid by beneficiaries with modified adjusted gross income above certain threshold amounts. The monthly actuarial rates for 2021 are $291.00 for aged enrollees and $349.90 for disabled enrollees.

The standard monthly Part B premium rate for all enrollees for 2021 is $148.50, which is equal to 50 percent of the monthly actuarial rate for aged enrollees (or approximately 25 percent of the expected average total cost of Part B coverage for aged enrollees) plus the $3.00 repayment amount required under current law. (The 2020 standard premium rate was $144.60, which included the $3.00 repayment amount.) The Part B deductible for 2021 is $203.00 for all Part B beneficiaries. If a beneficiary has to pay an income-related monthly adjustment, he or she will have to pay a total monthly premium of about 35, 50, 65, 80 or 85 percent of the total cost of Part B coverage plus a repayment amount of $4.20, $6.00, $7.80, $9.60 or $10.20, respectively.

The premium and related amounts announced in this notice are effective on January 1, 2021. Start Further Info M. Kent Clemens, (410) 786-6391.

End Further Info End Preamble Start Supplemental Information I. Background Part B is the voluntary portion of the Medicare program that pays all or part of the costs for physicians' services. Outpatient hospital services.

Certain home health services. Services furnished by rural health clinics, ambulatory surgical centers, and comprehensive outpatient rehabilitation facilities. And certain other medical and health services not covered by Medicare Part A, Hospital Insurance.

Medicare Part B is available to individuals who are entitled to Medicare Part A, as well as to U.S. Residents who have attained age 65 and are citizens and to aliens who were lawfully admitted for permanent residence and have resided in the United States for 5 consecutive years. Part B requires enrollment and payment of monthly premiums, as described in 42 CFR part 407, subpart B, and part 408, respectively.

The premiums paid by (or on behalf of) all enrollees fund approximately one-fourth of the total incurred costs, and transfers from the general fund of the Treasury pay approximately three-fourths of these costs. The Secretary of the Department of Health and Human Services (the Secretary) is required by section 1839 of the Social Security Act (the Act) to announce the Part B monthly actuarial rates for aged and disabled beneficiaries as well as the monthly Part B premium. The Part B annual deductible is included because its determination is directly linked to the aged actuarial rate.

The monthly actuarial rates for aged and disabled enrollees are used to determine the correct amount of general revenue financing per beneficiary each month. These amounts, according to actuarial estimates, will equal, respectively, one-half of the expected average monthly cost of Part B for each aged enrollee (age 65 or over) and one-half of the expected average monthly cost of Part B for each disabled enrollee (under age 65). The Part B deductible to be paid by enrollees is also announced.

Prior to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173), the Part B deductible was set in statute.

After setting the 2005 deductible amount at $110, section 629 of the MMA (amending section 1833(b) of the Act) required that the Part B deductible be indexed beginning in 2006. The inflation factor to be used each year is the annual percentage increase in the Part B actuarial rate for enrollees age 65 and over. Specifically, the 2021 Part B deductible is calculated by multiplying the 2020 deductible by the ratio of the 2021 aged actuarial rate to the 2020 aged actuarial rate.

The amount determined under this formula is then rounded to the nearest $1. The monthly Part B premium rate to be paid by aged and disabled enrollees is also announced. (Although the costs to the program per disabled enrollee are different than for the aged, the statute provides that the two groups pay the same premium amount.) Beginning with the passage of section 203 of the Social Security Amendments of 1972 (Pub.

L. 92-603), the premium rate, which was determined on a fiscal-year basis, was limited to the lesser of the actuarial rate for aged enrollees, or the current monthly premium rate increased by the same percentage as the most recent general increase in monthly Title II Social Security benefits. However, the passage of section 124 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) (Pub.

L. 97-248) suspended this premium determination process. Section 124 of TEFRA changed the premium basis to 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees).

Section 606 of the Social Security Amendments of 1983 (Pub. L. 98-21), section 2302 of the Deficit Reduction Act of 1984 (DEFRA 84) (Pub.

L. 98-369), section 9313 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA 85) (Pub. L.

99-272), section 4080 of the Omnibus Budget Reconciliation Act of Start Printed Page 719051987 (OBRA 87) (Pub. L. 100-203), and section 6301 of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) (Pub.

L. 101-239) extended the provision that the premium be based on 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees). This extension expired at the end of 1990.

The premium rate for 1991 through 1995 was legislated by section 1839(e)(1)(B) of the Act, as added by section 4301 of the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) (Pub. L. 101-508).

In January 1996, the premium determination basis would have reverted to the method established by the 1972 Social Security Act Amendments. However, section 13571 of the Omnibus Budget Reconciliation Act of 1993 (OBRA 93) (Pub. L.

103-66) changed the premium basis to 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees) for 1996 through 1998. Section 4571 of the Balanced Budget Act of 1997 (BBA) (Pub. L.

105-33) permanently extended the provision that the premium be based on 50 percent of the monthly actuarial rate for aged enrollees (that is, 25 percent of program costs for aged enrollees). The BBA included a further provision affecting the calculation of the Part B actuarial rates and premiums for 1998 through 2003. Section 4611 of the BBA modified the home health benefit payable under Part A for individuals enrolled in Part B.

Under this section, beginning in 1998, expenditures for home health services not considered “post-institutional” are payable under Part B rather than Part A. However, section 4611(e)(1) of the BBA required that there be a transition from 1998 through 2002 for the aggregate amount of the expenditures transferred from Part A to Part B. Section 4611(e)(2) of the BBA also provided a specific yearly proportion for the transferred funds.

The proportions were one-sixth for 1998, one-third for 1999, one-half for 2000, two-thirds for 2001, and five-sixths for 2002. For the purpose of determining the correct amount of financing from general revenues of the Federal Government, it was necessary to include only these transitional amounts in the monthly actuarial rates for both aged and disabled enrollees, rather than the total cost of the home health services being transferred. Section 4611(e)(3) of the BBA also specified, for the purpose of determining the premium, that the monthly actuarial rate for enrollees age 65 and over be computed as though the transition would occur for 1998 through 2003 and that one-seventh of the cost be transferred in 1998, two-sevenths in 1999, three-sevenths in 2000, four-sevenths in 2001, five-sevenths in 2002, and six-sevenths in 2003.

Therefore, the transition period for incorporating this home health transfer into the premium was 7 years while the transition period for including these services in the actuarial rate was 6 years. Section 811 of the MMA, which amended section 1839 of the Act, requires that, starting on January 1, 2007, the Part B premium a beneficiary pays each month be based on his or her annual income. Specifically, if a beneficiary's modified adjusted gross income is greater than the legislated threshold amounts (for 2021, $88,000 for a beneficiary filing an individual income tax return and $176,000 for a beneficiary filing a joint tax return), the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage.

In addition to the standard 25-percent premium, these beneficiaries now have to pay an income-related monthly adjustment amount. The MMA made no change to the actuarial rate calculation, and the standard premium, which will continue to be paid by beneficiaries whose modified adjusted gross income is below the applicable thresholds, still represents 25 percent of the estimated total cost to the program of Part B coverage for an aged enrollee. However, depending on income and tax filing status, a beneficiary can now be responsible for 35, 50, 65, 80, or 85 percent of the estimated total cost of Part B coverage, rather than 25 percent.

Section 402 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10) modified the income thresholds beginning in 2018, and section 53114 of the Bipartisan Budget Act of 2018 (BBA of 2018) (Pub.

L. 115-123) further modified the income thresholds beginning in 2019. For years beginning in 2019, the BBA of 2018 established a new income threshold.

If a beneficiary's modified adjusted gross income is greater than or equal to $500,000 for a beneficiary filing an individual income tax return and $750,000 for a beneficiary filing a joint tax return, the beneficiary is responsible for 85 percent of the estimated total cost of Part B coverage. The BBA of 2018 specified that these new income threshold levels be inflation-adjusted beginning in 2028. The end result of the higher premium is that the Part B premium subsidy is reduced, and less general revenue financing is required, for beneficiaries with higher income because they are paying a larger share of the total cost with their premium.

That is, the premium subsidy continues to be approximately 75 percent for beneficiaries with income below the applicable income thresholds, but it will be reduced for beneficiaries with income above these thresholds. The MMA specified that there be a 5-year transition period to reach full implementation of this provision. However, section 5111 of the Deficit Reduction Act of 2005 (DRA) (Pub.

L. 109-171) modified the transition to a 3-year period. Section 4732(c) of the BBA added section 1933(c) of the Act, which required the Secretary to allocate money from the Part B trust fund to the state Medicaid programs for the purpose of providing Medicare Part B premium assistance from 1998 through 2002 for the low-income Medicaid beneficiaries who qualify under section 1933 of the Act.

This allocation, while not a benefit expenditure, was an expenditure of the trust fund and was included in calculating the Part B actuarial rates through 2002. For 2003 through 2015, the expenditure was made from the trust fund because the allocation was temporarily extended. However, because the extension occurred after the financing was determined, the allocation was not included in the calculation of the financing rates for these years.

Section 211 of MACRA permanently extended this expenditure, which is included in the calculation of the Part B actuarial rates for 2016 and subsequent years. Another provision affecting the calculation of the Part B premium is section 1839(f) of the Act, as amended by section 211 of the Medicare Catastrophic Coverage Act of 1988 (MCCA 88) (Pub. L.

100-360). (The Medicare Catastrophic Coverage Repeal Act of 1989 (Pub. L.

101-234) did not repeal the revisions to section 1839(f) of the Act made by MCCA 88.) Section 1839(f) of the Act, referred to as the “hold-harmless” provision, provides that, if an individual is entitled to benefits under section 202 or 223 of the Act (the Old-Age and Survivors Insurance Benefit and the Disability Insurance Benefit, respectively) and has the Part B premium deducted from these benefit payments, the premium increase will be reduced, if necessary, to avoid causing a decrease in the individual's net monthly payment. This decrease in payment occurs if the increase in the individual's Social Security benefit due to the cost-of-living adjustment under section 215(i) of the Act is less than the increase in the premium. Specifically, the reduction in the premium amount applies if the individual is entitled to Start Printed Page 71906benefits under section 202 or 223 of the Act for November and December of a particular year and the individual's Part B premiums for December and the following January are deducted from the respective month's section 202 or 223 benefits.

The hold-harmless provision does not apply to beneficiaries who are required to pay an income-related monthly adjustment amount. A check for benefits under section 202 or 223 of the Act is received in the month following the month for which the benefits are due. The Part B premium that is deducted from a particular check is the Part B payment for the month in which the check is received.

Therefore, a benefit check for November is not received until December, but December's Part B premium has been deducted from it. Generally, if a beneficiary qualifies for hold-harmless protection, the reduced premium for the individual for that January and for each of the succeeding 11 months is the greater of either— The monthly premium for January reduced as necessary to make the December monthly benefits, after the deduction of the Part B premium for January, at least equal to the preceding November's monthly benefits, after the deduction of the Part B premium for December. Or The monthly premium for that individual for that December.

In determining the premium limitations under section 1839(f) of the Act, the monthly benefits to which an individual is entitled under section 202 or 223 of the Act do not include retroactive adjustments or payments and deductions on account of work. Also, once the monthly premium amount is established under section 1839(f) of the Act, it will not be changed during the year even if there are retroactive adjustments or payments and deductions on account of work that apply to the individual's monthly benefits. Individuals who have enrolled in Part B late or who have re-enrolled after the termination of a coverage period are subject to an increased premium under section 1839(b) of the Act.

The increase is a percentage of the premium and is based on the new premium rate before any reductions under section 1839(f) of the Act are made. Section 1839 of the Act, as amended by section 601(a) of the Bipartisan Budget Act of 2015 (Pub. L.

114-74), specified that the 2016 actuarial rate for enrollees age 65 and older be determined as if the hold-harmless provision did not apply. The premium revenue that was lost by using the resulting lower premium (excluding the forgone income-related premium revenue) was replaced by a transfer of general revenue from the Treasury, which will be repaid over time to the general fund. Similarly, section 1839 of the Act, as amended by section 2401 of the Continuing Appropriations Act, 2021 and Other Extensions Act (Pub.

L. 116-159), specifies that the 2021 actuarial rate for enrollees age 65 and older be determined as the sum of the 2020 actuarial rate for enrollees age 65 and older and one-fourth of the difference between the 2020 actuarial rate and the preliminary 2021 actuarial rate (as determined by the Secretary of HHS) for such enrollees. The premium revenue lost by using the resulting lower premium (excluding the forgone income-related premium revenue) will be replaced by a transfer of general revenue from the Treasury, which will be repaid over time.

Starting in 2016, in order to repay the balance due (which includes the transfer amounts and the forgone income-related premium revenue from the Bipartisan Budget Act of 2015 and the Continuing Appropriations Act, 2021 and Other Extensions Act), the Part B premium otherwise determined will be increased by $3.00. These repayment amounts will be added to the Part B premium otherwise determined each year and will be paid back to the general fund of the Treasury, and they will continue until the balance due is paid back. High-income enrollees pay the $3 repayment amount plus an additional $1.20, $3.00, $4.80, $6.60, or $7.20 in repayment as part of the income-related monthly adjustment amount (IRMAA) premium dollars, which reduce (dollar for dollar) the amount of general revenue received by Part B from the general fund of the Treasury.

Because of this general revenue offset, the repayment IRMAA premium dollars are not included in the direct repayments made to the general fund of the Treasury from Part B in order to avoid a double repayment. (Only the $3.00 monthly repayment amounts are included in the direct repayments). These repayment amounts will continue until the balance due is zero.

(In the final year of the repayment, the additional amounts may be modified to avoid an overpayment.) The repayment amounts (excluding those for high-income enrollees) are subject to the hold-harmless provision. The original balance due was $9,066,409,000, consisting of $1,625,761,000 in forgone income-related premium revenue plus a transfer amount of $7,440,648,000 from the provisions of the Bipartisan Budget Act of 2015. The increase in the balance due in 2021 will be $8,799,829,000, consisting of $946,046,000 in forgone income-related premium income plus a transfer amount of $7,853,783,000 from the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act.

An estimated $6,761,022,000 will have been collected for repayment to the general fund by the end of 2020. II. Provisions of the Notice A.

Notice of Medicare Part B Monthly Actuarial Rates, Monthly Premium Rates, and Annual Deductible The Medicare Part B monthly actuarial rates applicable for 2021 are $291.00 for enrollees age 65 and over and $349.90 for disabled enrollees under age 65. In section II.B. Of this notice, we present the actuarial assumptions and bases from which these rates are derived.

The Part B standard monthly premium rate for all enrollees for 2021 is $148.50. The following are the 2021 Part B monthly premium rates to be paid by (or on behalf of) beneficiaries who file either individual tax returns (and are single individuals, heads of households, qualifying widows or widowers with dependent children, or married individuals filing separately who lived apart from their spouses for the entire taxable year), or joint tax returns. Beneficiaries who file individual tax returns with income:Beneficiaries who file joint tax returns with income:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000Less than or equal to $176,000$0.00$148.50Greater than $88,000 and less than or equal to $111,000Greater than $176,000 and less than or equal to $222,00059.40207.90Start Printed Page 71907Greater than $111,000 and less than or equal to $138,000Greater than $222,000 and less than or equal to $276,000148.50297.00Greater than $138,000 and less than or equal to $165,000Greater than $276,000 and less than or equal to $330,000237.60386.10Greater than $165,000 and less than $500,000Greater than $330,000 and less than $750,000326.70475.20Greater than or equal to $500,000Greater than or equal to $750,000356.40504.90 In addition, the monthly premium rates to be paid by (or on behalf of) beneficiaries who are married and lived with their spouses at any time during the taxable year, but who file separate tax returns from their spouses, are as follows.

Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000$0.00$148.50Greater than $88,000 and less than $412,000326.70475.20Greater than or equal to $412,000356.40504.90 The Part B annual deductible for 2021 is $203.00 for all beneficiaries. B. Statement of Actuarial Assumptions and Bases Employed in Determining the Monthly Actuarial Rates and the Monthly Premium Rate for Part B Beginning January 2021 The actuarial assumptions and bases used to determine the monthly actuarial rates and the monthly premium rates for Part B are established by the Centers for Medicare &.

Medicaid Services' Office of the Actuary. The estimates underlying these determinations are prepared by actuaries meeting the qualification standards and following the actuarial standards of practice established by the Actuarial Standards Board. 1.

Actuarial Status of the Part B Account in the Supplementary Medical Insurance Trust Fund Under section 1839 of the Act, the starting point for determining the standard monthly premium is the amount that would be necessary to finance Part B on an incurred basis. This is the amount of income that would be sufficient to pay for services furnished during that year (including associated administrative costs) even though payment for some of these services will not be made until after the close of the year. The portion of income required to cover benefits not paid until after the close of the year is added to the trust fund and used when needed.

Because the premium rates are established prospectively, they are subject to projection error. Additionally, legislation enacted after the financing was established, but effective for the period in which the financing is set, may affect program costs. As a result, the income to the program may not equal incurred costs.

Trust fund assets must therefore be maintained at a level that is adequate to cover an appropriate degree of variation between actual and projected costs, and the amount of incurred, but unpaid, expenses. Numerous factors determine what level of assets is appropriate to cover variation between actual and projected costs. For 2021, the four most important of these factors are (1) the impact of the hypertension medications lasix on program spending.

(2) the difference from prior years between the actual performance of the program and estimates made at the time financing was established. (3) the likelihood and potential magnitude of expenditure changes resulting from enactment of legislation affecting Part B costs in a year subsequent to the establishment of financing for that year. And (4) the expected relationship between incurred and cash expenditures.

The first factor, the impact of the lasix on program spending, brings a higher-than-usual degree of uncertainty to projected costs for the 2021 Part B financing. The other three factors are analyzed on an ongoing basis, as the trends can vary over time. Table 1 summarizes the estimated actuarial status of the trust fund as of the end of the financing period for 2019 and 2020.

Table 1—Estimated Actuarial Status of the Part B Account in the Supplementary Medical Insurance Trust Fund as of the End of the Financing PeriodFinancing period endingAssets (in millions)Liabilities (in millions)Assets less liabilities (in millions)December 31, 2019$99,602$31,566$68,036December 31, 2020123,05132,88490,167 Start Printed Page 71908 2. Monthly Actuarial Rate for Enrollees Age 65 and Older The monthly actuarial rate for enrollees age 65 and older is one-half of the sum of monthly amounts for (1) the projected cost of benefits. And (2) administrative expenses for each enrollee age 65 and older, after adjustments to this sum to allow for interest earnings on assets in the trust fund and an adequate contingency margin.

The contingency margin is an amount appropriate to provide for possible variation between actual and projected costs and to amortize any surplus assets or unfunded liabilities. Section 1839 of the Act, as amended by section 2401 of the Continuing Appropriations Act, 2021 and Other Extensions Act (Pub. L.

116-159), specifies that the 2021 monthly actuarial rate for enrollees age 65 and older be determined as the sum of the 2020 monthly actuarial rate for enrollees age 65 and older and one-fourth of the difference between the 2020 monthly actuarial rate and the preliminary 2021 monthly actuarial rate (as determined by the Secretary of HHS) for such enrollees. The premium revenue lost by using the resulting lower premium (excluding the forgone income-related premium revenue) will be replaced by a transfer of general revenue from the Treasury, which will be repaid over time. The preliminary monthly actuarial rate for enrollees age 65 and older for 2021 is determined by first establishing per enrollee costs by type of service from program data through 2020 and then projecting these costs for subsequent years.

The projection factors used for financing periods from January 1, 2018 through December 31, 2021 are shown in Table 2. The 2020 monthly actuarial rate for enrollees age 65 and older is $283.20, and the preliminary 2021 monthly actuarial rate for enrollees age 65 and older is $314.30. In accordance with the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act, the 2021 monthly actuarial rate for enrollees age 65 and older is $291.00 ($283.20 + 0.25 × (314.30−283.20)).

As indicated in Table 3, the projected per enrollee amount required to pay for one-half of the total of benefits and administrative costs for enrollees age 65 and over for 2021 is $307.52. Based on current estimates, the assets at the end of 2020 are not sufficient to cover the amount of incurred, but unpaid, expenses, to provide for substantial variation between actual and projected costs, and to accommodate the unusually high degree of uncertainty due to the hypertension medications lasix. Thus, a positive contingency margin is needed to increase assets to a more appropriate level.

The preliminary monthly actuarial rate of $314.30 provides an adjustment of $8.17 for a contingency margin and −$1.39 for interest earnings. The contingency margin for 2021 is affected by several factors. First, in response to the lasix, about $43 billion was paid out of the Part B account as part of the Accelerated and Advanced Payment (AAP) programs.

Providers are to repay their AAP payments to Part B over time through reduced Part B claims payments. However, until the AAP payments have been repaid, the Part B account would not have the roughly $43 billion in assets, and the financing for 2021 would need to be increased to restore the assets used to make these payments. The Continuing Appropriations Act, 2021 and Other Extensions Act requires that a transfer be made from the Treasury to Part B to restore the roughly $43 billion in AAP payments paid out and specifies that any future AAP provider repayments be transferred to the Treasury.

Because the 2021 Part B financing includes the assumption that roughly $43 billion will be transferred from the Treasury to Part B before the end of calendar year 2020, the AAP payments do not impact contingency margin. Second, in order to take into account the uncertainty and potential impact of the hypertension medications lasix, assumptions were developed for testing and treatment for hypertension medications, utilization of non-hypertension medications-related care, potential costs for hypertension medications treatments, and possible paths of the lasix. Several Part B lasix cost scenarios were developed based on these assumptions.

The difference between the best-estimate lasix scenario and the highest-cost lasix scenario was used to establish the additional contingency margin needed to account for the potential costs and uncertainty from the lasix. Third, starting in 2011, manufacturers and importers of brand-name prescription drugs pay a fee that is allocated to the Part B account of the SMI trust. For 2021, the total of these brand-name drug fees is estimated to be $2.8 billion.

The contingency margin for 2021 has been reduced to account for this additional revenue. The traditional goal for the Part B reserve has been that assets minus liabilities at the end of a year should represent between 15 and 20 percent of the following year's total incurred expenditures. To accomplish this goal, a 17-percent reserve ratio, which is a fully adequate contingency reserve level, has been the normal target used to calculate the Part B premium.

The financing rates for 2021 are set above the normal target due to the higher-than-usual uncertainty for 2021. The actuarial rate of $291.00 per month for aged beneficiaries, as announced in this notice for 2021, reflects the combined effect of the factors and legislation previously described and the projected assumptions listed in Table 2. 3.

Monthly Actuarial Rate for Disabled Enrollees Disabled enrollees are those persons under age 65 who are enrolled in Part B because of entitlement to Social Security disability benefits for more than 24 months or because of entitlement to Medicare under the end-stage renal disease (ESRD) program. Projected monthly costs for disabled enrollees (other than those with ESRD) are prepared in a manner parallel to the projection for the aged using appropriate actuarial assumptions (see Table 2). Costs for the ESRD program are projected differently because of the different nature of services offered by the program.

As shown in Table 4, the projected per enrollee amount required to pay for one-half of the total of benefits and administrative costs for disabled enrollees for 2021 is $377.23. The monthly actuarial rate of $349.90 also provides an adjustment of −$1.61 for interest earnings and −$25.72 for a contingency margin, reflecting the same factors and legislation described previously for the aged actuarial rate at magnitudes appropriate to the disabled rate determination. Based on current estimates, the assets associated with the disabled Medicare beneficiaries at the end of 2020 are sufficient to cover the amount of incurred, but unpaid, expenses and to provide for a significant degree of variation between actual and projected costs.

As noted for the aged actuarial rate, the 2021 contingency margin is set above the normal target level in order to accommodate the higher uncertainty due to the hypertension medications lasix. The actuarial rate of $349.90 per month for disabled beneficiaries, as announced in this notice for 2021, reflects the combined net effect of the factors and legislation described previously for aged beneficiaries and the projection assumptions listed in Table 2. 4.

Sensitivity Testing Several factors contribute to uncertainty about future trends in medical care costs. It is appropriate to Start Printed Page 71909test the adequacy of the rates using alternative cost growth rate assumptions. The results of those assumptions are shown in Table 5.

One set represents increases that are higher and, therefore, more pessimistic than the current estimate. The other set represents increases that are lower and, therefore, more optimistic than the current estimate. The values for the alternative assumptions were determined from a statistical analysis of the historical variation in the respective increase factors.

The historical variation may not be representative of the current level of uncertainty due to the hypertension medications lasix. As indicated in Table 5, the monthly actuarial rates would result in an excess of assets over liabilities of $101,796 million by the end of December 2021 under the cost growth rate assumptions shown in Table 2 and under the assumption that the provisions of current law are fully implemented. This result amounts to 21.6 percent of the estimated total incurred expenditures for the following year.

Assumptions that are somewhat more pessimistic (and that therefore test the adequacy of the assets to accommodate projection errors) produce a surplus of $65,262 million by the end of December 2021 under current law, which amounts to 12.4 percent of the estimated total incurred expenditures for the following year. Under fairly optimistic assumptions, the monthly actuarial rates would result in a surplus of $176,475 million by the end of December 2021, or 34.2 percent of the estimated total incurred expenditures for the following year. The sensitivity analysis indicates that, in a typical year, the premium and general revenue financing established for 2021, together with existing Part B account assets, would be adequate to cover estimated Part B costs for 2021 under current law, should actual costs prove to be somewhat greater than expected.

However, the current level of uncertainty due to the lasix may differ from the historical variation included in this analysis. 5. Premium Rates and Deductible As determined in accordance with section 1839 of the Act, the following are the 2021 Part B monthly premium rates to be paid by beneficiaries who file either individual tax returns (and are single individuals, heads of households, qualifying widows or widowers with dependent children, or married individuals filing separately who lived apart from their spouses for the entire taxable year) or joint tax returns.

Beneficiaries who file individual tax returns with income:Beneficiaries who file joint tax returns with income:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000Less than or equal to $176,000$0.00$148.50Greater than $88,000 and less than or equal to $111,000Greater than $176,000 and less than or equal to $222,00059.40207.90Greater than $111,000 and less than or equal to $138,000Greater than $222,000 and less than or equal to $276,000148.50297.00Greater than $138,000 and less than or equal to $165,000Greater than $276,000 and less than or equal to $330,000237.60386.10Greater than $165,000 and less than $500,000Greater than $330,000 and less than $750,000326.70475.20Greater than or equal to $500,000Greater than or equal to $750,000356.40504.90 In addition, the monthly premium rates to be paid by beneficiaries who are married and lived with their spouses at any time during the taxable year, but who file separate tax returns from their spouses, are as follows. Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000$0.00$148.50Greater than $88,000 and less than $412,000326.70475.20Greater than or equal to $412,000356.40504.90 Table 2—Projection Factors 1 12-Month Periods Ending December 31 of 2018-2021[In percent]Calendar yearPhysicians' servicesDurable medical equipmentCarrier lab 2Physician- administered drugsOther carrier services 3Outpatient hospitalHome health agencyHospital lab 4Other intermediary services 5Managed careAged:20181.618.111.412.22.38.41.4−1.07.67.420193.87.34.311.02.25.63.9−3.65.58.42020−14.0−1.5−13.56.3−5.8−6.5−3.7−7.0−3.78.5202129.30.517.79.614.936.619.08.815.03.6Disabled:2018−0.613.53.77.91.94.80.5−1.35.37.620195.55.410.412.05.87.33.70.611.18.32020−9.30.3−15.211.51.6−3.7−1.5−3.8−0.69.5202124.71.523.08.98.834.922.46.822.23.01 All values for services other than managed care are per fee-for-service enrollee. Managed care values are per managed care enrollee.2 Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.3 Includes ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies, etc.Start Printed Page 719104 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.5 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals, etc.

Table 3—Derivation of Monthly Actuarial Rate for Enrollees Age 65 and Over for Financing Periods Ending December 31, 2018 Through December 31, 2021 CY 2018CY 2019CY 2020Preliminary CY 2021CY 2021Covered services (at level recognized):Physician fee schedule$72.28$73.02$60.48$76.83$76.83Durable medical equipment6.056.325.995.935.93Carrier lab 14.284.353.614.194.19Physician-administered drugs16.0717.3717.7419.9219.92Other carrier services 29.339.288.419.529.52Outpatient hospital49.4650.8445.7161.5261.52Home health8.858.958.299.729.72Hospital lab 32.172.041.821.951.95Other intermediary services 418.6119.1317.7020.0620.06Managed care100.65113.46129.87137.11137.11Total services287.76304.75299.62346.77346.77Cost sharing:Deductible−6.40−6.32−6.74−6.94−6.94Coinsurance−28.62−28.79−26.02−30.36−30.36Sequestration of benefits−5.05−5.39−1.78−6.17−6.17HIT payment incentives0.160.000.000.000.00Total benefits247.85264.26265.07303.30303.30Administrative expenses3.904.114.714.214.21Incurred expenditures251.75268.36269.79307.52307.52Value of interest−1.80−1.88−1.09−1.39−1.39Contingency margin for projection error and to amortize the surplus or deficit 511.95−1.5814.508.17−15.13Monthly actuarial rate$261.90$264.90$283.20$314.30$291.001 Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.2 Includes ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies, etc.3 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.4 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals, etc.5 The significant negative margin included in the 2021 actuarial rate is attributable to the application of the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act. Table 4—Derivation of Monthly Actuarial Rate for Disabled Enrollees for Financing Periods Ending December 31, 2018 Through December 31, 2020 CY 2018CY 2019CY 2020CY 2021Covered services (at level recognized):Physician fee schedule$73.05$72.63$61.25$72.93Durable medical equipment12.0912.0211.0210.81Carrier lab 15.716.004.735.51Physician-administered drugs14.8015.5415.8417.51Other carrier services 212.3212.3811.7012.20Outpatient hospital65.1665.5357.8675.43Home health6.956.786.197.20Hospital lab 32.612.482.212.26Other intermediary services 450.7852.7951.6853.18Managed care103.40124.70154.31168.50Total services346.87370.84376.79425.52Cost sharing:Deductible−6.16−6.05−6.45−6.65Coinsurance−41.95−41.78−38.85−41.50Sequestration of benefits−5.97−6.45−2.21−7.53HIT payment incentives0.160.000.000.00Total benefits292.95316.56329.29369.85Administrative expenses4.604.927.897.38Incurred expenditures297.55321.48337.15377.23Value of interest−2.68−2.52−1.38−1.61Start Printed Page 71911Contingency margin for projection error and to amortize the surplus or deficit 50.13−3.567.83−25.72Monthly actuarial rate$295.00$315.40$343.60$349.901 Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.2 Includes ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies, etc.3 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.4 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals, etc.5 The significant negative margin included in the 2021 actuarial rate is attributable to the application of the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act. Table 5—Actuarial Status of the Part B Account in the SMI Trust Fund Under Three Sets of Assumptions for Financing Periods Through December 31, 2021As of December 31,201920202021Actuarial status (in millions):Assets$99,602$123,051$138,974Liabilities$31,566$32,884$37,178Assets less liabilities$68,036$90,167$101,796Ratio 117.7%20.2%21.6%Low-cost projection:Actuarial status (in millions):Assets$99,602$144,338$176,457Liabilities$31,566$30,519$35,245Assets less liabilities$68,036$113,819$141,212Ratio 118.9%28.2%34.2%High-cost projection:Actuarial status (in millions):Assets$99,602$101,797$104,088Liabilities$31,566$35,245$38,826Assets less liabilities$68,036$66,552$65,262Ratio 116.7%13.7%12.4%1 Ratio of assets less liabilities at the end of the year to the total incurred expenditures during the following year, expressed as a percent.

III. Collection of Information Requirements This document does not impose information collection requirements—that is, reporting, recordkeeping, or third-party disclosure requirements. Consequently, there is no need for review by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C.

3501 et seq.). IV. Regulatory Impact Analysis A.

Statement of Need Section 1839 of the Act requires us to annually announce (that is, by September 30th of each year) the Part B monthly actuarial rates for aged and disabled beneficiaries as well as the monthly Part B premium. We also announce the Part B annual deductible because its determination is directly linked to the aged actuarial rate. B.

Overall Impact We have examined the impacts of this notice as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 1995, Pub.

L. 104-4), Executive Order 13132 on Federalism (August 4, 1999), the Congressional Review Act (5 U.S.C. 804(2)), and Executive Order 13771 on Reducing and Controlling Regulatory Costs (January 30, 2017).

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major notices with economically significant effects ($100 million or more in any one year). The 2021 standard Part B premium of $148.50 is $3.90 higher than the 2020 premium of $144.60.

We estimate that this premium increase, for the approximately 59 million Part B enrollees in 2021, will have an annual effect on the economy of $100 million or more. As a result, this notice is economically significant under section 3(f)(1) of Executive Order 12866 and is a major action as defined under the Congressional Review Act (5 U.S.C. 804(2)).

As discussed earlier, this notice announces that the monthly actuarial rates applicable for 2021 are $291.00 for enrollees age 65 and over and $349.90 for disabled enrollees under age 65. It also announces the 2021 monthly Part B premium rates to be paid by Start Printed Page 71912beneficiaries who file either individual tax returns (and are single individuals, heads of households, qualifying widows or widowers with dependent children, or married individuals filing separately who lived apart from their spouses for the entire taxable year) or joint tax returns. Beneficiaries who file individual tax returns with income:Beneficiaries who file joint tax returns with income:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000Less than or equal to $176,000$0.00$148.50Greater than $88,000 and less than or equal to $111,000Greater than $176,000 and less than or equal to $222,00059.40207.90Greater than $111,000 and less than or equal to $138,000Greater than $222,000 and less than or equal to $276,000148.50297.00Greater than $138,000 and less than or equal to $165,000Greater than $276,000 and less than or equal to $330,000237.60386.10Greater than $165,000 and less than $500,000Greater than $330,000 and less than $750,000326.70475.20Greater than or equal to $500,000Greater than or equal to $750,000356.40504.90 In addition, the monthly premium rates to be paid by beneficiaries who are married and lived with their spouses at any time during the taxable year, but who file separate tax returns from their spouses, are also announced and listed in the following chart.

Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses:Income- related monthly adjustment amountTotal monthly premium amountLess than or equal to $88,000$0.00$148.50Greater than $88,000 and less than $412,000326.70475.20Greater than or equal to $412,000356.40504.90 The RFA requires agencies to analyze options for regulatory relief of small businesses, if a rule has a significant impact on a substantial number of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Individuals and states are not included in the definition of a small entity.

This notice announces the monthly actuarial rates for aged (age 65 and over) and disabled (under 65) beneficiaries enrolled in Part B of the Medicare SMI program beginning January 1, 2021. Also, this notice announces the monthly premium for aged and disabled beneficiaries as well as the income-related monthly adjustment amounts to be paid by beneficiaries with modified adjusted gross income above certain threshold amounts. As a result, we are not preparing an analysis for the RFA because the Secretary has determined that this notice will not have a significant economic impact on a substantial number of small entities.

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds.

As we discussed previously, we are not preparing an analysis for section 1102(b) of the Act because the Secretary has determined that this notice will not have a significant effect on a substantial number of small rural hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any one year of $100 million in 1995 dollars, updated annually for inflation. In 2020, that threshold is approximately $156 million.

Part B enrollees who are also enrolled in Medicaid have their monthly Part B premiums paid by Medicaid. The cost to each state Medicaid program from the 2021 premium increase is estimated to be less than the threshold. This notice does not impose mandates that will have a consequential effect of the threshold amount or more on state, local, or tribal governments or on the private sector.

Executive Order 13132 establishes certain requirements that an agency must meet when it publishes a proposed rule (and subsequent final rule) that imposes substantial direct compliance costs on state and local governments, preempts state law, or otherwise has Federalism implications. We have determined that this notice does not significantly affect the rights, roles, and responsibilities of states. Accordingly, the requirements of Executive Order 13132 do not apply to this notice.

Executive Order 13771, titled “Reducing Regulation and Controlling Regulatory Costs,” was issued on January 30, 2017 (82 FR 9339, February 3, 2017). It has been determined that this notice is a transfer notice that does not impose more than de minimis costs and thus is not a regulatory action for the purposes of E.O. 13771.

In accordance with the provisions of Executive Order 12866, this notice was reviewed by the Office of Management and Budget. V. Waiver of Proposed Rulemaking We ordinarily publish a notice of proposed rulemaking in the Federal Register and invite public comment prior to a rule taking effect in accordance with section 1871 of the Act and section 553(b) of the Administrative Procedure Act (APA).

Section 1871(a)(2) of the Act provides that no rule, requirement, or other statement of policy (other than a national coverage determination) that establishes or changes a substantive legal standard Start Printed Page 71913governing the scope of benefits, the payment for services, or the eligibility of individuals, entities, or organizations to furnish or receive services or benefits under Medicare shall take effect unless it is promulgated through notice and comment rulemaking. Unless there is a statutory exception, section 1871(b)(1) of the Act generally requires the Secretary of the Department of Health and Human Services (the Secretary) to provide for notice of a proposed rule in the Federal Register and provide a period of not less than 60 days for public comment before establishing or changing a substantive legal standard regarding the matters enumerated by the statute. Similarly, under 5 U.S.C.

553(b) of the APA, the agency is required to publish a notice of proposed rulemaking in the Federal Register before a substantive rule takes effect. Section 553(d) of the APA and section 1871(e)(1)(B)(i) of the Act usually require a 30-day delay in effective date after issuance or publication of a rule, subject to exceptions. Sections 553(b)(B) and 553(d)(3) of the APA provide for exceptions from the advance notice and comment requirement and the delay in effective date requirements.

Sections 1871(b)(2)(C) and 1871(e)(1)(B)(ii) of the Act also provide exceptions from the notice and 60-day comment period and the 30-day delay in effective date. Section 553(b)(B) of the APA and section 1871(b)(2)(C) of the Act expressly authorize an agency to dispense with notice and comment rulemaking for good cause if the agency makes a finding that notice and comment procedures are impracticable, unnecessary, or contrary to the public interest. The annual updated amounts for the Part B monthly actuarial rates for aged and disabled beneficiaries, the Part B premium, and Part B deductible set forth in this notice do not establish or change a substantive legal standard regarding the matters enumerated by the statute or constitute a substantive rule that would be subject to the notice requirements in section 553(b) of the APA.

However, to the extent that an opportunity for public notice and comment could be construed as required for this notice, we find good cause to waive this requirement. Section 1839 of the Act requires the Secretary to determine the monthly actuarial rates for aged and disabled beneficiaries, as well as the monthly Part B premium (including the income-related monthly adjustment amounts to be paid by beneficiaries with modified adjusted gross income above certain threshold amounts), for each calendar year in accordance with the statutory formulae, in September preceding the year to which they will apply. Further, the statute requires that the agency promulgate the Part B premium amount, in September preceding the year to which it will apply, and include a public statement setting forth the actuarial assumptions and bases employed by the Secretary in arriving at the amount of an adequate actuarial rate for enrollees age 65 and older.

We include the Part B annual deductible, which is established pursuant to a specific formula described in section 1833(b) of the Act, because the determination of the amount is directly linked to the rate of increase in actuarial rate under section 1839(a)(1) of the Act. We have calculated the monthly actuarial rates for aged and disabled beneficiaries, the Part B deductible, and the monthly Part B premium as directed by the statute. Since the statute establishes both when the monthly actuarial rates for aged and disabled beneficiaries and the monthly Part B premium must be published and the information that the Secretary must factor into those amounts, we do not have any discretion in that regard.

We find notice and comment procedures to be unnecessary for this notice and we find good cause to waive such procedures under section 553(b)(B) of the APA and section 1871(b)(2)(C) of the Act, if such procedures may be construed to be required at all. Through this notice, we are simply notifying the public of the updates to the monthly actuarial rates for aged and disabled beneficiaries and the Part B deductible, as well as the monthly Part B premium amounts and the income-related monthly adjustment amounts to be paid by certain beneficiaries, in accordance with the statute, for CY 2021. As such, we also note that even if notice and comment procedures were required for this notice, for the previously stated reason, we would find good cause to waive the delay in effective date of the notice, as additional delay would be contrary to the public interest under section 1871(e)(1)(B)(ii) of the Act.

Publication of this notice is consistent with section 1839 of the Act, and we believe that any potential delay in the effective date of the notice, if such delay were required at all, could cause unnecessary confusion both for the agency and Medicare beneficiaries. Start Signature Dated. October 30, 2020.

Seema Verma, Administrator, Centers for Medicare &. Medicaid Services. Dated.

November 2, 2020. Alex M. Azar II, Secretary, Department of Health and Human Services.

End Signature End Supplemental Information [FR Doc. 2020-25029 Filed 11-6-20. 4:15 pm]BILLING CODE 4120-01-P.

What should I tell my health care provider before I take Lasix?

They need to know if you have any of these conditions:

  • abnormal blood electrolytes
  • diarrhea or vomiting
  • gout
  • heart disease
  • kidney disease, small amounts of urine, or difficulty passing urine
  • liver disease
  • an unusual or allergic reaction to furosemide, sulfa drugs, other medicines, foods, dyes, or preservatives
  • pregnant or trying to get pregnant
  • breast-feeding

Lasix tabs

Under the stewardship of the MidMichigan Health Foundation, this year, 23 area students will http://www.ec-saint-thomas-strasbourg.site.ac-strasbourg.fr/wp/?page_id=120 received scholarship awards from the Tolfree Scholarship, the Dr lasix tabs. George Schaiberger, Sr., Dr lasix tabs. Howard VanOosten and Dr.

Lloyd Wiegerink Medical lasix tabs Scholarship, and the Paul A. Poling Memorial Scholarship.Awardees receiving the Dr. George Schaiberger, Sr., Dr lasix tabs.

Howard VanOosten and Dr. Lloyd Wiegerink lasix tabs Medical Staff Memorial Scholarship are. Allie Morand, Camden Groff, Nicholas Morse, Anna Erickson, Emily Terry, lasix tabs Brooke Chenette, Tyler Walters, Austin Raymond, Jordan Williams, Andrew Waack, Rylie Alward, Nicholas Thomas and Madison Nachtrieb.

Those receiving the Tolfree Scholarship are. Allie Morand, Nicholas Morse, lasix tabs Anna Erickson, Emily Terry and Andrew Waack. Lastly, awardees receiving the Paul A.Poling Memorial Scholarship are Emily Terry, Anna Erickson, Nicholas Morse, Allie Morand and Andrew Waack.“The intent of our generous donors in creating these scholarships is to provide our rural counties, particularly those served by MidMichigan Medical Center – West Branch, with future generations of excellent health care professionals,” said Nicole Potter, director, MidMichigan Health Foundation.

€œWe congratulate all of this year’s recipients, as well as the parents and teachers who help them arrive lasix tabs at this major milestone in these students’ lives. We wish each one of them the best of success and hope to see them back again in a few years serving the people of their own hometown.”Examples of the health professions being pursued by these individuals include physical therapy, pre-medicine, nursing, health administration, sports medicine, neuroscience and human biology.Applications for the 2021-2022 school year will be accepted from Dec. 1, 2020, through lasix tabs March 1, 2021.

Those interested in reviewing the eligibility guidelines, including a scholarship application, may visit www.midmichigan.org/scholarships or call (989) 343-3694.Growers donate produce to staff and patients at MidMichigan Health Park – Bay.Residents in the Bay area have an additional opportunity to embrace healthy lifestyles near lasix tabs MidMichigan Health Park – Bay. Produce by the Park, a community garden that began late last year with a donation from MidMichigan Health Foundation, is flourishing, allowing patients, friends and neighbors to literally enjoy the fruits of their labor.Brenda Turner, director, MidMichigan Physicians Group, has a farming background and dreamt of a garden for her community for years. When the Health Park was built with ample property behind and support from the Foundation, lasix tabs that dream was brought to life.“We are so pleased to be able to support this project as it represents very well MidMichigan Health’s purpose of building healthy communities – together,” said Denise O’Keefe, executive director, MidMichigan Health Foundation.Other local organizations came on board to offer help.

Tri-County Equipment of Saginaw donated dirt, and the Agriscience classes at John Glenn High School volunteered to get plots prepared for gardening. The Building Trades program at lasix tabs Bay Arenac ISD built and installed a tool shed. Woodchips from Weiler Tree Service were donated to cut down on weeding, and Nature’s Own Landscaping and Irrigation hooked up a spigot in a central location so that all gardeners could access it easily.“During our first season, we had just a few plots of our two-acre garden assigned and less than ten participants,” said Ashleigh Palmer, practice manager, MidMichigan Health Park – Bay.

€œThis year, we have all plots filled with more lasix tabs than 40 participants. We have couples, families and individuals who lasix tabs share their experience, produce and recipes with each other. It’s a lot of fun to see the friendships that have developed among our gardeners.

The ground is fertile, so produce is thriving, and excess vegetables are being donated to patients of the facility.”Jarod Morse, 21, saw the garden information on Facebook and lasix tabs is excited to be participating. €œMy whole family - brother, sister and her fiancé, mom, and Papa - are working on the garden together,” Morse stated. A few lasix tabs of the items they are growing are cabbage, cauliflower and a variety of peppers.

€œThe best part,” he added, “is getting to share knowledge and smiles with other members of the garden.”Rows of produce growing in the community garden, Produce by the Park.MidMichigan Health staffers Shelby Kuch and Kellie Picard do much of the organizing, serving as “garden ambassadors.” They are excited to see it thriving.“It has been fun to see how each person has their own unique approach to gardening and harvesting,” said Kuch. €œThere are so many things being grown lasix tabs. Cabbage, corn, potatoes, broccoli, lasix tabs tomatoes, and beautiful sunflowers.

You wouldn’t believe the variety and the willingness to share what is harvested with other gardeners, members of the community and patients.”Picard is pleased to see elderly residents becoming involved. €œMany don’t have the room to plant where they lasix tabs live,” she explained. €œThis place gives them a chance to be outside, grow their own food, socialize with others and get some exercise.

It’s inspiring to see their work pay off in so many ways.”Those who are interested in securing a plot must fill out an application and waiver, lasix tabs and agree to the terms set by Produce by the Park. All skill levels are welcome and there is no cost associated with securing a plot.“Our goal has evolved,” said Palmer. €œWe hope to build upon this year’s successes to increase food security by providing access to fresh, healthy foods while reinforcing ties lasix tabs to the environment and encouraging community members to work together.

I think we are well on our way.”Those interested in more information on the Produce by the Park or to request an application may visit www.midmichigan.org/bay/garden or contact Palmer at (989) 778-2888 or ashleigh.palmer@midmichigan.org..

Under the stewardship of the MidMichigan Health Foundation, this year, 23 area students will received buy lasix 100mg scholarship awards from the Tolfree Scholarship, the Dr. George Schaiberger, buy lasix 100mg Sr., Dr. Howard VanOosten and Dr. Lloyd Wiegerink Medical Scholarship, and the Paul A buy lasix 100mg.

Poling Memorial Scholarship.Awardees receiving the Dr. George Schaiberger, Sr., buy lasix 100mg Dr. Howard VanOosten and Dr. Lloyd Wiegerink Medical buy lasix 100mg Staff Memorial Scholarship are.

Allie Morand, Camden Groff, Nicholas Morse, Anna Erickson, Emily buy lasix 100mg Terry, Brooke Chenette, Tyler Walters, Austin Raymond, Jordan Williams, Andrew Waack, Rylie Alward, Nicholas Thomas and Madison Nachtrieb. Those receiving the Tolfree Scholarship are. Allie Morand, Nicholas Morse, Anna buy lasix 100mg Erickson, Emily Terry and Andrew Waack. Lastly, awardees receiving the Paul A.Poling Memorial Scholarship are Emily Terry, Anna Erickson, Nicholas Morse, Allie Morand and Andrew Waack.“The intent of our generous donors in creating these scholarships is to provide our rural counties, particularly those served by MidMichigan Medical Center – West Branch, with future generations of excellent health care professionals,” said Nicole Potter, director, MidMichigan Health Foundation.

€œWe congratulate all buy lasix 100mg of this year’s recipients, as well as the parents and teachers who help them arrive at this major milestone in these students’ lives. We wish each one of them the best of success and hope to see them back again in a few years serving the people of their own hometown.”Examples of the health professions being pursued by these individuals include physical therapy, pre-medicine, nursing, health administration, sports medicine, neuroscience and human biology.Applications for the 2021-2022 school year will be accepted from Dec. 1, 2020, through March 1, 2021 buy lasix 100mg. Those interested in reviewing the eligibility guidelines, including a buy lasix 100mg scholarship application, may visit www.midmichigan.org/scholarships or call (989) 343-3694.Growers donate produce to staff and patients at MidMichigan Health Park – Bay.Residents in the Bay area have an additional opportunity to embrace healthy lifestyles near MidMichigan Health Park – Bay.

Produce by the Park, a community garden that began late last year with a donation from MidMichigan Health Foundation, is flourishing, allowing patients, friends and neighbors to literally enjoy the fruits of their labor.Brenda Turner, director, MidMichigan Physicians Group, has a farming background and dreamt of a garden for her community for years. When the Health Park was built with ample property buy lasix 100mg behind and support from the Foundation, that dream was brought to life.“We are so pleased to be able to support this project as it represents very well MidMichigan Health’s purpose of building healthy communities – together,” said Denise O’Keefe, executive director, MidMichigan Health Foundation.Other local organizations came on board to offer help. Tri-County Equipment of Saginaw donated dirt, and the Agriscience classes at John Glenn High School volunteered to get plots prepared for gardening. The Building Trades program at Bay Arenac ISD buy lasix 100mg built and installed a tool shed.

Woodchips from Weiler Tree Service were donated to cut down on weeding, and Nature’s Own Landscaping and Irrigation hooked up a spigot in a central location so that all gardeners could access it easily.“During our first season, we had just a few plots of our two-acre garden assigned and less than ten participants,” said Ashleigh Palmer, practice manager, MidMichigan Health Park – Bay. €œThis year, we have buy lasix 100mg all plots filled with more than 40 participants. We have couples, families and individuals who share their buy lasix 100mg experience, produce and recipes with each other. It’s a lot of fun to see the friendships that have developed among our gardeners.

The ground is fertile, buy lasix 100mg so produce is thriving, and excess vegetables are being donated to patients of the facility.”Jarod Morse, 21, saw the garden information on Facebook and is excited to be participating. €œMy whole family - brother, sister and her fiancé, mom, and Papa - are working on the garden together,” Morse stated. A few of the items they are growing are cabbage, cauliflower buy lasix 100mg and a variety of peppers. €œThe best part,” he added, “is getting to share knowledge and smiles with other members of the garden.”Rows of produce growing in the community garden, Produce by the Park.MidMichigan Health staffers Shelby Kuch and Kellie Picard do much of the organizing, serving as “garden ambassadors.” They are excited to see it thriving.“It has been fun to see how each person has their own unique approach to gardening and harvesting,” said Kuch.

€œThere are so buy lasix 100mg many things being grown. Cabbage, corn, potatoes, buy lasix 100mg broccoli, tomatoes, and beautiful sunflowers. You wouldn’t believe the variety and the willingness to share what is harvested with other gardeners, members of the community and patients.”Picard is pleased to see elderly residents becoming involved. €œMany don’t have the room to buy lasix 100mg plant where they live,” she explained.

€œThis place gives them a chance to be outside, grow their own food, socialize with others and get some exercise. It’s inspiring to see their work pay off in so many ways.”Those who are interested in securing a plot must fill out an application and waiver, and agree to the terms set buy lasix 100mg by Produce by the Park. All skill levels are welcome and there is no cost associated with securing a plot.“Our goal has evolved,” said Palmer. €œWe hope to build upon this year’s successes to increase food security by providing access to fresh, healthy foods while reinforcing ties to the buy lasix 100mg environment and encouraging community members to work together.

I think we are well on our way.”Those interested in more information on the Produce by the Park or to request an application may visit www.midmichigan.org/bay/garden or contact Palmer at (989) 778-2888 or ashleigh.palmer@midmichigan.org..

Lasix and weight gain

This edition lasix and weight gain of the Emergency Medicine Journal has ‘something for everyone’ (as always), and at least one article that will Viagra best buy be of interest to everyone (I think). The two main themes in this edition are ‘the difficult airway’ and Paediatric Emergency Medicine. However, we begin this Primary Survey by talking about gender.Gender differences in Emergency MedicineTwo articles look at lasix and weight gain gender disparity in Emergency Medicine (EM). A short report by Partiali et al looks at the proportion of female speakers, and the length of time these speakers are given to deliver their talks, at a major EM academic conference.

Although both proportion and ‘speaking-time’ are increasing over the period reviewed, there remains a lasix and weight gain large gender difference. In the paper by Parsons et al, the worldwide difference in academic representation between the genders is discussed, and is especially interesting given the fact that more females matriculate from medical school in both the USA (since 2017) and the UK (since 1996–7). The authors then go on to look at gender lasix and weight gain differences in medical leadership in EM in the USA. The discrepancy revealed in this paper will, unfortunately, be unsurprising.Whilst writing this ‘Primary Survey’ my bedtime reading is a novel by the late-Victorian writer George Gissing, who in many of his novels explored the position of women in the late nineteenth century.

One of the characters opines “Woman is still enslaved, though men nowadays think it necessary to disguise it.” Having read these two articles it may be that the medical profession has evolved little in this regard over the last 150 years.The difficult airwayThree papers in this edition look at difficult airways and their lasix and weight gain management. In a paper from Japan by Takahashi et al, there is a review of a database from a large observational study on emergency airway management. This has revealed an increase in major (but not minor) adverse events in the lasix and weight gain older population undergoing emergency intubation, largely due to post-intubation hypotension. From the Helicopter Emergency Medical Service in London, there is a 20 year review of emergency cricothyroidotomy which reveals a very low rate of requirement for surgical airways in the pre-hospital environmentWhen performed, it is often due to blood in the airway preventing laryngoscopy.

Gaffar et al have looked at trauma CT scans and calculated the average cricothyroid membrane depth, and factors associated with a greater lasix and weight gain depth. Some of these factors might be surprising, however these ought to be considered by those preparing to perform an emergency surgical airway.Paediatric Emergency MedicineThere are several papers looking at issues in Paediatric Emergency Medicine. The results from a Paediatric Emergency registry in Nicaragua (reviewed in Bressan et al) is sobering, and the use of point-of-care EEG in an ED (described by Simma et al) in intriguing." data-icon-position data-hide-link-title="0">Two further papers particularly catch the eye. The Editors Choice lasix and weight gain this month is a paper looking at the likely cervical spine imaging in a Paediatric population, when using three different clinical decision rules (CDRs) (Philips et al).

There were large differences between cervical spine injury rates and imaging rates. However the use of CDRs would have increased lasix and weight gain the rate of imaging. The second paper is the short report by Cameron et al, highlighting the dangers of travel cups to children. Of interest to all of those who use them.Other articles of interestThe problem of pre-hospital ‘missed stroke’ is considered in the systematic review by Jones lasix and weight gain et al, and reading this paper reveals the challenges faced by clinicians ‘in the field’.

The clinical impact of this, and the potential for improving sensitivity of tools to identify stroke pre-hospital is discussed.Two original research papers relating to hypertension medications are of interest. Lyall and Lone look at the effect on non-hypertension medications admissions during the first lockdown in Scotland, while Bertaina et al look at lasix and weight gain non-invasive ventilation in acute respiratory failure due to hypertension medications.And finally…And the article I think will be of interest to everyone?. This is the Best Evidence topic report on homemade or cloth facemasks as a preventative measure for respiratory lasix transmission- an evidence review on a topic that, is affecting all our lives.‘Tis a lesson you should heedTry, try again.If at first you don’t succeed,Try, try again.— Thomas H Palmer Teacher’s ManualPaediatric cervical spine injuries are rare events, particularly in young children. An individual emergency provider may see less than a handful in her entire career, lasix and weight gain even as she is continuously presented with patients considered at risk for injury.

In the same career, each provider will likely expose thousands of children to significant doses of radiation with an indeterminate but finite risk of inducing a downstream malignancy. Thus, with the increasing awareness of the cumulative risks associated with radiation exposure, the decision as to which patient should be radiographically studied and at what threshold often becomes an uncomfortable one.Useful lasix and weight gain clinical decision rules (CDRs) for identifying cervical spine injuries have been derived, validated and are broadly embraced for adult patients. The National Emergency X-Radiography Utilization Study (NEXUS) from the US and the Canadian C-Spine Rules (CCR).1 2 No comparable, validated paediatric decision-making tools have been created and medical providers have been largely left to extrapolate the findings of adult studies to their paediatric patients whose injuries and risks differ mechanistically and physiologically from their future selves. In an effort to provide better guidance to emergency providers, the investigators of the NEXUS trial analysed a paediatric subset with a very limited sample size (n=3065 with 30 cervical spine injuries), while the Pediatric Emergency Care Applied Research Network (PECARN) attempted to tackle the problem differently through a case-controlled methodology.3 4 Both of these paediatric efforts suffer significant limitations compared with the afore-mentioned large prospective observational studies.In a side-by-side comparison of these three decision tools, ….

This edition buy lasix 100mg of the Emergency Medicine Journal has ‘something for everyone’ http://www.cardozaartgallery.com/viagra-best-buy/ (as always), and at least one article that will be of interest to everyone (I think). The two main themes in this edition are ‘the difficult airway’ and Paediatric Emergency Medicine. However, we begin this Primary Survey by talking about gender.Gender differences in Emergency MedicineTwo articles look at gender disparity in Emergency buy lasix 100mg Medicine (EM). A short report by Partiali et al looks at the proportion of female speakers, and the length of time these speakers are given to deliver their talks, at a major EM academic conference.

Although both buy lasix 100mg proportion and ‘speaking-time’ are increasing over the period reviewed, there remains a large gender difference. In the paper by Parsons et al, the worldwide difference in academic representation between the genders is discussed, and is especially interesting given the fact that more females matriculate from medical school in both the USA (since 2017) and the UK (since 1996–7). The authors then go on to look at gender differences in medical leadership in EM in the USA buy lasix 100mg. The discrepancy revealed in this paper will, unfortunately, be unsurprising.Whilst writing this ‘Primary Survey’ my bedtime reading is a novel by the late-Victorian writer George Gissing, who in many of his novels explored the position of women in the late nineteenth century.

One of the characters opines “Woman is still enslaved, though men nowadays think it necessary to disguise buy lasix 100mg it.” Having read these two articles it may be that the medical profession has evolved little in this regard over the last 150 years.The difficult airwayThree papers in this edition look at difficult airways and their management. In a paper from Japan by Takahashi et al, there is a review of a database from a large observational study on emergency airway management. This has revealed an increase in major (but buy lasix 100mg not minor) adverse events in the older population undergoing emergency intubation, largely due to post-intubation hypotension. From the Helicopter Emergency Medical Service in London, there is a 20 year review of emergency cricothyroidotomy which reveals a very low rate of requirement for surgical airways in the pre-hospital environmentWhen performed, it is often due to blood in the airway preventing laryngoscopy.

Gaffar et al buy lasix 100mg have looked at trauma CT scans and calculated the average cricothyroid membrane depth, and factors associated with a greater depth. Some of these factors might be surprising, however these ought to be considered by those preparing to perform an emergency surgical airway.Paediatric Emergency MedicineThere are several papers looking at issues in Paediatric Emergency Medicine. The results from a Paediatric Emergency registry in Nicaragua (reviewed in Bressan et al) is sobering, and the use of point-of-care EEG in an ED (described by Simma et al) in intriguing." data-icon-position data-hide-link-title="0">Two further papers particularly catch the eye. The Editors Choice this month is a paper looking at the likely cervical spine imaging in a Paediatric buy lasix 100mg population, when using three different clinical decision rules (CDRs) (Philips et al).

There were large differences between cervical spine injury rates and imaging rates. However the use of CDRs would have increased the rate of imaging buy lasix 100mg. The second paper is the short report by Cameron et al, highlighting the dangers of travel cups to children. Of interest to all of those who use them.Other articles of interestThe problem of pre-hospital ‘missed stroke’ is considered buy lasix 100mg in the systematic review by Jones et al, and reading this paper reveals the challenges faced by clinicians ‘in the field’.

The clinical impact of this, and the potential for improving sensitivity of tools to identify stroke pre-hospital is discussed.Two original research papers relating to hypertension medications are of interest. Lyall and buy lasix 100mg Lone look at the effect on non-hypertension medications admissions during the first lockdown in Scotland, while Bertaina et al look at non-invasive ventilation in acute respiratory failure due to hypertension medications.And finally…And the article I think will be of interest to everyone?. This is the Best Evidence topic report on homemade or cloth facemasks as a preventative measure for respiratory lasix transmission- an evidence review on a topic that, is affecting all our lives.‘Tis a lesson you should heedTry, try again.If at first you don’t succeed,Try, try again.— Thomas H Palmer Teacher’s ManualPaediatric cervical spine injuries are rare events, particularly in young children. An individual emergency provider may buy lasix 100mg see less than a handful in her entire career, even as she is continuously presented with patients considered at risk for injury.

In the same career, each provider will likely expose thousands of children to significant doses of radiation with an indeterminate but finite risk of inducing a downstream malignancy. Thus, with the increasing awareness of the cumulative risks associated with radiation exposure, the decision as to which patient should be radiographically studied and buy lasix 100mg at what threshold often becomes an uncomfortable one.Useful clinical decision rules (CDRs) for identifying cervical spine injuries have been derived, validated and are broadly embraced for adult patients. The National Emergency X-Radiography Utilization Study (NEXUS) from the US and the Canadian C-Spine Rules (CCR).1 2 No comparable, validated paediatric decision-making tools have been created and medical providers have been largely left to extrapolate the findings of adult studies to their paediatric patients whose injuries and risks differ mechanistically and physiologically from their future selves. In an effort to provide better guidance to emergency providers, the investigators of the NEXUS trial analysed a paediatric subset with a very limited sample size (n=3065 with 30 cervical spine injuries), while the Pediatric Emergency Care Applied Research Network (PECARN) attempted to tackle the problem differently through a case-controlled methodology.3 4 Both of these paediatric efforts suffer significant limitations compared with the afore-mentioned large prospective observational studies.In a side-by-side comparison of these three decision tools, ….

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Start Preamble best place to buy lasix online http://ilovepte.com/pte-vendors/ Centers for Medicare &. Medicaid Services (CMS), HHS. Continuation of effectiveness and extension best place to buy lasix online of timeline for publication of the final rule. This document announces the continuation of, effectiveness of, and the extension of the timeline for publication of a final rule. We are issuing this document in accordance with section 1871(a)(3)(C) of the Social Security Act (the Act), which allows an interim final rule to remain in effect after the expiration of the timeline specified in section 1871(a)(3)(B) of the Act if the Secretary publishes a notice of continuation explaining why we did not comply with the regular publication timeline.

Effective September 4, 2020, the Medicare provisions adopted in the interim final best place to buy lasix online rule published on September 6, 2016 (81 FR 61538), continue in effect and the regular timeline for publication of the final rule is extended for an additional year, until September 6, 2021. Start Further Info Steve Forry (410) 786-1564 or Jaqueline Cipa (410) 786-3259. End Further Info End Preamble Start Supplemental Information Section 1871(a) of the Social Security Act (the Act) sets forth certain procedures for promulgating regulations necessary to carry out the administration of the insurance programs under Title XVIII of the Act. Section 1871(a)(3)(A) best place to buy lasix online of the Act requires the Secretary, in consultation with the Director of the Office of Management and Budget (OMB), to establish a regular timeline for the publication of final regulations based on the previous publication of a proposed rule or an interim final rule. In accordance with section 1871(a)(3)(B) of the Act, such timeline may vary among different rules, based on the complexity of the rule, the number and scope of the comments received, and other relevant factors.

However, the timeline for publishing the final rule, cannot exceed 3 years from the date of publication of the proposed or interim final rule, unless there are exceptional circumstances. After consultation with the Director of OMB, the Secretary published a document, which appeared in the December 30, 2004 Federal Register on (69 FR 78442), establishing a general 3-year timeline for publishing Medicare final rules after best place to buy lasix online the publication of a proposed or interim final rule. Section 1871(a)(3)(C) of the Act states that upon expiration of the regular timeline for the publication of a final regulation after opportunity for public comment, a Medicare interim final rule shall not continue in effect unless the Secretary publishes a notice of continuation of the regulation that includes an explanation of why the regular timeline was not met. Upon publication of such notice, the regular timeline for publication of the final regulation is treated as having been extended for 1 additional year. On September 6, 2016 Federal Register (81 FR 61538), the Department of Health and Human Services (HHS) issued a department-wide interim final rule titled “Adjustment of Civil Monetary Penalties for Inflation” that established new regulations at 45 CFR part 102 to adjust for inflation the maximum civil monetary penalty amounts for the best place to buy lasix online various civil monetary penalty authorities for all agencies within the Department.

HHS took this action to comply with the Federal Civil Penalties Inflation Adjustment Act of 1990 (the Inflation Adjustment Act) (28 U.S.C. 2461 note 2(a)), as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (section 701 of the Bipartisan Budget Act of 2015, (Pub. L. 114-74), enacted on November 2, 2015). In addition, this September 2016 interim final rule included updates to certain agency-specific regulations to reflect the new provisions governing the adjustment of civil monetary penalties for inflation in 45 CFR part 102.

One of the purposes of the Inflation Adjustment Act was to create a mechanism to allow for regular inflationary adjustments to federal civil monetary penalties. Section 2(b)(1) of the Inflation Adjustment Act. The 2015 amendments removed an inflation update exclusion that previously Start Printed Page 55386applied to the Social Security Act as well as to the Occupational Safety and Health Act. The 2015 amendments also “reset” the inflation calculations by excluding prior inflationary adjustments under the Inflation Adjustment Act and requiring agencies to identify, for each penalty, the year and corresponding amount(s) for which the maximum penalty level or range of minimum and maximum penalties was established (that is, originally enacted by Congress) or last adjusted other than pursuant to the Inflation Adjustment Act. In accordance with section 4 of the Inflation Adjustment Act, agencies were required to.

(1) Adjust the level of civil monetary penalties with an initial “catch-up” adjustment through an interim final rulemaking (IFR) to take effect by August 1, 2016. And (2) make subsequent annual adjustments for inflation. In the September 2016 interim final rule, HHS adopted new regulations at 45 CFR part 102 get lasix online to govern adjustment of civil monetary penalties for inflation. The regulation at 45 CFR 102.1 provides that part 102 applies to each statutory provision under the laws administered by the Department of Health and Human Services concerning civil monetary penalties, and that the regulations in part 102 supersede existing HHS regulations setting forth civil monetary penalty amounts. The civil money penalties and the adjusted penalty amounts administered by all HHS agencies are listed in tabular form in 45 CFR 102.3.

In addition to codifying the adjusted penalty amounts identified in § 102.3, the HHS-wide interim final rule included several technical conforming updates to certain agency-specific regulations, including various CMS regulations, to identify their updated information, and incorporate a cross-reference to the location of HHS-wide regulations. Because the conforming changes to the Medicare provisions were part of a larger, omnibus departmental interim final rule, we inadvertently missed setting a target date for the final rule to make permanent the changes to the Medicare regulations in accordance with section 1871(a)(3)(A) of the Act and the procedures outlined in the December 2004 document. Therefore, in the January 2, 2020 Federal Register (85 FR 7), we published a document continuing the effectiveness of effect and the regular timeline for publication of the final rule for an additional year, until September 6, 2020. Consistent with section 1871(a)(3)(C) of the Act, we are publishing this second notice of continuation extending the effectiveness of the technical conforming changes to the Medicare regulations that were implemented through interim final rule and to allow time to publish a final rule. On January 31, 2020, pursuant to section 319 of the Public Health Service Act (PHSA), the Secretary determined that a Public Health Emergency (PHE) exists for the United States to aid the nation's healthcare community in responding to hypertension medications.

On March 11, 2020, the World Health Organization (WHO) publicly declared hypertension medications a lasix. On March 13, 2020, the President declared the hypertension medications lasix a national emergency. This declaration, along with the Secretary's January 31, 2020 declaration of a PHE, conferred on the Secretary certain waiver authorities under section 1135 of the Act. On March 13, 2020, the Secretary authorized waivers under section 1135 of the Act, effective March 1, 2020.[] Effective July 25, 2020, the Secretary renewed the January 31, 2020 determination that was previously renewed on April 21, 2020, that a PHE exists and has existed since January 27, 2020. The unprecedented nature of this national emergency has placed enormous responsibilities upon CMS to respond appropriately, and resources have had to be re-allocated throughout the agency in order to be responsive.

Therefore, the Medicare provisions adopted in interim final regulation continue in effect and the regular timeline for publication of the final rule is extended for an additional year, until September 6, 2021. Start Signature Wilma M. Robinson, Deputy Executive Secretary to the Department, Department of Health and Human Services. End Signature End Supplemental Information [FR Doc. 2020-19657 Filed 9-4-20.

8:45 am]BILLING CODE 4120-01-PThis document is unpublished. It is scheduled to be published on 09/18/2020. Once it is published it will be available on this page in an official form. Until then, you can download the unpublished PDF version. Although we make a concerted effort to reproduce the original document in full on our Public Inspection pages, in some cases graphics may not be displayed, and non-substantive markup language may appear alongside substantive text.

If you are using public inspection listings for legal research, you should verify the contents of documents against a final, official edition of the Federal Register. Only official editions of the Federal Register provide legal notice to the public and judicial notice to the courts under 44 U.S.C. 1503 &. 1507. Learn more here..

Start Preamble Centers for buy lasix with prescription Medicare buy lasix 100mg &. Medicaid Services (CMS), HHS. Continuation of effectiveness and extension of timeline for publication of the final rule buy lasix 100mg. This document announces the continuation of, effectiveness of, and the extension of the timeline for publication of a final rule. We are issuing this document in accordance with section 1871(a)(3)(C) of the Social Security Act (the Act), which allows an interim final rule to remain in effect after the expiration of the timeline specified in section 1871(a)(3)(B) of the Act if the Secretary publishes a notice of continuation explaining why we did not comply with the regular publication timeline.

Effective September 4, 2020, the Medicare provisions adopted in the interim final rule published on September 6, 2016 (81 FR 61538), continue in effect and the regular timeline for publication of the final buy lasix 100mg rule is extended for an additional year, until September 6, 2021. Start Further Info Steve Forry (410) 786-1564 or Jaqueline Cipa (410) 786-3259. End Further Info End Preamble Start Supplemental Information Section 1871(a) of the Social Security Act (the Act) sets forth certain procedures for promulgating regulations necessary to carry out the administration of the insurance programs under Title XVIII of the Act. Section 1871(a)(3)(A) of the Act requires the Secretary, in consultation with the Director of the Office of Management and Budget (OMB), to establish a regular timeline for the publication of final regulations buy lasix 100mg based on the previous publication of a proposed rule or an interim final rule. In accordance with section 1871(a)(3)(B) of the Act, such timeline may vary among different rules, based on the complexity of the rule, the number and scope of the comments received, and other relevant factors.

However, the timeline for publishing the final rule, cannot exceed 3 years from the date of publication of the proposed or interim final rule, unless there are exceptional circumstances. After consultation with the Director of OMB, the Secretary published a document, which appeared in the December 30, 2004 Federal Register on buy lasix 100mg (69 FR 78442), establishing a general 3-year timeline for publishing Medicare final rules after the publication of a proposed or interim final rule. Section 1871(a)(3)(C) of the Act states that upon expiration of the regular timeline for the publication of a final regulation after opportunity for public comment, a Medicare interim final rule shall not continue in effect unless the Secretary publishes a notice of continuation of the regulation that includes an explanation of why the regular timeline was not met. Upon publication of such notice, the regular timeline for publication of the final regulation is treated as having been extended for 1 additional year. On September 6, 2016 Federal Register (81 FR 61538), the Department of Health and Human Services (HHS) issued a department-wide interim final rule titled “Adjustment of Civil Monetary Penalties for Inflation” that established new regulations at 45 CFR part 102 to adjust for inflation the maximum civil monetary penalty amounts for the buy lasix 100mg various civil monetary penalty authorities for all agencies within the Department.

HHS took this action to comply with the Federal Civil Penalties Inflation Adjustment Act of 1990 (the Inflation Adjustment Act) (28 U.S.C. 2461 note 2(a)), as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (section 701 of the Bipartisan Budget Act of 2015, (Pub. L. 114-74), enacted on November 2, 2015). In addition, this September 2016 interim final rule included updates to certain agency-specific regulations to reflect the new provisions governing the adjustment of civil monetary penalties for inflation in 45 CFR part 102.

One of the purposes of the Inflation Adjustment Act was to create a mechanism to allow for regular inflationary adjustments to federal civil monetary penalties. Section 2(b)(1) of the Inflation Adjustment Act. The 2015 amendments removed an inflation update exclusion that previously Start Printed Page 55386applied to the Social Security Act as well as to the Occupational Safety and Health Act. The 2015 amendments also “reset” the inflation calculations by excluding prior inflationary adjustments under the Inflation Adjustment Act and requiring agencies to identify, for each penalty, the year and corresponding amount(s) for which the maximum penalty level or range of minimum and maximum penalties was established (that is, originally enacted by Congress) or last adjusted other than pursuant to the Inflation Adjustment Act. In accordance with section 4 of the Inflation Adjustment Act, agencies were required to.

(1) Adjust the level of civil monetary penalties with an initial “catch-up” adjustment through an interim final rulemaking (IFR) to take effect by August 1, 2016. And (2) make subsequent annual adjustments for inflation. In the September 2016 http://whitemountainmilers.com/green-hills-preserveredstone-quarry-area-multiple-distances/ interim final rule, HHS adopted new regulations at 45 CFR part 102 to govern adjustment of civil monetary penalties for inflation. The regulation at 45 CFR 102.1 provides that part 102 applies to each statutory provision under the laws administered by the Department of Health and Human Services concerning civil monetary penalties, and that the regulations in part 102 supersede existing HHS regulations setting forth civil monetary penalty amounts. The civil money penalties and the adjusted penalty amounts administered by all HHS agencies are listed in tabular form in 45 CFR 102.3.

In addition to codifying the adjusted penalty amounts identified in § 102.3, the HHS-wide interim final rule included several technical conforming updates to certain agency-specific regulations, including various CMS regulations, to identify their updated information, and incorporate a cross-reference to the location of HHS-wide regulations. Because the conforming changes to the Medicare provisions were part of a larger, omnibus departmental interim final rule, we inadvertently missed setting a target date for the final rule to make permanent the changes to the Medicare regulations in accordance with section 1871(a)(3)(A) of the Act and the procedures outlined in the December 2004 document. Therefore, in the January 2, 2020 Federal Register (85 FR 7), we published a document continuing the effectiveness of effect and the regular timeline for publication of the final rule for an additional year, until September 6, 2020. Consistent with section 1871(a)(3)(C) of the Act, we are publishing this second notice of continuation extending the effectiveness of the technical conforming changes to the Medicare regulations that were implemented through interim final rule and to allow time to publish a final rule. On January 31, 2020, pursuant to section 319 of the Public Health Service Act (PHSA), the Secretary determined that a Public Health Emergency (PHE) exists for the United States to aid the nation's healthcare community in responding to hypertension medications.

On March 11, 2020, the World Health Organization (WHO) publicly declared hypertension medications a lasix. On March 13, 2020, the President declared the hypertension medications lasix a national emergency. This declaration, along with the Secretary's January 31, 2020 declaration of a PHE, conferred on the Secretary certain waiver authorities under section 1135 of the Act. On March 13, 2020, the Secretary authorized waivers under section 1135 of the Act, effective March 1, 2020.[] Effective July 25, 2020, the Secretary renewed the January 31, 2020 determination that was previously renewed on April 21, 2020, that a PHE exists and has existed since January 27, 2020. The unprecedented nature of this national emergency has placed enormous responsibilities upon CMS to respond appropriately, and resources have had to be re-allocated throughout the agency in order to be responsive.

Therefore, the Medicare provisions adopted in interim final regulation continue in effect and the regular timeline for publication of the final rule is extended for an additional year, until September 6, 2021. Start Signature Wilma M. Robinson, Deputy Executive Secretary to the Department, Department of Health and Human Services. End Signature End Supplemental Information [FR Doc. 2020-19657 Filed 9-4-20.

8:45 am]BILLING CODE 4120-01-PThis document is unpublished. It is scheduled to be published on 09/18/2020. Once it is published it will be available on this page in an official form. Until then, you can download the unpublished PDF version. Although we make a concerted effort to reproduce the original document in full on our Public Inspection pages, in some cases graphics may not be displayed, and non-substantive markup language may appear alongside substantive text.

If you are using public inspection listings for legal research, you should verify the contents of documents against a final, official edition of the Federal Register. Only official editions of the Federal Register provide legal notice to the public and judicial notice to the courts under 44 U.S.C. 1503 &. 1507. Learn more here..