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Effective March buy kamagra online uk paypal 19, 2020, and until further notice, the Commission no longer accepts any hand or messenger delivered filings. This is a temporary measure taken to help protect the health and safety of individuals, and to mitigate the transmission of erectile dysfunction treatment. See FCC Announces Closure of FCC Headquarters Open Window and Change in Hand-Delivery Policy, Public Notice, DA 20-304 (March 19, 2020).

Https://www.fcc.gov/​document/​fcc-closes-headquarters-open-window-and-changes-hand-delivery-policy. People with Disabilities. Contact the FCC to request reasonable accommodations (accessible format documents, sign language interpreters, CART, etc.) by email.

FCC504@fcc.gov or phone. 202-418-0530 or TTY. 202-418-0432.

For detailed instructions for submitting comments and additional information on the rulemaking process, see the SUPPLEMENTARY INFORMATION section of this document. Start Further Info Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388, Michelle.Sclater@fcc.gov. End Further Info End Preamble Start Supplemental Information This is a summary of the Commission's further notice of proposed rulemaking (FNPRM) in WC Docket No.

18-336, adopted on April 22, 2021 and released on April 23, 2021. The full text of the document is available at https://docs.fcc.gov/​public/​attachments/​FCC-21-47A1.pdf. To request materials in accessible formats for people with disabilities (e.g., braille, large print, electronic files, audio format, etc.) or to request reasonable accommodations (e.g., accessible format documents, sign language interpreters, CART, etc.), send an email to fcc504@fcc.gov or call the Consumer &.

Governmental Affairs Bureau at (202) 418-0530 (voice) or (202) 418-0432 (TTY). Synopsis I. Further Notice of Proposed Rulemaking A.

Text-to-988 Can Save Lives 1. In this FNPRM, we tentatively conclude that text-to-988 functionality will greatly improve consumer access to the National Suicide Prevention Lifeline (Lifeline), particularly for at-risk populations, and thereby save lives. We seek comment on this tentative conclusion, and on the benefits of text messaging as a means to facilitate access to the critical mental health resources offered by the Lifeline generally.

2. We tentatively conclude that ensuring that Americans in crisis can text 988 is likely to save lives. In the 988 notice of proposed rulemaking, the Commission observed that “Americans, particularly younger Americans, increasingly rely on texting to communicate,” and sought comment on how to account for this fact in establishing 988 as a nationwide 3-digit code for the Lifeline.

In response, numerous experts in mental health and other fields have submitted comments in this proceeding underscoring the importance of texting as a vital communications medium by which many individuals may wish to obtain crisis counseling. Further, many of these commenters noted that texting is particularly important for “members of vulnerable communities such as young people, low-income individuals, members of the LGBTQ community, and individuals who are deaf and hard of hearing.” We seek comment on our tentative conclusion and the assertions of these commenters regarding the importance of texting as a means to access the lifesaving resources offered by the Lifeline. 3.

Just as “Americans in crisis are in need of an easy-to-remember number to access the Lifeline's potentially life-saving resources” by telephone, in our preliminary view Americans have a similarly strong need for an easy-to-remember number to reach the Lifeline by text. Because stakeholders will widely advertise 988 as the telephone number for the Lifeline, we preliminarily believe that providing text access at the same number will generate synergies that enhance the value of efforts to promote 988. Conversely, we fear that if text-to-988 is not available, Americans in crisis may be confused by efforts to promote 988 as the Lifeline's telephone number and mistakenly believe that they can reach the Lifeline by texting 988, putting lives at risk.

We seek comment on this preliminary analysis. 4. As the Commission noted in the 988 Report and Order, young people are disproportionately at risk for mental health crises.

They are also more likely to be most comfortable communicating via text. According to the National Alliance on Mental Illness, “[n]early 95% of teens have access to smart phones and say that texting is the primary way that they connect.” For this reason, the International Council for Helplines describes the increasing use of “chat and text services. .

. For those who are in a mental health crisis,” pointing to a recent survey indicating that “75% of millennials prefer texting over talking.” According to Mental Health America, “[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,” including a study finding that young people “were more likely to forgo psychological support than talk in person or over the phone.” As a result, Mental Health America argues, the “data strongly support[ ] the implementation of texting for providing resources to individuals experiencing suicidal ideation.” We seek comment on these views and whether adopting a text-to-988 mandate would provide particular benefits for young Americans. Are young people more inclined to seek help by text than by telephone, and if Start Printed Page 31405so, would making it easier to text the Lifeline save lives?.

5. In our preliminary view, facilitating Lifeline accessibility by text message to 988 is also likely to provide significant benefits to many other at-risk communities as well, further justifying our proposed mandate. As the Commission explained in the 988 Report and Order, a broad range of American communities are disproportionately impacted by suicide, including Veterans, LGBTQ individuals, racial and ethnic minorities, and rural Americans.

Many members of these affected communities may prefer to seek help through text messages. For example, Mental Health America reports that data they collect demonstrate that individuals “who identify as Black or African American are more likely to report that they would like to receive a phone number they can immediately call or text for help” than members of any other race or ethnicity. Do commenters agree with Mental Health America that making crisis counseling services available via text message “may mean the difference between accessing psychological support and forgoing it, especially among youth of color?.

€ Is Mental Health America correct that easy access to crisis services via text may be the difference between seeking and forgoing help for such groups, and if so would use of a 3-digit dialing code for the Lifeline make a significant difference in widespread understanding that such crisis services are available?. 6. Indeed, demographic evidence regarding usage of currently available non-governmental text and chat options indicate that texting is a particularly valuable means to obtain help, not only for young people, but also for many members of low income, minority, and other communities that are disproportionately impacted by mental health crises.

Several commenters in this proceeding have pointed to the successes that private non-profit services like the Trevor Project have had in providing crisis counseling to at-risk communities through text messages, offering that their experiences demonstrate the need to provide text access to 988. In addition, as one commenter to the 988 notice of proposed rulemaking argued, adding text access to 988 could allow the Lifeline and Veterans Crisis Line “to more efficiently route those in need to specialized services,” further leveraging the expertise of organizations like the Trevor Project, which provides mental health support and counseling specific to the needs of LGBTQ youth. We preliminarily agree with this assessment and believe that establishing text access to 988 will complement the important work already being done by these and other private sector organizations, and further facilitate access to the lifesaving resources offered by the Lifeline and Veterans Crisis Line.

We seek comment on these views and on the benefits of text-to-988 for at-risk groups. Are there additional at-risk communities that may benefit from texting as an option to access the Lifeline?. 7.

Likewise, we preliminarily believe that our tentative conclusion is further justified because implementing text-to-988 capability will provide substantial benefits for individuals with disabilities who uniquely rely on text-based media to communicate. As the Communications Equality Advocates and others note, texting is an indispensable means of communication for individuals with disabilities. These individuals have increasingly adopted widely available text messaging platforms such as those offered by CMRS providers and interconnected text messaging services in lieu of specialized legacy devices.

Further, texting may be the only means for such individuals to contact 988 directly and efficiently. Access to telecommunications for individuals with disabilities is a longstanding Commission priority and statutory obligation, and facilitating access to 988 for deaf and hard of hearing individuals is a particularly important policy objective in light of studies finding a significantly increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. We seek comment on these views and whether our proposal would ease access to lifesaving counseling for individuals with disabilities.

Do commenters agree with the Communications Equality Advocates that the ability for individuals normally using text for the bulk of their communications, including people with disabilities, to access trained mental health professionals using text-to-988 will be of “paramount importance”?. Currently, how do people with disabilities reach the Lifeline?. How would texting grant access or enhance their ability to communicate with the Lifeline?.

We seek comment on whether texting would be more accessible than the options currently available, including the Lifeline's online chat portal. 8. We tentatively conclude that the potential lifesaving benefits of expanding access to suicide prevention and mental health crisis services for all Americans—and particularly the at-risk groups discussed above—justifies a text-to-988 mandate, and we seek comment on this view.

The Commission's designation of 988 as the 3-digit telephone number for the Lifeline reflected its expectation that a simple, easy-to-remember, 3-digit dialing code for suicide prevention and mental health crisis counseling would “help increase the effectiveness of suicide prevention efforts, ease access to crisis services, reduce the stigma surrounding suicide and mental health conditions, and ultimately save lives.” We preliminarily believe that establishing text access to 988 will further advance these important objectives by providing mental health crisis counseling through a nationally available, easy-to-remember number that Americans will also associate with the telephonic Lifeline. Do commenters agree with the Communications Equality Advocates that individuals in crisis “are likely to first use their preferred, familiar mode of communication to reach out for help?. € We seek comment on this analysis, and on our proposed conclusion that a text-to-988 mandate is likely to offer substantial, lifesaving benefits to all Americans affected by mental health crises, particularly for many members of at-risk communities.

Is a text-to-988 mandate likely to have a significant impact on the likelihood of Americans considering suicide or in a mental health crisis to contact the Lifeline?. Would mandating text-to-988 amplify the benefits of promoting 988 as the telephone number for the Lifeline?. What are the costs or drawbacks to our proposal?.

9. In our preliminary view, the Lifeline's soft launch of a texting capability is a significant changed circumstance that supports mandating text-to-988. When the Commission adopted the 988 Report and Order, the Lifeline was not capable of receiving or responding to text messages.

The Commission, stating that it has no authority to require the Lifeline to develop texting capability, deferred “consideration of mandating text-to-988 at this time so that we could revisit the issue promptly should the Lifeline develop integrated texting.” Now, the Lifeline is capable of responding to texts sent to the Lifeline. The Lifeline's ability to respond to texts significantly strengthens the case for imposing a text-to-988 mandate on providers. We seek comment on this evaluation.

10. We preliminarily expect many of the same lifesaving benefits from texting to 911 to accrue from texting to 988. In its comments in support of adopting a text-to-988 requirement, CTIA notes that text-to-911 functionality “has saved countless lives and enabled public safety to keep pace with the modern Start Printed Page 31406communications preferences of consumers.” Given the parallels between the Commission's efforts to promote text access to 911 and our proposals in this FNPRM, are there lessons learned in the context of establishing text-to-911 capability that would be instructive here?.

CTIA states that there are “significant technical and policy differences between the national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.” For example, unlike calls to 911, which carriers route to one of thousands of local PSAPs across the country based on the caller's geographic location, all calls to 988 are routed to a central toll free number, and are then directed within the Lifeline network to a local crisis center. How might these or other differences between the 911 and 988 networks affect our proposal to adopt a text-to-988 requirement?. B.

Proposed Implementation of Text-to-988 1. Scope of Text-to-988 Requirement 11. Text Formats.

We seek comment on an appropriate scope of text messages that covered text providers must transmit to 988. At present, the Lifeline is capable of receiving text messages sent to the existing 10-digit number in “short message service” (SMS) format. The Commission's Truth in Caller ID rules define the term `short message service' or SMS as “a wireless messaging service that enables users to send and receive short text messages, typically 160 characters or fewer, to or from mobile phones and can support a host of applications.” We recognize, however, that our federal partners may incorporate additional capabilities for receiving and responding to text messages in the future.

We seek to adopt a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers by requiring support of formats that the Lifeline is not yet capable of receiving. To that end, we propose (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. And (2) directing the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number.

We seek comment on this proposal in detail below. 12. First, we propose to define the outer bound of text messages that covered text providers may be required to transmit to 988 based on the definition of “text message” that Congress enacted in 2018 in the context of Truth in Caller ID requirements.

The term “text message” (i) means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number or N11 service code. (ii) includes a [SMS] message and a multimedia message service (commonly referred to as `MMS') message. And (iii) does not include—(I) a real-time, two-way voice or video communication.

Or (II) a message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in clause (ii). The Commission's Truth in Caller ID rules define MMS as “a wireless messaging service that is an extension of the SMS protocol and can deliver a variety of media, and enables users to send pictures, videos, and attachments over wireless messaging channels.” We seek comment on this proposed scope. We believe this definition has several advantages—it incorporates multimedia messages.

It is not limited to specific technologies. And it reflects a recent determination by Congress, albeit in a different policy context. For the purpose of our text-to-988 rules, we propose adding “or 988” to the phrase “10-digit telephone number or N11 service code” so that text messages from the Lifeline identified by the 3-digit code 988 are included within the scope of covered text providers' obligations, and we seek comment on this proposal.

We seek comment on whether using the Truth in Caller ID definition appropriately sets an outer bound that would achieve our goals of adopting a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers. 13. We note that the Truth in Caller ID statutory definition of “text message” excludes “real-time, two-way voice or video communications,” as well as “messages sent over.

. . IP-enabled messaging services to another user of the same messaging service.” If we adopt the Truth in Caller ID definition, we seek comment on how we should interpret each of these two exclusions here.

Is there any reason to adopt a different interpretation of the relevant exclusions in this context compared to the Truth in Caller ID context?. € Would adopting the Truth in Caller ID definition of “text message,” with the exclusions specified above, prevent us from possibly adding “next-generation” text messages to our requirements in the future?. 14.

We also seek comment on alternative outer scopes of required texts. For instance, should we adopt the scope of our text-to-911 rules, which require providers to route “a message, consisting of text characters, sent to the short code `911' and intended to be delivered to a PSAP by a covered text provider, regardless of the text messaging platform used”?. In the Text-to-911 Second Report and Order, the Commission identified SMS and MMS messages as examples of text messages included within the scope of this proposed rule.

We seek comment on whether the Truth in Caller ID definition, the text-to-911 definition, or another definition offers the best model here. We note that the Truth in Caller ID model is newer than the text-to-911 definition, originates with Congress rather than the Commission, and unlike the text-to-911 definition explicitly includes images, sounds, and other non-textual information. On the other hand, the Commission developed the text-to-911 definition in a more analogous policy context than the Truth in Caller ID definition.

Do these or other considerations suggest that one or the other model is superior?. 15. Should we ensure that any definition we adopt encompasses next-generation forms of text messaging, such as MMS, Rich Communications Services (RCS), and/or real-time text (RTT), and what modifications—if any—would we need to make to the definitions we are considering to ensure that such forms are within our proposed scope?.

RCS has been described as a “successor protocol” to SMS, or as “next-generation” SMS. What are the fundamental differences between SMS, MMS, and RCS?. How would the costs to implement SMS, MMS, and RCS differ?.

The Commission has previously concluded that “messages sent over other IP-enabled messaging services that are not SMS or MMS—such as [RCS]—are excluded from” the Truth in Caller ID definition of text message “to the extent such messages are sent to other users of the same messaging service.” Would it be necessary to modify the Truth in Caller ID definition for our purposes to ensure that it includes RCS or other next-generation services?. 16. We also seek comment on whether we should ensure that our proposed outer bound definition of text message encompasses RTT.

Telecommunications for the Deaf and Hard of Hearing, Inc., et al. Have urged us to mandate the ability to reach 988 by RTT, noting that the Commission “has acknowledged the benefits of RTT in crisis situations such as `allow[ing] for interruption and reduc[ing] the risk of crossed messages Start Printed Page 31407because the. .

. Call taker is able to read the caller's message as it is being typed, rather than waiting until the caller presses the `send' key.” We seek comment on this assertion and other potential benefits and drawbacks of RTT to 988. We note that pursuant to the 2016 RTT Order, all wireless service providers are permitted to support RTT on their IP networks for purposes of 911 compliance (and for purposes of complying with the general accessibility requirements of Parts 6, 7, and 14 of the Commission's rules) as an alternative to supporting TTY communications over IP.

In light of the deployment of such RTT capabilities in wireless IP networks, are there any impediments to wireless service providers routing RTT texts to the 988 number, in the event that Lifeline chooses to support RTT?. Do newer text messaging protocols like RTT and RCS represent a significant portion of the text messaging ecosystem, or are they likely to in the near future?. Are consumers likely to expect the ability to use these kinds of platforms to send text messages to 988?.

Do these texting solutions make texting more accessible for individuals with disabilities?. Are there other reasons to include, or exclude, these types of applications from our definition?. Are there any text message formats that we should specifically exclude from the definition we adopt?.

For example, in crafting the text-to-911 rules, the Commission chose to exclude from its requirements a variety of services, including “relay service. . .

, mobile satellite service (MSS), and in-flight text messaging services,” as well as “text messages that originate from Wi-Fi only locations or that are transmitted from devices that cannot access the CMRS network.” Should we adopt any similar exclusions here?. 17. Second, we seek comment on how to structure our delegation to the Bureau to ensure that covered text providers support formats within the scope of the definition we adopt that the Lifeline can receive.

We propose, as an initial matter, requiring covered text providers to support transmission of SMS messages to 988, since that is what the Lifeline can presently receive. We further propose directing the Bureau, after consultation with our federal partners at SAMHSA and the VA, to issue a Public Notice no less frequently than annually proposing and seeking comment on requiring covered text providers to transmit any new message formats to 988 that the Lifeline can receive and that are within the scope of the definition we adopt. If the Bureau proposes requiring implementation of a new message format, we further propose directing the Bureau, after notice and comment, to issue a second Public Notice, requiring covered text providers to transmit the new message format to 988 by a fixed deadline that we specify unless the record demonstrates that implementation is not technically feasible.

We seek comment on this proposal. Does it appropriately balance the need for expedient implementation with avoiding unduly burdening covered text providers with implementing formats that the Lifeline cannot receive?. Should we require the Bureau to issue a Public Notice more or less often than annually?.

Or is there another mechanism, such as one similar to the Commission's Text-to-911 PSAP registry, whereby PSAPs issue a valid request for texting service from covered text providers, that we should consider?. Is technical feasibility an appropriate standard for exclusion, or do commenters recommend a different standard?. Should we have a standard for exclusion by the Bureau at all?.

If we do not have a standard for excluding certain technologies, is notice and comment necessary?. What is an appropriate implementation deadline for us to specify after the Bureau issues its Public Notice requiring implementation?. For instance, would six months be sufficient?.

Should we instead allow the Bureau flexibility to set an appropriate deadline?. Should we provide any further direction to the Bureau regarding the evaluation we propose to require?. 18.

We also seek comment on structuring the scope of covered text messages differently. For instance, should we simply adopt a definition of “text message” and require covered text providers to support all such formats, regardless of whether the Lifeline can support that format presently?. Should we adopt a narrower definition of “text message” that conforms to what the Lifeline can support at present?.

While we appreciate the simplicity of either of these approaches compared to our proposal, how would commenters address our concern that the former is unnecessarily burdensome, and the latter is not adequately future-proofed?. 19. Covered Text Providers.

We propose to apply our text-to-988 requirement to “covered text providers” as that term is defined in the text-to-911 rules, to “include[ ] all CMRS providers as well as all providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.” We note that the term “covered text provider” used in this notice of proposed rulemaking differs from the term “covered providers” used in the rules the Commission adopted in the 988 Order, which refers to all telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers. We seek comment on this proposal, and on any alternative approaches to the scope of entities that must establish text-to-988 transmission capability.

For example, if we can apply the definition of “text message” in the Truth in Caller ID rules to texting to 988, should we apply our text-to-988 rules to providers of “text messaging services,” as defined in section 227 of the Act and our Truth in Caller ID rules?. In that context, we define “text messaging service” as “a service that enables the transmission or receipt of a text message.” Is the Truth in Caller ID model preferable, for instance because it may incorporate a broader range of providers that support text messaging service, or is our proposal preferable, for instance because it is more specific?. We also seek comment on other possible models and scopes of covered providers.

Would using “CMRS providers” exclude services over certain spectrum bands or non-switched wireless services that transmit text messages to 988, and should we instead include “wireless carriers,” or a different term, in our definition of “covered text providers?. € 20. Interconnected Text Messaging Services.

In adopting the text-to-911 rules, the Commission observed that there are a variety of widely available text messaging services and platforms with different technological capabilities, including SMS, MMS, and “over-the-top” (OTT) applications delivered over internet protocol (IP)-based mobile data networks. As the Commission explained in the Text-to-911 Second Report and Order, “SMS requires use of an underlying carrier's SMS Center (SMSC) to send and receive messages from other users” while “[MMS]-based messaging makes use of the SMSC but also involves the use of different functional elements to enable transport of the message over IP networks.” A third category, OTT applications, may be offered by CMRS providers or third parties and allow consumers “to send text messages using SMS, MMS or directly via IP over a data connection to dedicated messaging servers and gateways.” These OTT services, which are often downloaded through mobile app stores, are increasingly popular with consumers and may be interconnected with the publicly Start Printed Page 31408switched telephone network (PSTN) or not. For purposes of the Commission's text-to-911 rules, interconnected text messaging applications enable consumers to “send text messages to all or substantially all text-capable U.S.

Telephone numbers and receive text messages from the same,” while non-interconnected applications “only support communication with a defined set of users of compatible applications but do not support general communication with text-capable telephone numbers.” The Commission's text-to-911 rules include interconnected text messaging services but exclude non-interconnected applications because they do not provide the ability to communicate with text-capable U.S. Telephone numbers. 21.

As in the text-to-911 rules, we propose to apply our text-to-988 requirements to interconnected text messaging services, thereby excluding non-interconnected applications from the requirements. We seek comment on this approach. This approach is also analogous to the Commission's decision in the 988 Report and Order to apply to “providers that access the [PSTN] on an interconnected basis to reach all Americans” and any “providers that access the [PSTN] on an interconnected basis to reach all Americans.” We note that the Commission's Truth in Caller ID rules provide an exemption for messages “sent over an IP-enabled messaging service to another user of the same messaging service, except [for an SMS or MMS message],” which similarly operates to exclude non-interconnected text messaging services.

Since the services provided by the Lifeline require two-way communication and, by definition, non-interconnected text messaging applications cannot support two-way texting with “all or substantially all text-capable U.S. Telephone numbers,” we believe it is unlikely that these services would be technically capable of supporting text-to-988 functionality. We seek comment on this view.

Are there any tools available to the Commission to mitigate the potential for consumer confusion regarding the availability of text-to-988 across different text messaging platforms and technologies, particularly with respect to non-interconnected text messaging applications?. 2. Routing Texts to 988 22.

We propose to require that covered text providers route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK), and we seek comment on this proposal. This proposal is consistent with the Commission's decision for routing calls to 988 in the 988 Report and Order. In the 988 Report and Order, the Commission required “that service providers transmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline,” finding that a centralized routing solution will allow for faster implementation of the 988 3-digit dialing code, lower costs to maintain 988 routing, and provide continued easy access to Lifeline by callers with disabilities.

We preliminarily believe that there are similar benefits to routing texts to 988 to a single, centralized number and seek comment on this view. 23. There is support in the record thus far for routing to the Lifeline.

CTIA supports directing texts sent to 988 to the Lifeline as a “central point for receiving such communications,” consistent with the Commission's mandate for routing 988 voice calls. Vibrant Emotional Health, the administrator of the Lifeline, argues in support of text-to-988 functionality integrated into the current Lifeline structure for routing voice and chat services, with oversight squarely within the role of the Lifeline's administrator. We seek comment on these assessments.

24. We anticipate that requiring covered text providers to route to a single destination provides SAMHSA and the VA with flexibility to develop their own routing solutions among the local crisis centers, including adding new crisis centers in the future, as compared to requiring covered text providers to implement additional updates or routing changes as more centers are added. Callers to 1-800-273-8255 (TALK) can reach the Veterans Crisis Line by pressing option 1 to connect with one of three linked call centers in New York, Georgia, or Kansas.

For other calls, calls to the Lifeline from anywhere in the United States are routed to the closest certified local crisis center according to the caller's area code or, should the closest center be overwhelmed by call volume, experience a disruption of service, or if the call is placed from part of a state not covered by Lifeline's network, the system automatically routes calls to a backup center. We seek comment on this preliminary analysis. Do the current obligations to route voice calls to 988 to the Lifeline 10-digit number offer any opportunities for streamlining implementation or reducing costs associated with routing texts to 988 to the same number?.

25. In the alternative, we seek comment on whether instead to follow a model more comparable to the text-to-911 architecture, whereby covered text providers route directly to a PSAP by requiring routing directly to a Lifeline local crisis center or to a Veterans Crisis Line crisis center. We anticipate that this approach would be significantly more costly than centralized routing and seek comment on this preliminary view.

Is it easier to route texts to a single number than to individual crisis centers?. As the Veterans Crisis Line is not currently set up for geographic distribution, would this architecture be appropriate for messages by Veterans or Service Members?. Are covered text providers able to leverage existing text-to-911 systems to reduce costs if required to route texts to 988 directly to local crisis centers?.

In the 988 Report and Order, the Commission recognized that some commenters expressed there may be benefits to routing voice calls to individual crisis centers, such as familiarity with a caller's area and potentially easier coordination with local emergency services, but ultimately concluded that the advantages associated with routing to a single number outweighed the benefits of localized routing. Does that rationale apply here?. Are there benefits to routing texts to the individual crisis centers that are unique to text messages, such as providing localized support to the public in the vicinity of the crisis center?.

What are the costs or drawbacks to covered text providers to route texts to the Lifeline 10-digit number versus the local crisis centers?. Which approach will lead to speedier implementation, and how should that impact our analysis?. Is there another alternative approach, other than centralized routing or routing by crisis center, that we should consider?.

26. Currently, Veterans and Service Members may dial the Lifeline to reach the Veterans Crisis Line via voice call, but the Lifeline texting service and the VA's short code texting service require contacting separate numbers. How should we account for this distinction in evaluating what rules to adopt to ensure that Veterans, Service Members, and their families are able to reach the Veterans Crisis Line directly and promptly?.

We seek comment on whether and how we can act to facilitate integration of the Veterans Crisis Line's separate short code-based texting service into text-to-988 routing. Are there specific actions that the Commission should take to allow users to text 988 and reach both the Lifeline and Veteran-specific assistance?. For instance, should we require covered text providers to provide an automated inquiry as to whether the texter is a Veteran or Service Member and route Start Printed Page 31409the text to either the existing Lifeline number or the existing short code for Veterans depending on the response?.

Alternatively, would it be feasible to immediately prompt individuals texting to 988 to reply with the number “1” or “Vet” to be routed to the Veterans Crisis Line, similar to the experience for voice callers?. Are other prompts preferable?. We seek comment on possible solutions to ensure that texts are routed to the proper counseling services via the Lifeline or the Veterans Crisis Line, including input on technical feasibility, ways to minimize consumer confusion, and implementation costs.

Should other text or chat services be integrated into 988 text routing, and if so, how?. 27. We seek comment on whether we should require covered text providers to enable text-to-988 messages to include location information.

As required by the National Suicide Hotline Designation Act of 2020, the Bureau will report to Congress on the costs and feasibility of providing location information with 988 calls on April 17, 2021. In our preliminary view, given that we have not adopted a location mandate in the context of calls to 988, we believe it would be premature to adopt a mandate here, and we seek comment on this view. Does someone who sends a text message to 988 expect that their location will be transmitted to the Lifeline?.

If consumers generally are aware that calls and texts to 911 include their location, would the same expectation apply to texts to 988?. Would including location information deter at-risk individuals from texting to 988?. We seek comment on any complications inherent in this plan and on ways for covered text providers to work with SAMHSA and the VA to limit misrouting of texts.

3. Implementation Timeframe for Text-to-988 28. Uniform Nationwide Deadline.

We seek comment on an appropriate implementation timeframe for requiring covered text providers to support texting to 988 on a nationwide basis. We preliminarily propose adopting a uniform nationwide deadline for implementation for all covered text providers and for all covered 988 text messages, as determined by the Bureau. In the 988 Report and Order, the Commission determined that the “rollout of 988 will be most effective if [it] set a single implementation deadline so that stakeholders can clearly and consistently communicate to the American public when 988 will be universally available.” We preliminarily believe that the same holds true here, and we seek comment on this view.

Are there other benefits to a uniform nationwide implementation deadline?. What drawbacks, if any, exist?. 29.

Although we propose adopting a uniform nationwide deadline, we seek comment on whether we should adopt any extensions or exemptions for certain classes of providers or categories of text messages. Should we adopt any extensions or exemptions for smaller, rural, or regional covered text providers?. If so, under what circumstances would such exemptions be appropriate?.

Are there unique technical considerations that necessitate different implementation timelines for certain covered text providers?. If so, what are they and why?. Are there any other considerations, such as any existing contractual obligations between our federal partners and other entities, that we should take into account in setting a deadline or deadlines?.

30. Appropriate Deadline. We observe that CTIA and other commenters have previously argued that the Commission should not mandate text-to-988 before the Lifeline is capable of receiving and responding to texts, in part because the Lifeline's readiness to receive and respond to text messages is crucial to implementing text-to-988 successfully.

We seek comment on this assertion. We also seek comment on CTIA's proposal to require covered text providers to “deliver text-to-988 to the Lifeline by July 16, 2022, or six months after the Lifeline demonstrates its readiness to accept text messages, whichever is later.” Is the Lifeline's pilot program sufficient to demonstrate that it is ready to accept text messages?. If not, how should we determine that the Lifeline has demonstrated readiness to accept text messages, both from a technical and operational standpoint?.

How should we take into account the capabilities of the Veterans Crisis Line in establishing a deadline?. Understanding that the Lifeline and Veterans Crisis Line successfully accepting and responding to text messages to 988 will require coordination between several stakeholders, we emphasize that the Commission will continue to coordinate closely with our federal partners, SAMHSA and the VA, in their efforts to enable crisis centers to respond to text messages to 988 and establish a reasonable implementation timeframe for text-to-988. We reiterate that the Commission does not wish to determine for SAMHSA how it allocates the Lifeline's resources, nor do we have the authority to require the Lifeline and its crisis centers to be capable of receiving and responding to text messages to 988.

31. We seek comment on whether the Commission should require all covered text providers to support text-to-988 by July 16, 2022, the same implementation deadline for telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers to support voice calls to 988. Is this technically, economically and operationally feasible?.

Are there benefits to requiring a uniform implementation timeline for all voice and text communications to 988?. We observe that some covered text providers have already implemented voice calling to 988. For those providers, will requiring covered text providers to implement text-to-988 on the same timeline as voice calling to 988 create any efficiencies, such as reducing fixed costs?.

Is there an expectation that once 988 is deployed nationwide for voice communications that texting to 988 will be similarly available?. Will a uniform implementation deadline discourage covered text providers from potentially supporting text to 988 before July 16, 2022?. Are there other potential benefits or drawbacks to uniform implementation deadlines for providers supporting voice calling and texting to 988?.

32. Alternatively, we seek comment on whether we should separate the timeline for implementing text-to-988 from the implementation timeline for voice-to-988. Is a phased-in approach preferable?.

Would it be beneficial to consider balance of telecommunications activation needs and organizational response needs by SAMHSA and the VA?. Would it be less burdensome on providers working to implement 988 for voice calls in accordance with the 988 Report and Order?. Would a phased-in implementation timeline create consumer confusion regarding the availability of texting to 988?.

If phased-in implementation deadlines would create consumer confusion, would requiring certain covered text providers to implement text-to-988 more quickly minimize consumer confusion?. For example, if a covered text provider has already implemented voice calling to 988 and is advertising the availability of 988 to its customers, should the provider be required to implement text-to-988 before other covered text providers?. Are there other risks associated with a phased-in approach to an implementation timeline for voice and text communications to 988 as compared to uniform implementation timeline?.

What, if any, phased-in deadlines should the Commission consider?. 33. We also seek comment on whether we should we adopt the same timeline for all covered text providers, regardless of the text messaging technology they use.

Are there other preparedness concerns that we should take into Start Printed Page 31410consideration when determining an implementation timeframe?. 4. Technical Considerations 34.

We seek comment on the specific technical considerations for covered text providers and equipment and software vendors—including those providers who are rural or small businesses—necessary to implement text-to-988. We propose to allow covered text providers to use any reliable method or methods (e.g., mobile-switched, IP-based) to support text routing and transmission to 988, similar to text-to-911 implementation. We seek comment on this proposal.

35. Network Upgrades. We seek comment on possible upgrades covered text providers would have to make to their networks to support text-to-988 capability.

Since we propose to allow covered text providers to use any reliable method or methods to support text routing and delivery to 988, are any necessary network hardware or software upgrades small in scope?. What specific components would require upgrading?. Can the current solutions to enable text-to-911 capability be leveraged to support text-to-988, or are the implementation options for covered text providers to support text-to-988 significantly different?.

CTIA notes “there are significant technical and policy differences between national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.” We seek comment on CTIA's view, especially with regard to any “significant” technical differences. Conversely, do commenters agree with Communications Equality Advocates that the costs to covered text providers for implementation of text-to-988 should be substantially lower than those associated with implementing text-to-911?. We seek further comment on the potential integration of text-to-988 solutions with existing systems, as well as other network considerations specific to covered text providers to support text-to-988.

36. We also seek comment on whether there are unique network considerations for different text messaging service technologies within the proposed outer bound scope of text-to-988 service that impact implementation. CTIA comments that its member companies are “optimistic about the technical feasibility of supporting text-to-988,” provided that implementation is consistent with existing capabilities of native SMS messaging.

Do commenters agree?. Are there fewer network upgrades necessary to support SMS-only texts to 988?. What specific network upgrades would be required should we obligate covered text providers to support other text messaging formats, such as MMS, RTT, or RCS?.

Given that the Commission has recognized MMS as “an extension of the SMS protocol,” would support for MMS messaging be comparably feasible to support for SMS?. How does the evolution of texting services to new or future formats affect network upgrade options and implementation, and how should our rules account for such evolution?. Would requiring support for certain text messaging formats be more feasible for covered text providers to implement than others?.

37. We specifically seek comment on the technical implementation capability and network upgrades necessary for interconnected text messaging service providers. Similar to the Commission's conclusion in the Text-to-911 proceeding, we anticipate that many interconnected text messaging service providers may choose to use a CMRS network-based solution to deliver texts to 988 and seek comment on this expectation.

Have there been developments in text-to-911 delivery by interconnected text messaging service providers that such providers can use in text-to-988 implementation?. In the text-to-911 context, the Commission's rules state. To the extent that CMRS providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 911 text messages originating on such other covered text providers' application services.

Covered text providers using the CMRS network to deliver 911 text messages must clearly inform consumers that, absent an SMS plan with the consumer's underlying CMRS provider, the covered text provider may be unable to deliver 911 text messages. CMRS providers may migrate to other technologies and need not retain SMS networks solely for other covered text providers' 911 use, but must notify the affected covered text providers not less than 90 days before the migration is to occur. We seek comment on adopting this or a comparable requirement here.

We recognize that text-to-911 network integration is necessary to facilitate a CMRS network-based solution, and we seek comment on whether the same integration is necessary for transmission of text-to-988 communications by other covered text providers using that solution. We seek comment on the relationship between CMRS providers and interconnected text messaging service providers to maintain support and capability for text-to-988 service based on the technical solutions available. We emphasize that, as in the text-to-911 proceeding, even if we were to adopt a rule comparable to the text-to-911 rule above, we do not intend to establish an open-ended obligation for CMRS providers to maintain underlying SMS network support merely for the use of other providers.

Further, similar to the Commission's position in the Text-to-911 Second Report and Order, if we adopt a rule comparable to the text-to-911 rule above, we propose concluding that it is the responsibility of the covered text provider using the CMRS-based solution to ensure that its text messaging service is technically compatible with the CMRS providers' SMS-based network and devices, and in conformance with any applicable technical standards. We seek comment on this proposal. Finally, as in the text-to-911 context, if we adopt a rule comparable to the text-to-911 rule above, we propose requiring CMRS providers to make any necessary specifications for accessing their SMS networks available to other covered text providers upon request, and to inform such covered text providers in advance of any changes to these specifications.

We seek comment on this proposal. 38. We also seek comment on specific technical considerations for covered text providers that are rural or regional providers, or small businesses.

Are there unique impediments or challenges to implementation that these types of providers face that warrant further consideration?. 39. Equipment Upgrades.

We seek comment on possible equipment or software upgrades required for covered text providers to implement text-to-988. What challenges will equipment (e.g., handsets, network infrastructure) and software vendors face with respect to the implementation and deployment of text-to-988?. For example, are upgrades required for operating systems, firmware, or other software on mobile devices to support text-to-988 capability?.

Are there upgrades necessary by vendors that are beyond the covered text providers' control that require additional coordination?. Will new standards need to be defined to ensure interoperability?. 40.

In the Text-to-911 proceeding, the Commission clarified that legacy devices that are incapable of sending texts via 3-digit codes are not subject to the text-to-911 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-911. If the device's text messaging software can be upgraded over the air to support a text to 911, however, then the Commission required the covered text provider to make the necessary software upgrade available. Should we include a Start Printed Page 31411similar exemption for legacy devices under any text-to-988 requirements we may adopt?.

Have circumstances changed in the past seven years such that we should adopt a different approach here?. 5. Cost Recovery 41.

Consistent with the Commission's decision in the 988 Report and Order, we propose to require that all covered text providers bear their own costs to implement text-to-988 capability to the Lifeline 10-digit number. As with call routing to 988, we do not anticipate any shared industry costs are necessary to implement text-to-988, in contrast to previous non-988 numbering proceedings where the Commission established a cost recovery mechanism. As proposed, costs to support text-to-988 would be borne by each provider, specific to the solutions each has adopted to route texts to 988 ultimately to the Lifeline's current toll free access number, presently 1-800-273-8255 (TALK).

We seek comment on this proposal. 42. We believe this approach promotes efficiency in implementation and avoids unnecessary administrative costs.

Section 251(e)(2) of the Act states that “[t]he cost of establishing telecommunications numbering administration arrangements and number portability shall be borne by all telecommunications carriers on a competitively neutral basis.” The Commission typically applies cost recovery mechanisms in situations involving some type of numbering administration arrangement, such as when the Commission hires a third party to develop a database for industry use, to ensure that the statutory cost neutrality requirements are met. Here, as with implementation of voice calls to 988, circumstances do not require establishment of a numbering administration arrangement as there will not be shared costs. Therefore, we believe the section 251(e)(2) requirements do not apply.

Furthermore, even if section 251(e)(2) applies, we believe it is satisfied if we require each provider to bear its own costs because each provider's costs will be proportional to the size and quality of its network. We seek comment on this analysis. 6.

Bounce-Back Messages 43. We seek comment on whether and in what circumstances to require covered text providers to send automatic bounce-back messages where text-to-988 service is unavailable. Throughout the ongoing roll-out of text-to-911 services across the U.S., the Commission has required covered text providers to send an automatic reply, or bounce-back, text message when a consumer attempts to send a text message to a PSAP by means of the 3-digit code “911” and the covered text provider cannot deliver the text because (1) the consumer is located in an area where text-to-911 is not available, or (2) the covered text provider either does not support text-to-911 generally or does not support it in the particular area at the time of the consumer's attempted text.

Unlike in the text-to-911 context, where availability varies by geography and is based on whether the local PSAP can receive texts, our proposals herein would require covered text providers to support nationwide texting to the Lifeline via the 988 3-digit code on a uniform nationwide deadline. If we were to adopt our proposal, should we nonetheless require bounce-back messages?. If so, when and under what circumstances?.

Should we require covered text providers to make available bounce-back messages sooner than we require implementation of text-to-988?. Would requiring bounce-back messages be appropriate if we adopt a uniform nationwide deadline for text-to-988 capability later than July 16, 2022—the uniform nationwide deadline for covered providers to support calls to 988?. Would requiring bounce-back messages be appropriate if we adopt exemptions or extensions for some providers?.

44. We seek comment on the potential benefits and costs of a bounce-back requirement. In the text-to-911 context, the Commission determined that “there is a clear benefit and present need for persons who attempt to send emergency text messages to know immediately if their text cannot be delivered to the proper authorities,” noting that feedback where text-to-911 is not available may be lifesaving by directing a person to seek out an alternative means of communicating with emergency services.

Is that the case here as well?. Because some individuals with disabilities may rely exclusively on texting for communicating, are there unique benefits of a bounce-back requirement for these individuals?. Since the Commission designated 988 as the 3-digit dialing code to access the Lifeline, efforts have been underway to educate the public about using this 3-digit code to reach help by telephone in times of mental health crisis, including its availability for routing voice calls to the Lifeline by July 16, 2022.

In the absence of a bounce-back, might such advertising confuse the public about the availability of texting to 988?. Would an automated bounce-back help to prevent such confusion?. Are there other advantages to requiring covered text providers to send bounce-back messages for attempts to text 988 where service is unavailable?.

Are any providers included under the proposed “covered text providers” definition currently sending bounce-back messages to texts sent to 988?. 45. What are the costs of requiring a bounce-back message?.

What work or upgrades would be necessary for text service providers to implement an automatic bounce-back reply?. Given that covered text providers must provide a bounce-back in circumstances in which text-to-911 is unavailable, would adding a comparable bounce-back message for 988 be easier than if that existing infrastructure were not in place?. Would requiring text service providers to build bounce-back capabilities deter resources from more rapid deployment of text-to-988?.

46. We seek comment on how requiring bounce-back messages may impact the public's ability to seek help from the Lifeline in times of mental crisis. What are the potential benefits to receiving an automatic bounce-back message when text-to-988 service is unavailable?.

Are there any drawbacks to the public of requiring covered text providers to send bounce-back messages when text-to-988 is not available?. One commenter contends that if at-risk texters receive a bounce-back message regarding the unavailability of services, “the risks of disengagement and adverse outcomes increase.” Do commenters agree with the assessment that an automatic bounce-back message will negatively impact individuals seeking help during a crisis?. Would a bounce-back message have the effect of making the sender more discouraged, such that it that could increase, not decrease, the likelihood of suicide?.

Alternatively, if there is no automatic reply, and the sender is left wondering whether the Lifeline received the text message, would that uncertainty also increase sender's likelihood of suicide?. We seek comment on whether the benefits of receiving an automatic bounce-back message outweigh the potential risk of disengagement. 47.

If we were to adopt a bounce-back requirement, we seek comment on the specific requirement we should adopt. To align with the scope of the proposed outer bound text-to-988 capability requirements, we propose that if we were to adopt a bounce-back requirement, we would require all covered text providers to provide automatic bounce-back messages to text messages, as defined by our outer bound Start Printed Page 31412proposal herein, sent to 988 where text-to-988 service is unavailable. We seek comment on this approach.

Are there unique considerations for different technologies within the outer bound scope of text message that we should consider under our bounce-back message proposal, including such impact on technical implementation or costs?. Should we consider requiring covered text providers to send automatic bounce-back messages in reply to messages outside the scope of the outer bound definition?. Are there additional text or chat service providers that offer services beyond the proposed outer bound definition that we should include within the scope of our proposed bounce-back requirement?.

Should we limit any bounce-back requirement to covered text providers, as proposed, or should the requirement sweep more broadly?. CTIA asserts that text-to-988 implementation should be consistent with existing SMS capabilities. Should any bounce-back requirement we may explore likewise remain consistent with SMS?.

Is sending a bounce-back message in response to texts to 988 feasible on legacy SMS systems?. We seek comment on the impact including other text or chat service providers, or other forms of messages, may have on the implementation costs, technical feasibility, and timeframe for our proposed bounce-back message requirements. 48.

Should we adopt a bounce-back requirement, we seek comment on whether and how to expand on the circumstances in which a covered text provider must provide a bounce-back message due to unavailability of text-to-988. In the text-to-911 context, when a customer is roaming away from his or her “home network” (i.e., the network of the customer's mobile carrier), the CMRS provider operating the customer's home network is nonetheless responsible for providing a bounce-back message when required. And the provider operating the network on which the customer is roaming must not impede the bounce-back response by the home network operator.

We seek comment on adopting a similar requirement here. Additionally, we anticipate that there may be circumstances in which the Lifeline is unable to receive and respond to texts, including where demand may exceed its capacity to respond. In instances amounting essentially to a “busy signal” for text delivery, are covered text providers capable of determining that the text cannot be delivered to 988?.

Would covered text providers be able to determine if a text to 988 is undeliverable due to the Lifeline's inability, whether temporary or sustained, to receive and respond to the texts?. Or should we establish a mechanism whereby the Lifeline may inform providers of a temporary suspension of text-to-988 service, and should the bounce-back requirement apply until the suspension is lifted?. Lastly, we seek comment on considerations, either within the control of the covered text provider or the Lifeline's administrators, in which a message from an individual in crisis attempting to reach 988 may not be delivered, and therefore may benefit from receipt of a bounce-back message directing the individual to contact 988 by alternative means.

Are there additional circumstances where we should require covered text providers to send bounce-back messages in response to 988 texts?. 49. If we were to adopt a bounce-back requirement, we propose to adopt the same exceptions to our bounce-back notification requirement for text-to-988 as currently exist for the Commission's text-to-911 rules.

If we adopt that same approach, a covered text provider would not be required to provide an automatic bounce-back message when. (1) Transmission of the text message is not controlled by the provider. (2) a consumer is attempting to text 988, through a text messaging application that requires CMRS service, from a non-service initialized handset.

(3) the text-to-988 message cannot be delivered due to a failure in the Lifeline's routing network that has not been reported to the provider. Or (4) a consumer is attempting to text 988 through a device that is incapable of sending texts via 3-digit codes, provided that the software for the device cannot be upgraded over the air to allow text-to-988. We seek comment on this approach.

Are there other situations where a covered text provider should not be required to send bounce-back messages to consumers attempting to text to 988?. Furthermore, we seek comment on the circumstances in which the provider of a pre-installed or downloaded interconnected text application would be considered to have “control” over the transmission of text messages for the purposes of any requirements we adopt. If a user or third party modifies or manipulates the application after it is installed or downloaded so that it no longer supports bounce-back messaging, should the application provider be presumed not to have control?.

50. If we adopt a bounce-back requirement, should we specify or provide guidance regarding the content of the bounce-back message, and if so, what should we specify or encourage?. Similar to automatic messages sent in response to undeliverable texts to 911, we propose that any bounce-back messages to consumers attempting to text 988 would not require all covered text providers to use identical wording for their automatic responses.

Rather, if we were to adopt a bounce-back requirement, we propose that a covered text provider would be deemed to have met its obligation so long as the bounce-back message to 988 includes, at a minimum, two essential points of information. (1) That text-to-988 is not available. And (2) identify other means to reach the Lifeline, such as by telephone.

We seek comment on this approach and on alternatives. We seek comment on what role our federal partners and non-governmental mental health organizations could play in developing best practices regarding the content of messages. 7.

Role of the Substance Abuse and Mental Health Services Administration and the Department of Veterans Affairs 51. Although the Commission has an important role to play in expanding access to crisis counseling through its implementation of 988, SAMHSA and the VA are ultimately responsible for ensuring the continued success of these lifesaving resources. As such, we propose to direct the Bureau to continue to coordinate the implementation of 988 with SAMHSA and the VA, including any issues pertaining to the delivery of text messages to 988.

52. We seek comment on this proposal. How we can best support the work of our federal partners in administering the Lifeline and Veterans Crisis Line?.

We recognize that many commenters have stressed the importance of ensuring adequate funding and staffing for the Lifeline and the Veterans Crisis Line over the course of this proceeding. Although these issues are beyond our jurisdiction, are there unique considerations pertaining to staffing, funding, or the availability of other resources at the Lifeline or Veterans Crisis Line that we should be aware of as we consider adopting rules to require the delivery of text messages to 988?. How should we account for the possibility that text-to-988 may be popular and increase demands on the Lifeline and Veterans Crisis Line?.

What resources will be needed for the Lifeline and Veterans Crisis Line to ensure that text-to-988 is a success?. How should we account for our federal partners' budget cycles?. We are cognizant of the potential burdens our proposals may impose upon our federal partners, Start Printed Page 31413including personnel, equipment, and resource allocation, and we seek comment on the impact the possible implementation solutions may have on SAMHSA and the VA when supporting text-to-988 service.

To that end, we intend to coordinate with SAMHSA and the VA, and we encourage other industry stakeholders in the wireless and texting service industry to coordinate with these agencies as well. Assuming that our adoption of rules implementing text-to-988 capability will require expenditure of additional resources by SAMHSA and the VA, are there ways that we can structure our rules to minimize the burden on our federal partners?. Are there any steps we should take to deter misuse of text-to-988, so as to limit the unnecessary expenditure of resources by our federal partners?.

Are there any solutions that have been employed in other contexts, such as text-to-911, that we or others should adapt here to deter misuse of text-to-988?. 53. In addition, we encourage SAMHSA and the VA to coordinate with outside organizations that have expertise in providing crisis counseling via text message as they develop the infrastructure to receive and respond to text messages which may one day be delivered to the Lifeline and Veterans Crisis Line via 988.

Many commenters in this proceeding have urged collaboration between private entities like the Trevor Project and federal agencies providing similar services. We therefore seek comment on how to facilitate such coordination across federal agencies and the private sector, as we work towards our shared goal of ensuring that all Americans have ready access to mental health counseling and support services. C.

Legal Authority 54. We propose concluding that we have the authority to adopt the rules proposed and for which we seek comment in this further notice of proposed rulemaking under Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA). We seek comment on these and any other sources of authority available to us.

In particular, we seek comment on whether, and if so, to what extent, our numbering authority under section 251(e) of the Act provides an additional source of authority for the rules proposed and for which we seek comment in this further notice of proposed rulemaking. Finally, we also seek comment on whether we should employ our ancillary authority. We note that, in our preliminary review, the National Suicide Hotline Designation Act of 2020 does not provide additional support for—nor does it hinder—the actions proposed in this further notice of proposed rulemaking.

We seek comment on these views. 55. The rules we propose and for which we seek comment in this further notice of proposed rulemaking are analogous to those the Commission has adopted to facilitate text-to-911 communications, which relied, in part, on the Commission's Title III authority over wireless carriers, including sections 301, 303, 307, 309, and 316.

We propose concluding that, with respect to CMRS providers, Title III provides us with appropriate authority to require wireless carriers to support text-to-988 service and to require delivery of a bounce-back message to consumers in cases where delivery of a text to 988 cannot be completed. As the Supreme Court has long recognized, Title III grants the Commission a “comprehensive mandate” regarding regulation of spectrum usage, and courts have routinely found that Title III provides the Commission with “broad authority to manage spectrum. .

. In the public interest.” As we explain, we believe the rules we propose in this further notice of proposed rulemaking are likely to have significant public interest benefits. And, the Commission has previously found that its Title III licensing authority supported adoption of a similar set of obligations in the text-to-911 context.

Therefore, we believe that with respect to CMRS providers, Title III provides sufficient authority here. We note that, following the release of the Text-to-911 Order, the Commission released a Declaratory Ruling classifying SMS and MMS services as “information services” under the Act. However, as the Commission explicitly noted in the Declaratory Ruling, this determination “does not affect the general applicability of the spectrum allocation and licensing provisions of Title III and the Commission's rules” to SMS and MMS services, nor does it affect the specific application of sections 301, 303, 307, 309, and 316 to the Commission's text-to-911 rules.

We seek comment on this analysis. 56. With respect to interconnected text messaging service providers, we propose to find that the CVAA provides us with authority to adopt the proposals in this further notice of proposed rulemaking, as some commenters in this proceeding suggest.

Congress enacted the CVAA to increase the accessibility of modern communications technologies to people with disabilities, including access related to emergency services, and the Commission relied, in part, on this authority when it adopted similar text-to-911 requirements. The CVAA provides the Commission with authority to “achiev[e] equal access to emergency services by individuals with disabilities, as a part of the migration to a national internet protocol-enabled emergency network.” In particular, the CVAA granted the Commission the authority to adopt regulations to implement recommendations proposed by the Emergency Access Advisory Committee established by the CVAA, which concern access to 911 and NG911 services, and to adopt “other regulations” as are necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network. We tentatively conclude that the CVAA provides authority for our proposals because access to 988 is similar to 911 access for the purposes of our CVAA authority.

We seek comment on this tentative conclusion. Do commenters agree that access to the Lifeline or Veterans Crisis Line through 988 constitute “access to emergency services” under the CVAA?. Do commenters agree that text-to-988 is necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network?.

More generally, does the CVAA provide us with authority to adopt the rules proposed in this further notice of proposed rulemaking?. 57. We seek comment on any other sources of authority available to the Commission to adopt the proposals detailed in this further notice of proposed rulemaking.

In particular, we seek comment on whether our section 251(e) authority over numbering provides authority to require support for text-to-988 service. Section 251(e)(1) of the Act grants us “exclusive jurisdiction over those portions of the North American Numbering Plan that pertain to the United States” and provides that numbers must be made “available on an equitable basis.” This provision gives the Commission “authority to set policy with respect to all facets of numbering administration in the United States.” The Commission found in the 988 Report and Order that section 251(e) provides us with the ability to regulate interconnected and one-way VoIP providers that make use of numbering resources when they connect with the PSTN. We seek comment on whether our numbering authority provides an additional, independent basis to adopt rules with respect to CMRS providers Start Printed Page 31414and interconnected text messaging services.

58. We also seek comment on the Commission's authority to mandate location information with text-to-988 service. Section 222 of the Communications Act, as amended, provides strong legal protections for customer proprietary network information (CPNI), including geolocation information.

Section 222(d) provides exceptions to allow CPNI and call location data to be shared for “emergency services.” We seek comment on whether this could encompass the transmission of geolocation information with 988 calls. Should we choose to require covered text providers to include location information with texts to 988, does section 222 authorize the disclosure of location information with texts to 988?. Are there other privacy concerns that we should consider with regard to texts to 988?.

59. Finally, we seek comment on whether exercise of our ancillary authority would be necessary or appropriate to support any of our proposed rules. The Commission relied in part on ancillary authority to apply the bounce-back notification requirement to providers of interconnected text messaging services when it adopted text-to-911 requirements.

Would a similar finding be appropriate with respect to any aspect of our text-to-988 rules?. D. Benefits and Costs of Text-to-988 60.

We expect to find that the benefits of requiring service providers to support text-to-988 service will exceed the costs of implementation. We seek comment on this proposal, and any specific data regarding both the benefits of facilitating access to the Lifeline via texts to 988 and on the costs or burdens implementation of text-to-988 may impose upon covered text providers. 61.

Suicide causes shock, anguish, grief, and guilt among victims' families and friends. Suicide attempts exact a similarly heavy toll on the community and the victim. The long-lasting damage from mental distress and suicide can extend deep into communities.

As outlined above, we preliminarily believe that enabling text-to-988 service will improve access to lifesaving resources for individuals contemplating suicide or experiencing mental health crises, especially for members of at-risk communities such as young people, LGBTQ, people of color, and individuals with disabilities, thereby saving lives. By expanding access to counseling, text-to-988 may help break the cycle of pain, suffering, and suicide. We seek comment generally on these and other important benefits that may follow from increased access to mental health resources via texting to 988.

62. We further seek comment on ways to quantify these benefits. Of course, the benefits to individuals who the Lifeline or Veterans Crisis Line places on a path to recovery, much less to their families and friends, cannot be reduced to dollars and cents.

That being said, even if text-to-988 service could annually place just one-per-one-thousand suicide victims on a path to long-term recovery, the economic gain would be $19.2 million in any single year, for a present-value of $78.7 million over five years and $134.9 million over ten years. In estimating benefits, we focus on teens and individuals with disabilities, as individuals in these groups are more likely to use a text-to-988 capability. Based on the most recent CDC data from 2015-2019, 11,283 youth (ages 15-19) and an estimated 13,101 individuals who are deaf, hard of hearing, deafblind or speech disabled committed suicide (using an estimated incidence among adults of 6%), or an average of more than 2,000 per year for each group.

To calculate the estimated benefits for a single year, we multiply the annual average by 0.1% and the VSL (2,000 * 0.001 * $9.6 million = $19.2 million). We discount over five years and ten years at a 7% discount rate. We seek comment on this analysis.

63. Our proposed analysis does not examine certain categories of benefits. For example, we have not estimated the cost savings from medical expenses and loss-of-work avoided through reduced suicides and suicide attempts.

We also have not estimated the cost savings of reduced burdens on PSAPs, police, ambulance, and fire and rescue services, which currently respond to some 911 texts that will be routed to the Lifeline, where they will be more effectively and efficiently de-escalated or otherwise resolved. Moreover, we have not examined the benefits of text-to-988 usage by every demographic group. For example, smartphone ownership and suicide are particularly common in younger age groups.

According to the Common Sense Census. Media Use by Tweens and Teens, 2019, 53% of children have their own smartphone by age 11, and 69% have one at age 12. Currently, our estimated benefits analysis looks at youth ages 15-19.

To accurately estimate these benefits, we seek comment on how broadly we should define youth who may text to 988. Relatedly, there is the possibility that adults without hearing or speech disabilities may rely exclusively on text-to-988 for added privacy or convenience, meriting inclusion in our benefit estimates. We also seek comment on ways to better assess the long-term impact of text-to-988 service.

Without longitudinal studies evaluating the long-term effectiveness of suicide call centers, we cannot pinpoint how many suicides text-to-988 will prevent in the long run. Available survey-based studies, however, reveal call centers can substantially reduce suicides during the initial call and follow-up periods. We seek comment on the types and magnitudes of these and other benefits not covered in this further notice of proposed rulemaking, as well as any overlooked categories of costs.

64. In the Text-to-911 proceeding, the Commission estimated that the total cost for covered providers to implement text-to-911 service amounted to less than $21 million. The costs of nationwide deployment of text-to-911 fell into three categories.

CMRS and PSAP system cost components. Interconnected text providers' software upgrades. And bounce-back messaging application alterations and server platform modifications.

Assuming that all or most of the software and equipment necessary to receive and transmit 911 texts will again be needed to deploy text-to-988, we expect that the implementation costs for text-to-988 service will be comparable to the costs for text-to-911 service. Using cost estimates from the Text-to-911 proceeding as a model, we estimate it will cost $19,024,916 for CMRS providers to implement text-to-988, $613,275 for interconnected text messaging service providers to implement text-to-988, and $7,310,340 for Lifeline to route texts to local crisis centers. We convert the estimate for CMRS providers to implement text-to-911 service to 2021 dollars by multiplying by a Consumer Price Index (CPI) factor of 1.16, then discounting over five years at a 7% discount rate.

Similarly, we convert the estimate for interconnected text messaging providers to implement text-to-911 service into 2021 dollars by using a CPI factor of 1.105. To soberly assess Lifeline capability, we assume that 100% of Lifeline call centers may require SMS upgrades and thus multiply PSAP software estimates by 2.22. To estimate the costs to equip the more than 180 Lifeline crisis centers, we calculate an average cost based on an estimated per PSAP cost of $40,613 (=($263,277,595 + $12,891,283)/6,800), for a total of $7,310,340 (=180 * $40,613).

Therefore, we preliminarily estimate that total costs for implementing text-to-988 will be approximately $27 million. We seek Start Printed Page 31415comment on this analysis, including our preliminary assumption that text-to-911 software and equipment can be leveraged for texting to 988. Do commenters agree with CTIA that there are “significant technical and policy differences” between 988 and 911 service, and if so, how might those differences impact our evaluation?.

Furthermore, we seek comment on whether cost estimates for PSAPs from the Text-to-911 proceeding reflect an appropriate estimate for costs to the Lifeline or Veterans Crisis Line. Are there other costs borne by the Lifeline or Veterans Crisis Line needed to implement text-to-988 service?. 65.

We preliminarily assume that some costs may be streamlined or reduced due to the previous implementation of text-to-911, which may be leveraged to facilitate text-to-988 capability and seek comment on this assumption. As a result, we anticipate that costs for covered text providers to implement text-to-988 may be less than what we estimate above and seek comment on this finding. We further seek comment on what extent covered text providers may rely upon existing text-to-911 services and how to quantify the costs needed to upgrade such systems to support text-to-988.

66. Deterring suicide has benefits that simply cannot be reduced to numbers—saving lives has value beyond measure. While recognizing this fact, to illustrate how the benefits of our proposal relate to the more aptly quantified costs, we attempt to estimate the quantifiable value of suicide prevention using a measure of collective willingness to pay.

We propose calculating that the level of suicide prevention needed to generate benefits exceeding our preliminary estimate of $27 million in text-to-988 costs is a total of four suicides avoided over five years. Specifically, the level of teen suicide prevention needed to generate benefits exceeding $27 million is one per 2,821, and the level of suicide prevention among individuals with disabilities to generate benefits exceeding $27 million is one per 3,275. Even assuming that text-to-988 prevented no suicides in its inaugural year as the service rolled out but prevented one suicide in each of the ensuing four years, measured in terms of the public's willingness to pay for that mortality reduction, the present value of the benefit would be $30.39 million, more than three million dollars greater than the total cost.

The present value would be an uneven stream of payments of $9.6 million ($0 in Year 1 + $9.6 million per year in Year 2 through Year 5) at a 7% discount rate. We seek comment on our analysis. 67.

Using break-even points and highly attainable suicide reductions that are well below those suggested by survey studies, we estimate that the benefits of text-to-988 will far exceed the costs. Pooling teenagers and individuals with disabilities, we estimate that text-to-988 would need to prevent one suicide out of every six thousand in order to break-even in the first five years of deployment. Slightly raising the bar to preventing one suicide per one thousand, we further estimate that the more than $157.5 million estimated benefit from modestly reducing suicides in two vulnerable populations far exceeds the text-to-988 deployment costs of $19.6 million incurred by CMRS and interconnected text providers.

Even if sizable Lifeline deployment costs are added, increasing estimated total cost to nearly $27 million, the estimated benefits of text-to-988 remain greater by a multiple of nearly six. Over ten years, the benefits rise to $269.8 million, exceeding costs by a multiple of nearly ten. We seek comment on these estimates.

We also seek comment on the methods and underlying benefits and costs estimates, including those submitted by third parties, used to arrive at our overall proposed conclusion. II. Initial Regulatory Flexibility Analysis 1.

As required by the Regulatory Flexibility Act of 1980, as amended (RFA), the Commission has prepared this Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities by the policies and rules proposed in this Implementation of the National Suicide Hotline Improvement Act of 2018 further notice of proposed rulemaking (FNPRM). The Commission requests written public comments on this IRFA. Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments provided on the first page of the further notice of proposed rulemaking.

The Commission will send a copy of the further notice of proposed rulemaking, including this IRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA). In addition, the further notice of proposed rulemaking and IRFA (or summaries thereof) will be published in the Federal Register. A.

Need for, and Objectives of, the Proposed Rules 2. In this FNPRM, the Commission proposes and seeks comment on requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, the PSTN (covered text providers) to enable delivery of text messages to 988. The Commission proposes to require that covered text providers route 988 text messages to the National Suicide Prevention Lifeline's (Lifeline) 10-digit number, currently 1-800-273-8255 (TALK).

The Commission believes these proposed rules will expand the availability of mental health and crisis counseling resources to Americans who suffer from depressive or suicidal thoughts, by allowing individuals in crisis to reach the Lifeline by texting 988. B. Legal Basis 3.

The legal basis for any action that may be taken pursuant to this FNPRM is contained in sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251, 301, 303, 307, 309, 316. C.

Description and Estimate of the Number of Small Entities to Which the Proposed Rules Will Apply 4. The RFA directs agencies to provide a description of, and where feasible, an estimate of the number of small entities that may be affected by the proposed rules and by the rule revisions on which the Notice seeks comment, if adopted. The RFA generally defines the term “small entity” as having the same meaning as the terms “small business,” “small organization,” and “small governmental jurisdiction.” In addition, the term “small business” has the same meaning as the term “small-business concern” under the Small Business Act.

A “small-business concern” is one which. (1) Is independently owned and operated. (2) is not dominant in its field of operation.

And (3) satisfies any additional criteria established by the SBA. 5. Small Businesses, Small Organizations, Small Governmental Jurisdictions.

Our actions, over time, may affect small entities that are not easily categorized at present. We therefore describe here, at the outset, three broad groups of small entities that could be directly affected herein. First, while there are industry specific size standards for small businesses that are used in the regulatory flexibility analysis, according to data from the Small Business Administration's (SBA) Office of Advocacy, in general a small business is an independent business having fewer than 500 employees.

These types of small businesses represent 99.9% of all businesses in the United Start Printed Page 31416States, which translates to 30.7 million businesses. 6. Next, the type of small entity described as a “small organization” is generally “any not-for-profit enterprise which is independently owned and operated and is not dominant in its field.” The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000 or less to delineate its annual electronic filing requirements for small exempt organizations.

Nationwide, for tax year 2018, there were approximately 571,709 small exempt organizations in the U.S. Reporting revenues of $50,000 or less according to the registration and tax data for exempt organizations available from the IRS. 7.

Finally, the small entity described as a “small governmental jurisdiction” is defined generally as “governments of cities, counties, towns, townships, villages, school districts, or special districts, with a population of less than fifty thousand.” U.S. Census Bureau data from the 2017 Census of Governments indicate that there were 90,075 local governmental jurisdictions consisting of general purpose governments and special purpose governments in the United States. Of this number there were 36,931 general purpose governments (county, municipal and town or township) with populations of less than 50,000 and 12,040 special purpose governments—independent school districts with enrollment populations of less than 50,000.

Accordingly, based on the 2017 U.S. Census of Governments data, we estimate that at least 48,971 entities fall into the category of “small governmental jurisdictions.” 8. Wired Telecommunications Carriers.

The U.S. Census Bureau defines this industry as “establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired communications networks. Transmission facilities may be based on a single technology or a combination of technologies.

Establishments in this industry use the wired telecommunications network facilities that they operate to provide a variety of services, such as wired telephony services, including VoIP services, wired (cable) audio and video programming distribution, and wired broadband internet services. By exception, establishments providing satellite television distribution services using facilities and infrastructure that they operate are included in this industry.” The SBA has developed a small business size standard for Wired Telecommunications Carriers, which consists of all such companies having 1,500 or fewer employees. U.S.

Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small.

9. Local Exchange Carriers (LECs). Neither the Commission nor the SBA has developed a size standard for small businesses specifically applicable to local exchange services.

The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 show that there were 3,117 firms that operated for the entire year. Of that total, 3,083 operated with fewer than 1,000 employees. Thus under this category and the associated size standard, the Commission estimates that the majority of local exchange carriers are small entities.

10. Incumbent LECs. Neither the Commission nor the SBA has developed a small business size standard specifically for incumbent local exchange services.

The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 indicate that 3,117 firms operated the entire year. Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, the Commission estimates that most providers of incumbent local exchange service are small businesses that may be affected by our actions.

According to Commission data, one thousand three hundred and seven (1,307) Incumbent Local Exchange Carriers reported that they were incumbent local exchange service providers. Of this total, an estimated 1,006 have 1,500 or fewer employees. Thus, using the SBA's size standard the majority of incumbent LECs can be considered small entities.

11. Competitive Local Exchange Carriers (Competitive LECs). Competitive Access Providers (CAPs), Shared-Tenant Service Providers, and Other Local Service Providers.

Neither the Commission nor the SBA has developed a small business size standard specifically for these service providers. The appropriate NAICS Code category is Wired Telecommunications Carriers and under that size standard, such a business is small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 indicate that 3,117 firms operated during that year. Of that number, 3,083 operated with fewer than 1,000 employees. Based on these data, the Commission concludes that the majority of Competitive LECS, CAPs, Shared-Tenant Service Providers, and Other Local Service Providers, are small entities.

According to Commission data, 1,442 carriers reported that they were engaged in the provision of either competitive local exchange services or competitive access provider services. Of these 1,442 carriers, an estimated 1,256 have 1,500 or fewer employees. In addition, 17 carriers have reported that they are Shared-Tenant Service Providers, and all 17 are estimated to have 1,500 or fewer employees.

Also, 72 carriers have reported that they are Other Local Service Providers. Of this total, 70 have 1,500 or fewer employees. Consequently, based on internally researched FCC data, the Commission estimates that most providers of competitive local exchange service, competitive access providers, Shared-Tenant Service Providers, and Other Local Service Providers are small entities.

12. We have included small incumbent LECs in this present RFA analysis. As noted above, a “small business” under the RFA is one that, inter alia, meets the pertinent small business size standard (e.g., a telephone communications business having 1,500 or fewer employees), and “is not dominant in its field of operation.” The SBA's Office of Advocacy contends that, for RFA purposes, small incumbent LECs are not dominant in their field of operation because any such dominance is not “national” in scope.

We have therefore included small incumbent LECs in this RFA analysis, although we emphasize that this RFA action has no effect on Commission analyses and determinations in other, non-RFA contexts. 13. Interexchange Carriers (IXCs).

Neither the Commission nor the SBA has developed a small business size standard specifically for Interexchange Carriers. The closest applicable NAICS Code category is Wired Telecommunications Carriers. The applicable size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicate that 3,117 firms operated for the entire year. Of that number, 3,083 operated with fewer than 1,000 employees.

According to internally developed Commission data, 359 companies reported that their primary telecommunications service activity was the provision of interexchange services. Of this total, an estimated 317 have 1,500 or fewer employees. Start Printed Page 31417Consequently, the Commission estimates that the majority of interexchange service providers are small entities.

14. Local Resellers. The SBA has not developed a small business size standard specifically for Local Resellers.

The SBA category of Telecommunications Resellers is the closest NAICs code category for local resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications.

They do not operate transmission facilities and infrastructure. Mobile virtual network operators (MVNOs) are included in this industry. Under the SBA's size standard, such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data from 2012 show that 1,341 firms provided resale services during that year. Of that number, all operated with fewer than 1,000 employees.

Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 213 carriers have reported that they are engaged in the provision of local resale services. Of these, an estimated 211 have 1,500 or fewer employees and two have more than 1,500 employees.

Consequently, the Commission estimates that the majority of local resellers are small entities. 15. Toll Resellers.

The Commission has not developed a definition for Toll Resellers. The closest NAICS Code Category is Telecommunications Resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. MVNOs are included in this industry.

The SBA has developed a small business size standard for the category of Telecommunications Resellers. Under that size standard, such a business is small if it has 1,500 or fewer employees. 2012 U.S.

Census Bureau data show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities.

According to Commission data, 881 carriers have reported that they are engaged in the provision of toll resale services. Of this total, an estimated 857 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of toll resellers are small entities.

16. Other Toll Carriers. Neither the Commission nor the SBA has developed a definition for small businesses specifically applicable to Other Toll Carriers.

This category includes toll carriers that do not fall within the categories of interexchange carriers, operator service providers, prepaid calling card providers, satellite service carriers, or toll resellers. The closest applicable size standard under SBA rules is for Wired Telecommunications Carriers. The applicable SBA size standard consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicates that 3,117 firms operated during that year. Of that number, 3,083 operated with fewer than 1,000 employees.

Thus, under this category and the associated small business size standard, the majority of Other Toll Carriers can be considered small. According to internally developed Commission data, 284 companies reported that their primary telecommunications service activity was the provision of other toll carriage. Of these, an estimated 279 have 1,500 or fewer employees.

Consequently, the Commission estimates that most Other Toll Carriers are small entities. 17. Prepaid Calling Card Providers.

Neither the Commission nor the SBA has developed a small business definition specifically for prepaid calling card providers. The most appropriate NAICS code-based category for defining prepaid calling card providers is Telecommunications Resellers. This industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. Mobile virtual networks operators (MVNOs) are included in this industry.

Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that 1,341 firms provided resale services during that year.

Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these prepaid calling card providers can be considered small entities. According to the Commission's Form 499 Filer Database, 86 active companies reported that they were engaged in the provision of prepaid calling cards.

The Commission does not have data regarding how many of these companies have 1,500 or fewer employees, however, the Commission estimates that the majority of the 86 active prepaid calling card providers that may be affected by these rules are likely small entities. 18. Wireless Telecommunications Carriers (except Satellite).

Neither the SBA nor the Commission has developed a size standard specifically applicable to Wireless Carriers and Service Providers. The closest applicable is Wireless Telecommunications Carriers (except Satellite), which the SBA small business size standard is such a business is small if it 1,500 persons or less. For this industry, U.S.

Census Bureau data for 2012 show that there were 967 firms that operated for the entire year. Of this total, 955 firms had employment of 999 or fewer employees and 12 had employment of 1000 employees or more. Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Carriers and Service Providers are small entities.

19. According to internally developed Commission data for all classes of Wireless Service Providers, there are 970 carriers that reported they were engaged in the provision of wireless services. Of this total, an estimated 815 have 1,500 or fewer employees, and 155 have more than 1,500 employees.

Thus, using available data, we estimate that the majority of Wireless Carriers and Service Providers can be considered small. 20. Cable and Other Subscription Programming.

The U.S. Census Bureau defines this industry as establishments primarily engaged in operating studios and facilities for the broadcasting of programs on a subscription or fee basis. The broadcast programming is typically narrowcast in nature (e.g., limited format, such as news, sports, education, or youth-oriented).

These establishments produce programming in their own facilities or acquire programming from external sources. The programming material is usually delivered to a third party, such as cable systems or direct-to-home satellite Start Printed Page 31418systems, for transmission to viewers.” The SBA size standard for this industry establishes as small any company in this category with annual receipts less than $41.5 million. Based on U.S.

Census Bureau data for 2012, 367 firms operated for the entire year. Of that number, 319 firms operated with annual receipts of less than $25 million a year and 48 firms operated with annual receipts of $25 million or more. Based on this data, the Commission estimates that a majority of firms in this industry are small.

21. Cable Companies and Systems (Rate Regulation). The Commission has also developed its own small business size standards, for the purpose of cable rate regulation.

Under the Commission's rules, a “small cable company” is one serving 400,000 or fewer subscribers nationwide. Industry data indicate that there are 4,600 active cable systems in the United States. Of this total, all but five cable operators nationwide are small under the 400,000-subscriber size standard.

In addition, under the Commission's rate regulation rules, a “small system” is a cable system serving 15,000 or fewer subscribers. Commission records show 4,600 cable systems nationwide. Of this total, 3,900 cable systems have fewer than 15,000 subscribers, and 700 systems have 15,000 or more subscribers, based on the same records.

Thus, under this standard as well, we estimate that most cable systems are small entities. 22. Cable System Operators (Telecom Act Standard).

The Communications Act of 1934, as amended, also contains a size standard for small cable system operators, which is “a cable operator that, directly or through an affiliate, serves in the aggregate fewer than one percent of all subscribers in the United States and is not affiliated with any entity or entities whose gross annual revenues in the aggregate exceed $250,000,000.” As of 2019, there were approximately 48,646,056 basic cable video subscribers in the United States. Accordingly, an operator serving fewer than 486,460 subscribers shall be deemed a small operator if its annual revenues, when combined with the total annual revenues of all its affiliates, do not exceed $250 million in the aggregate. Based on available data, we find that all but five cable operators are small entities under this size standard.

We note that the Commission neither requests nor collects information on whether cable system operators are affiliated with entities whose gross annual revenues exceed $250 million. Therefore, we are unable at this time to estimate with greater precision the number of cable system operators that would qualify as small cable operators under the definition in the Communications Act. 23.

All Other Telecommunications. The “All Other Telecommunications” category is comprised of establishments primarily engaged in providing specialized telecommunications services, such as satellite tracking, communications telemetry, and radar station operation. This industry also includes establishments primarily engaged in providing satellite terminal stations and associated facilities connected with one or more terrestrial systems and capable of transmitting telecommunications to, and receiving telecommunications from, satellite systems.

Establishments providing internet services or voice over internet protocol (VoIP) services via client-supplied telecommunications connections are also included in this industry. The SBA has developed a small business size standard for “All Other Telecommunications”, which consists of all such firms with annual receipts of $35 million or less. For this category, U.S.

Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of those firms, a total of 1,400 had annual receipts less than $25 million and 15 firms had annual receipts of $25 million to $49,999,999. Thus, the Commission estimates that the majority of “All Other Telecommunications” firms potentially affected by our action can be considered small.

24. Radio and Television Broadcasting and Wireless Communications Equipment Manufacturing. This industry comprises establishments primarily engaged in manufacturing radio and television broadcast and wireless communications equipment.

Examples of products made by these establishments are. Transmitting and receiving antennas, cable television equipment, GPS equipment, pagers, cellular phones, mobile communications equipment, and radio and television studio and broadcasting equipment. The SBA has established a small business size standard for this industry of 1,250 or fewer employees.

U.S. Census Bureau data for 2012 show that 841 establishments operated in this industry in that year. Of that number, 828 establishments operated with fewer than 1,000 employees, 7 establishments operated with between 1,000 and 2,499 employees and 6 establishments operated with 2,500 or more employees.

Based on this data, we conclude that a majority of manufacturers in this industry are small. 25. Semiconductor and Related Device Manufacturing.

This industry comprises establishments primarily engaged in manufacturing semiconductors and related solid state devices. Examples of products made by these establishments are integrated circuits, memory chips, microprocessors, diodes, transistors, solar cells and other optoelectronic devices. The SBA has developed a small business size standard for Semiconductor and Related Device Manufacturing, which consists of all such companies having 1,250 or fewer employees.

U.S. Census Bureau data for 2012 show that there were 862 establishments that operated that year. Of this total, 843 operated with fewer than 1,000 employees.

Thus, under this size standard, the majority of firms in this industry can be considered small. 26. Software Publishers.

This industry comprises establishments primarily engaged in computer software publishing or publishing and reproduction. Establishments in this industry carry out operations necessary for producing and distributing computer software, such as designing, providing documentation, assisting in installation, and providing support services to software purchasers. These establishments may design, develop, and publish, or publish only.

The SBA has established a size standard for this industry of annual receipts of $41.5 million or less per year. U.S. Census data for 2012 indicates that 5,079 firms operated for the entire year.

Of that number 4,691 firms had annual receipts of less than $25 million and 166 firms had annual receipts of $25,000,000 to $49,999,999. Based on this data, we conclude that a majority of firms in this industry are small. 27.

Internet Service Providers (Broadband). Broadband internet service providers include wired (e.g., cable, DSL) and VoIP service providers using their own operated wired telecommunications infrastructure fall in the category of Wired Telecommunication Carriers. Wired Telecommunications Carriers are comprised of establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired telecommunications networks.

Transmission facilities may be based on a single technology or a combination of technologies. The SBA size standard for this category classifies a business as small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 show that there were 3,117 firms that operated Start Printed Page 31419that year. Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, under this size standard the majority of firms in this industry can be considered small.

28. Internet Service Providers (Non-Broadband). Internet access service providers such as Dial-up internet service providers, VoIP service providers using client-supplied telecommunications connections and internet service providers using client-supplied telecommunications connections (e.g., dial-up ISPs) fall in the category of All Other Telecommunications.

The SBA has developed a small business size standard for All Other Telecommunications which consists of all such firms with gross annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year.

Of these firms, a total of 1,400 had gross annual receipts of less than $25 million. Consequently, under this size standard a majority of firms in this industry can be considered small. 29.

All Other Information Services. The U.S. Census Bureau has determined that this category “comprises establishments primarily engaged in providing other information services (except news syndicates, libraries, archives, internet publishing and broadcasting, and Web search portals).” The SBA has developed a small business size standard for this category, which consists of all such firms with annual receipts of $30 million or less.

U.S. Census Bureau data for 2012 show that there were 512 firms that operated for the entire year. Of those firms, a total of 498 had annual receipts less than $25 million and 7 firms had annual receipts of $25 million to $49, 999,999.

Consequently, we estimate that the majority of these firms are small entities that may be affected by our action. D. Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 30.

The FNPRM proposes and seeks comment on rules to require covered text providers to support text messaging to 988. It tentatively concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations, and thereby save lives. The proposed rules would require CMRS providers and interconnected text messaging service providers to route texts sent to 988 to the 10-digit Lifeline number, presently 1-800-273-8255 (TALK).

The FNPRM proposes (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. And (2) directing the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number. The FNPRM seeks comment on this proposal.

The Commission preliminarily believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules for different covered text providers. The Commission proposes that the costs and/or administrative burdens associated with the rules will not unduly burden small entities. E.

Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 31. The RFA requires an agency to describe any significant alternatives that it has considered in reaching its proposed approach, which may include the following four alternatives (among others). (1) The establishment of differing compliance or reporting requirements or timetables that take into account the resources available to small entities.

(2) the clarification, consolidation, or simplification of compliance and reporting requirements under the rules for such small entities. (3) the use of performance rather than design standards. And (4) an exemption from coverage of the rule, or any part thereof, for such small entities.

32. In the FNPRM, the Commission seeks comment from all entities, including small entities, regarding the impact of these proposed rules on small entities. The Commission seeks comment on the impact, cost or otherwise, that requiring text messaging to 988 capability will impose on regional and rural carriers and small businesses.

The Commission also seeks comment on whether to adopt any exemptions for small businesses and if so, under what circumstances. The Commission asks and will consider alternatives to the proposals and on alternative ways of implementing the proposals. F.

Federal Rules That May Duplicate, Overlap, or Conflict With the Proposed Rules 33. None. III.

Procedural Matters 34. Ex Parte Rules. This proceeding shall be treated as a “permit-but-disclose” proceeding in accordance with the Commission's ex parte rules.

Persons making ex parte presentations must file a copy of any written presentation or a memorandum summarizing any oral presentation within two business days after the presentation (unless a different deadline applicable to the Sunshine period applies). Persons making oral ex parte presentations are reminded that memoranda summarizing the presentation must (1) list all persons attending or otherwise participating in the meeting at which the ex parte presentation was made, and (2) summarize all data presented and arguments made during the presentation. If the presentation consisted in whole or in part of the presentation of data or arguments already reflected in the presenter's written comments, memoranda or other filings in the proceeding, the presenter may provide citations to such data or arguments in his or her prior comments, memoranda, or other filings (specifying the relevant page and/or paragraph numbers where such data or arguments can be found) in lieu of summarizing them in the memorandum.

Documents shown or given to Commission staff during ex parte meetings are deemed to be written ex parte presentations and must be filed consistent with Rule 1.1206(b). In proceedings governed by Rule 1.49(f) or for which the Commission has made available a method of electronic filing, written ex parte presentations and memoranda summarizing oral ex parte presentations, and all attachments thereto, must be filed through the electronic comment filing system available for that proceeding, and must be filed in their native format (e.g., .doc, .xml, .ppt, searchable .pdf). Participants in this proceeding should familiarize themselves with the Commission's ex parte rules.

35. Initial Regulatory Flexibility Analysis. Pursuant to the Regulatory Flexibility Act (RFA), the Commission has prepared an Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities of the policies and actions considered in this FNPRM.

Written public comments are requested on this IRFA. Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments on the FNPRM. The Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, will send a copy of the FNPRM, including the IRFA, to the Chief Counsel for Advocacy of the Small Business Administration.Start Printed Page 31420 36.

Comment Filing Procedures. Pursuant to §§ 1.415 and 1.419 of the Commission's rules, 47 CFR 1.415, 1.419, interested parties may file comments and reply comments on or before the dates indicated on the first page of this document. Comments may be filed using the Commission's Electronic Comment Filing System (ECFS).

See Electronic Filing of Documents in Rulemaking Proceedings, 63 FR 24121 (1998). Electronic Filers. Comments may be filed electronically using the internet by accessing ECFS.

Https://www.fcc.gov/​ecfs/​. Paper Filers. Parties who choose to file by paper must file an original and one copy of each filing.

Filings can be sent by commercial overnight courier, or by first-class or overnight U.S. Postal Service mail. All filings must be addressed to the Commission's Secretary, Office of the Secretary, Federal Communications Commission.

Commercial overnight mail (other than U.S. Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701. U.S.

Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554. Effective March 19, 2020, and until further notice, the Commission no longer accepts any hand or messenger delivered filings. This is a temporary measure taken to help protect the health and safety of individuals, and to mitigate the transmission of erectile dysfunction treatment.

See FCC Announces Closure of FCC Headquarters Open Window and Change in Hand-Delivery Policy, Public Notice, 35 FCC Rcd 2788 (OS 2020), https://www.fcc.gov/​document/​fcc-closes-headquarters-open-window-and-changes-hand-delivery-policy. 37. People with Disabilities.

To request materials in accessible formats for people with disabilities (braille, large print, electronic files, audio format), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice). 38.

Paperwork Reduction Act of 1995 Analysis. This document may contain proposed new or modified information collection requirements. The Commission, as part of its continuing effort to reduce paperwork burdens, invites the general public and the Office of Management and Budget (OMB) to comment on the information collection requirements contained in this document, as required by the Paperwork Reduction Act of 1995, Public Law 104-13.

In addition, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, we seek specific comment on how we might further reduce the information collection burden for small business concerns with fewer than 25 employees. 39. Contact Person.

For further information about this rulemaking proceeding, please contact Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388 or michelle.sclater@fcc.gov. IV. Ordering Clauses 40.

It is ordered, pursuant to sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251, 301, 303, 307, 309, 316, that the FNPRM in WC Docket No. 18-336 is adopted.

41. It is further ordered that the Petition for Reconsideration filed by Communications Equality Advocates is granted in part to the extent described herein.

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MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% kamagra 100 chewable tablet of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program. In this article kamagra 100 chewable tablet.

The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP. Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid kamagra 100 chewable tablet with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed.

Here is an example. Sam is age 50 and has kamagra 100 chewable tablet Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies.

$400 - $65 = $335 kamagra 100 chewable tablet. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP. 2 kamagra 100 chewable tablet.

Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as “MAGI-like budgeting.” Under MAGI rules income kamagra 100 chewable tablet can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL.

If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they kamagra 100 chewable tablet can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3. New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting.

During the kamagra 100 chewable tablet transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS. The consumer kamagra 100 chewable tablet is entitled to MIPP payments for at least three months during the transition.

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

NOTE during erectile dysfunction treatment emergency their case may remain with NYSoH for more than 12 months. See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note.

During the erectile dysfunction treatment emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on erectile dysfunction treatment eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC).

Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article.

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

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

1619B. 5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021).

They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check.

In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as.

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

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

Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin.

Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program. The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS). Unfortunately, the notice is not consumer-friendly and may be confusing. See attached sample for what to look for.

Health Insurance Premium Payment Program (HIPP) HIPP is a sister program to MIPP and will reimburse consumers for private third party health insurance when deemed “cost effective.” Directives:.

Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program buy kamagra online uk paypal (MIPP) cheap kamagra supplier uk. The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people.

Some people buy kamagra online uk paypal are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits. MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL).

Even if their income is under the QI-1 MSP level (135% buy kamagra online uk paypal FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program. In this article.

The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party buy kamagra online uk paypal health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP. Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down.

Those consumers buy kamagra online uk paypal can qualify for MIPP and have their Part B premiums reimbursed. Here is an example. Sam is age 50 and has Medicare and MBI-WPD.

She gets $1500/mo gross from Social Security Disability and also makes $400/month through work buy kamagra online uk paypal activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335.

Her countable earned income is buy kamagra online uk paypal 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP. 2.

Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare buy kamagra online uk paypal Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL.

MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income buy kamagra online uk paypal is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP.

(See GIS 18 MA/001 - 2018 Medicaid buy kamagra online uk paypal Managed Care Transition for Enrollees Gaining Medicare, #4) 3. New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP.

However, the transition buy kamagra online uk paypal time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS. The consumer is entitled to MIPP payments for at least three months during the transition.

Once the case is with the LDSS she should buy kamagra online uk paypal automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c).

These consumers should receive MIPP payments for as buy kamagra online uk paypal long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during erectile dysfunction treatment emergency their case may remain with NYSoH for more than 12 months. See here.

See GIS 18 MA/001 - 2018 Medicaid buy kamagra online uk paypal Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note address. During the erectile dysfunction treatment emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS.

They should keep the same MAGI budgeting buy kamagra online uk paypal and automatically receive MIPP payments. See GIS 20 MA/04 or this article on erectile dysfunction treatment eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC).

Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled buy kamagra online uk paypal Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN.

See this article buy kamagra online uk paypal. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums.

See page 96 of buy kamagra online uk paypal the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP. If higher than the threshold, they can be reimbursed via MIPP.

See also buy kamagra online uk paypal 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &.

1619B. 5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit.

The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019.

Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium.

Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as.

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

Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment.

Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP.

If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin.

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Kamagra gold vs kamagra

Patients Figure kamagra gold vs kamagra 1. Figure 1 kamagra gold vs kamagra. Enrollment and Randomization.

Of the 1114 kamagra gold vs kamagra patients who were assessed for eligibility, 1062 underwent randomization. 541 were assigned to the remdesivir group and 521 to the placebo group (intention-to-treat population) (Figure 1). 159 (15.0%) were categorized as having mild-to-moderate kamagra gold vs kamagra disease, and 903 (85.0%) were in the severe disease stratum.

Of those assigned to receive remdesivir, 531 patients (98.2%) received the treatment as assigned. Fifty-two patients had remdesivir treatment discontinued before day 10 because of an adverse event or a kamagra gold vs kamagra serious adverse event other than death and 10 withdrew consent. Of those assigned to receive placebo, 517 patients (99.2%) received placebo as assigned.

Seventy patients kamagra gold vs kamagra discontinued placebo before day 10 because of an adverse event or a serious adverse event other than death and 14 withdrew consent. A total of 517 patients in the remdesivir group and 508 in the placebo group completed the trial through day 29, recovered, or died. Fourteen patients kamagra gold vs kamagra who received remdesivir and 9 who received placebo terminated their participation in the trial before day 29.

A total of 54 of the patients who were in the mild-to-moderate stratum at randomization were subsequently determined to meet the criteria for severe disease, resulting in 105 patients in the mild-to-moderate disease stratum and 957 in the severe stratum. The as-treated population included 1048 patients who received the assigned treatment (532 in the remdesivir group, including one patient kamagra gold vs kamagra who had been randomly assigned to placebo and received remdesivir, and 516 in the placebo group). Table 1.

Table 1 kamagra gold vs kamagra. Demographic and Clinical Characteristics of the Patients at Baseline. The mean age of the patients was 58.9 years, kamagra gold vs kamagra and 64.4% were male (Table 1).

On the basis of the evolving epidemiology of erectile dysfunction treatment during the trial, 79.8% of patients were enrolled at sites in North America, 15.3% in Europe, and 4.9% in Asia (Table S1 in the Supplementary Appendix). Overall, 53.3% of the patients were White, 21.3% kamagra gold vs kamagra were Black, 12.7% were Asian, and 12.7% were designated as other or not reported. 250 (23.5%) were kamagra gold vs kamagra Hispanic or Latino.

Most patients had either one (25.9%) or two or more (54.5%) of the prespecified coexisting conditions at enrollment, most commonly hypertension (50.2%), obesity (44.8%), and type 2 diabetes mellitus (30.3%). The median number of days between symptom onset and randomization was 9 (interquartile range, 6 kamagra gold vs kamagra to 12) (Table S2). A total of 957 patients (90.1%) had severe disease at enrollment.

285 patients (26.8%) met category 7 criteria kamagra gold vs kamagra on the ordinal scale, 193 (18.2%) category 6, 435 (41.0%) category 5, and 138 (13.0%) category 4. Eleven patients (1.0%) had missing ordinal scale data at enrollment. All these patients kamagra gold vs kamagra discontinued the study before treatment.

During the study, 373 patients (35.6% of the 1048 patients in the as-treated population) received hydroxychloroquine and 241 (23.0%) received a glucocorticoid (Table S3). Primary Outcome Figure 2 kamagra gold vs kamagra. Figure 2.

Kaplan–Meier Estimates kamagra gold vs kamagra of Cumulative Recoveries. Cumulative recovery estimates are shown in the overall population (Panel A), in patients with a baseline score of 4 on the ordinal scale (not receiving oxygen. Panel B), kamagra gold vs kamagra in those with a baseline score of 5 (receiving oxygen.

Panel C), in those with a baseline score of 6 (receiving high-flow oxygen or noninvasive mechanical ventilation. Panel D), and in those with a baseline score of 7 (receiving mechanical ventilation or extracorporeal membrane oxygenation kamagra gold vs kamagra [ECMO]. Panel E).Table 2.

Table 2 kamagra gold vs kamagra. Outcomes Overall and According to Score on the Ordinal Scale in the Intention-to-Treat Population. Figure 3 kamagra gold vs kamagra.

Figure 3 kamagra gold vs kamagra. Time to Recovery According to Subgroup. The widths of the confidence intervals have not been adjusted for multiplicity and therefore cannot kamagra gold vs kamagra be used to infer treatment effects.

Race and ethnic group were reported by the patients.Patients in the remdesivir group had a shorter time to recovery than patients in the placebo group (median, 10 days, as compared with 15 days. Rate ratio kamagra gold vs kamagra for recovery, 1.29. 95% confidence interval [CI], 1.12 to 1.49.

P<0.001) (Figure kamagra gold vs kamagra 2 and Table 2). In the severe disease stratum (957 patients) the median time to recovery was 11 days, as compared with 18 days (rate ratio for recovery, 1.31. 95% CI, 1.12 to 1.52) (Table S4) kamagra gold vs kamagra.

The rate ratio for recovery was largest among patients with a baseline ordinal score of 5 (rate ratio for recovery, 1.45. 95% CI, 1.18 kamagra gold vs kamagra to 1.79). Among patients with a baseline score of 4 and those with a baseline score of 6, the rate ratio estimates for recovery were 1.29 (95% CI, 0.91 to 1.83) and 1.09 (95% CI, 0.76 to 1.57), respectively.

For those receiving mechanical ventilation or ECMO at enrollment (baseline ordinal kamagra gold vs kamagra score of 7), the rate ratio for recovery was 0.98 (95% CI, 0.70 to 1.36). Information on interactions of treatment with baseline ordinal score as a continuous variable is provided in Table S11. An analysis adjusting for baseline ordinal score as a covariate was conducted to kamagra gold vs kamagra evaluate the overall effect (of the percentage of patients in each ordinal score category at baseline) on the primary outcome.

This adjusted analysis produced a similar treatment-effect estimate (rate ratio for recovery, 1.26. 95% CI, kamagra gold vs kamagra 1.09 to 1.46). Patients who underwent randomization during the first 10 days after the onset of symptoms had a rate ratio for recovery of 1.37 (95% CI, 1.14 to 1.64), whereas patients who underwent randomization more than 10 days after the onset of symptoms had a rate ratio for recovery of 1.20 (95% CI, 0.94 to 1.52) (Figure 3).

The benefit of remdesivir was kamagra gold vs kamagra larger when given earlier in the illness, though the benefit persisted in most analyses of duration of symptoms (Table S6). Sensitivity analyses in which data kamagra gold vs kamagra were censored at earliest reported use of glucocorticoids or hydroxychloroquine still showed efficacy of remdesivir (9.0 days to recovery with remdesivir vs. 14.0 days to recovery with placebo.

Rate ratio, kamagra gold vs kamagra 1.28. 95% CI, 1.09 to 1.50, and 10.0 vs. 16.0 days kamagra gold vs kamagra to recovery.

Rate ratio, 1.32. 95% CI, 1.11 kamagra gold vs kamagra to 1.58, respectively) (Table S8). Key Secondary Outcome The odds of improvement in the ordinal scale score were higher in the remdesivir group, as determined by a proportional odds model at the day 15 visit, than in the placebo group (odds ratio for improvement, 1.5.

95% CI, 1.2 to 1.9, adjusted for disease severity) (Table kamagra gold vs kamagra 2 and Fig. S7). Mortality Kaplan–Meier estimates of mortality by kamagra gold vs kamagra day 15 were 6.7% in the remdesivir group and 11.9% in the placebo group (hazard ratio, 0.55.

95% CI, 0.36 to 0.83). The estimates by day 29 were kamagra gold vs kamagra 11.4% and 15.2% in two groups, respectively (hazard ratio, 0.73. 95% CI, 0.52 to 1.03).

The between-group differences in mortality varied considerably kamagra gold vs kamagra according to baseline severity (Table 2), with the largest difference seen among patients with a baseline ordinal score of 5 (hazard ratio, 0.30. 95% CI, 0.14 to 0.64). Information on interactions of treatment with baseline kamagra gold vs kamagra ordinal score with respect to mortality is provided in Table S11.

Additional Secondary Outcomes Table 3. Table 3 kamagra gold vs kamagra. Additional Secondary kamagra gold vs kamagra Outcomes.

Patients in the remdesivir group had a shorter time to improvement of one or of two categories on the ordinal scale from baseline than patients in the placebo group (one-category improvement. Median, 7 kamagra gold vs kamagra vs. 9 days.

Rate ratio kamagra gold vs kamagra for recovery, 1.23. 95% CI, 1.08 to 1.41. Two-category improvement kamagra gold vs kamagra.

Median, 11 vs. 14 days kamagra gold vs kamagra. Rate ratio, 1.29.

95% CI, 1.12 to 1.48) (Table kamagra gold vs kamagra 3). Patients in the remdesivir group had a shorter time to discharge or to a National Early Warning Score of 2 or lower than those in the placebo group (median, 8 days vs. 12 days kamagra gold vs kamagra.

Hazard ratio, 1.27. 95% CI, 1.10 to kamagra gold vs kamagra 1.46). The initial length of hospital stay was shorter in the remdesivir group than in the placebo group (median, 12 days vs.

17 days) kamagra gold vs kamagra. 5% of patients in the remdesivir group were readmitted to the hospital, as compared with 3% in the placebo group. Among the 913 patients receiving oxygen at enrollment, those in the remdesivir group continued kamagra gold vs kamagra to receive oxygen for fewer days than patients in the placebo group (median, 13 days vs.

21 days), kamagra gold vs kamagra and the incidence of new oxygen use among patients who were not receiving oxygen at enrollment was lower in the remdesivir group than in the placebo group (incidence, 36% [95% CI, 26 to 47] vs. 44% [95% CI, 33 to 57]). For the kamagra gold vs kamagra 193 patients receiving noninvasive ventilation or high-flow oxygen at enrollment, the median duration of use of these interventions was 6 days in both the remdesivir and placebo groups.

Among the 573 patients who were not receiving noninvasive ventilation, high-flow oxygen, invasive ventilation, or ECMO at baseline, the incidence of new noninvasive ventilation or high-flow oxygen use was lower in the remdesivir group than in the placebo group (17% [95% CI, 13 to 22] vs. 24% [95% kamagra gold vs kamagra CI, 19 to 30]). Among the 285 patients who were receiving mechanical ventilation or ECMO at enrollment, patients in the remdesivir group received these interventions for fewer subsequent days than those in the placebo group (median, 17 days vs.

20 days), and the incidence of new mechanical kamagra gold vs kamagra ventilation or ECMO use among the 766 patients who were not receiving these interventions at enrollment was lower in the remdesivir group than in the placebo group (13% [95% CI, 10 to 17] vs. 23% [95% CI, 19 to 27]) (Table 3). Safety Outcomes In the kamagra gold vs kamagra as-treated population, serious adverse events occurred in 131 of 532 patients (24.6%) in the remdesivir group and in 163 of 516 patients (31.6%) in the placebo group (Table S17).

There were 47 serious respiratory failure adverse events in the remdesivir group (8.8% of patients), including acute respiratory failure and the need for endotracheal intubation, and 80 in the placebo group (15.5% of patients) (Table S19). No deaths kamagra gold vs kamagra were considered by the investigators to be related to treatment assignment. Grade 3 or 4 adverse events occurred on or before day 29 in 273 patients (51.3%) in the remdesivir group and in 295 (57.2%) in the placebo group (Table S18).

41 events were judged by the investigators to be related to remdesivir and 47 events kamagra gold vs kamagra to placebo (Table S17). The most common nonserious adverse events occurring in at least 5% of all patients included decreased glomerular filtration rate, decreased hemoglobin level, decreased lymphocyte count, respiratory failure, anemia, pyrexia, hyperglycemia, increased blood creatinine level, and increased blood glucose level (Table S20). The incidence of these adverse events was generally kamagra gold vs kamagra similar in the remdesivir and placebo groups.

Crossover After the data and safety monitoring board recommended that the preliminary primary analysis report be provided to the sponsor, data on a total of 51 patients (4.8% of the total study enrollment) — 16 (3.0%) in the remdesivir group and 35 (6.7%) in the placebo group — were unblinded. 26 (74.3%) of those in the placebo kamagra gold vs kamagra group whose data were unblinded were given remdesivir. Sensitivity analyses evaluating the unblinding (patients whose treatment assignments were unblinded had their data censored at the time of unblinding) and crossover (patients in the placebo group treated with remdesivir had their data censored at the initiation of remdesivir treatment) produced results similar to those of the primary analysis (Table S9).Patients Figure 1.

Figure 1 kamagra gold vs kamagra. Enrollment and Trial kamagra gold vs kamagra Design. Table 1.

Table 1 kamagra gold vs kamagra. Characteristics of the Patients at Baseline. From June 17 through August 21, kamagra gold vs kamagra 2020, a total of 467 patients underwent randomization to receive either LY-CoV555 (317 patients) or placebo (150 patients), and the patients in the LY-CoV555 group were assigned to one of three dose subgroups.

Of the patients who had undergone randomization, 452 met the criteria for inclusion in the primary analysis (309 in the LY-CoV555 group and 143 in the placebo group). LY-CoV555 was kamagra gold vs kamagra administered to these patients in doses of 700 mg (101 patients), 2800 mg (107 patients), or 7000 mg (101 patients) (Figure 1). The two trial groups were well balanced regarding risk factors at the time of enrollment (Table 1).

Nearly 70% of the patients had at least one risk factor — an age of 65 years or older, a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of 35 or more, or at least one relevant coexisting illness — for kamagra gold vs kamagra severe erectile dysfunction treatment. After undergoing randomization, patients received an infusion of LY-CoV555 or placebo within a median of 4 days after the onset of symptoms. At the time of randomization, more than 80% of the patients had only kamagra gold vs kamagra mild symptoms.

The observed mean PCR cycle threshold (Ct) value of 23.9 on the day of infusion (equating to approximately 2.5 million RNA equivalents) matched expectations that a recently diagnosed population would have a high viral burden. The conversion from Ct value to kamagra gold vs kamagra viral load is described in Section 6.10 of the statistical analysis plan. Primary Outcome Table 2.

Table 2 kamagra gold vs kamagra. Change from Baseline in Viral Load. By day kamagra gold vs kamagra 11, the majority of patients had a substantial trend toward viral clearance, including those in the placebo group.

The observed mean decrease from baseline in the log viral load for the entire population was −3.81 (baseline mean, 6.36. Day 11 mean, kamagra gold vs kamagra 2.56). This value corresponded to a decrease by more than a factor of 4300 in the erectile dysfunction burden, for an elimination kamagra gold vs kamagra of more than 99.97% of viral RNA.

For patients who received the 2800-mg dose of LY-CoV555, the difference from placebo in the decrease from baseline was −0.53 (95% confidence interval [CI], −0.98 to −0.08. P=0.02), for a kamagra gold vs kamagra lower viral load by a factor of 3.4 (Table 2). However, smaller differences from placebo in the decrease from baseline were observed among the patients who received the 700-mg dose (−0.20.

95% CI, −0.66 to kamagra gold vs kamagra 0.25. P=0.38) and the 7000-mg dose (0.09. 95% CI, kamagra gold vs kamagra −0.37 to 0.55.

P=0.70). Secondary Viral Outcomes On day 3, among the patients who received the 2800-mg dose of LY-CoV555, the observed difference from placebo in the decrease from baseline in the mean log viral load was −0.64 kamagra gold vs kamagra (95% CI, −1.11 to −0.17) (Table 2). The other two doses of LY-CoV555 showed similar improvements in viral clearance at day 3, with a difference from placebo in the change from baseline of −0.42 (95% CI, −0.89 to 0.06) for the 700-mg dose and −0.42 (95% CI, −0.90 to 0.06) for the 7000-mg dose.

The difference from placebo in the change from baseline for kamagra gold vs kamagra the pooled doses of LY-CoV555 was −0.49 (95% CI, −0.87 to −0.11). Exploratory Measures of Viral Clearance Figure 2. Figure 2 kamagra gold vs kamagra.

erectile dysfunction Viral Load in All Patients and According to Trial Group on Day 7. Panel A shows the erectile dysfunction viral load kamagra gold vs kamagra (as measured by the cycle threshold on reverse-transcriptase–polymerase-chain-reaction assay) for all the patients who received either LY-CoV555 or placebo and for whom viral-load data were available at the time of the interim analysis. The box plots indicate the patients who were not hospitalized, and the red squares indicate those who were hospitalized.

Such hospital kamagra gold vs kamagra contact was found to be associated with a high viral load on day 7. The boxes represent interquartile ranges, with the horizontal line in each box representing the median and the whiskers showing the minimum and maximum values (excluding outliers that were more than 1.5 times the values represented at each end of the box). Panel B shows the cumulative probability that patients in each trial group would have the indicated kamagra gold vs kamagra cycle threshold of viral load on day 7.In the pooled trial population, an association was observed between slower viral clearance and more hospitalization events.

Figure 2A presents the absolute viral load among hospitalized patients (pooled across randomization strata) as well as kamagra gold vs kamagra a box plot of viral loads among nonhospitalized patients. On day 7, all the available measures of viral load among hospitalized patients were higher than the median values among the nonhospitalized patients. Among the patients with a higher viral load on kamagra gold vs kamagra day 7, the frequency of hospitalization was 12% (7 of 56 patients) among those who had a Ct value of less than 27.5, as compared with a frequency of 0.9% (3 of 340 patients) among those with a lower viral load.

(The erectile dysfunction N1 gene primer determines a Ct value that is equivalent to approximately 570,000 nucleic acid–based amplification tests per milliliter with the use of the erectile dysfunction reference panel of the Food and Drug Administration.) Since this difference was not anticipated and emerged from post hoc exploratory analysis, it is unclear whether it would be applicable to other populations. Figure 2B shows the cumulative probability that patients in each trial kamagra gold vs kamagra group would have the indicated cycle threshold of viral load on day 7. erectile dysfunction treatment–Related Hospitalization Table 3.

Table 3 kamagra gold vs kamagra. Hospitalization. At day 29, the percentage of patients who were hospitalized with erectile dysfunction treatment kamagra gold vs kamagra was 1.6% (5 of 309 patients) in the LY-CoV555 group and 6.3% (9 of 143 patients) in the placebo group (Table 3).

The percentage of patients according to the LY-CoV555 dose who were hospitalized was similar to the overall percentage, with 1.0% (1 of 101) in the 700-mg subgroup, 1.9% (2 of 107) in the 2800-mg subgroup, and 2.0% (2 of 101) in the 7000-mg subgroup. In a post hoc analysis examining hospitalization among patients who were 65 years of age or older and among those with a BMI of 35 or more, kamagra gold vs kamagra the percentage who were hospitalized was 4% (4 of 95) in the LY-CoV555 group and 15% (7 of 48) in the placebo group. Only 1 patient in the trial (in the placebo group) was admitted to an intensive care unit.

Symptom Score Figure 3 kamagra gold vs kamagra. Figure 3. Symptom Scores kamagra gold vs kamagra from Day 2 to Day 11.

Shown is the difference in the change from baseline (delta value) in symptom scores between the LY-CoV555 group and the placebo group from day 2 to day 11. The symptom kamagra gold vs kamagra scores ranged from 0 to 24 and included eight domains, each of which was graded on a scale of 0 (no symptoms) to 3 (severe symptoms). The 𝙸 bars represent 95% confidence intervals.

Details about the symptom-scoring methods are provided in the Supplementary Appendix.To assess the effect kamagra gold vs kamagra of treatment on erectile dysfunction treatment symptoms, we compared the change from baseline in symptom scores between the LY-CoV555 group and the placebo group (Figure 3 and Fig. S1 in the Supplementary Appendix) kamagra gold vs kamagra. The symptom score ranged from 0 to 24 and included eight domains that were graded from 0 (no symptoms) to 3 (severe symptoms).

From day 2 to day 6, the change in the symptom score from baseline was better in the LY-CoV555 group than in the placebo group, with values of −0.79 (95% CI, −1.35 to −0.24) on day 2, −0.57 (95% CI, −1.12 to −0.01) on day 3, −1.04 (95% CI, −1.60 to −0.49) on day 4, −0.73 (95% CI, −1.28 to kamagra gold vs kamagra −0.17) on day 5, and −0.79 (95% CI, −1.35 to −0.23) on day 6. The change from baseline in the symptom score continued to be better in the LY-CoV555 group than in the placebo group from day 7 to day 11, although by these time points most of the patients in the two groups had fully recovered or had only very mild symptoms. Safety Table 4 kamagra gold vs kamagra.

Table 4. Adverse Events kamagra gold vs kamagra. Serious adverse events occurred in none of the 309 patients in LY-CoV555 group and in 0.7% (1 of 143 patients) in the placebo group (Table 4).

The percentage of patients who had an adverse event during treatment was 22.3% (69 of 309) in the LY-CoV555 group and 24.5% (35 of 143) kamagra gold vs kamagra in the placebo group. Diarrhea was reported in 3.2% of the patients (10 of 309) in the LY-CoV555 group and in 4.9% (7 of 143) in the placebo group. Vomiting was reported in 1.6% (5 of 309) and 2.8% (4 of 143), kamagra gold vs kamagra respectively.

The most frequently reported adverse event in the LY-CoV555 group was nausea (3.9%), whereas diarrhea (4.9%) was the most frequent adverse event in the placebo group. Infusion-related reactions were reported in 2.3% of the patients (7 of 309) in the LY-CoV555 group and in 1.4% (2 of 143) in kamagra gold vs kamagra the placebo group. Most of these events — which included pruritus, flushing, rash, and facial swelling — occurred during the infusion and were reported as mild in severity.

No changes in kamagra gold vs kamagra vital signs were noted during these reactions, and the infusions were completed in all instances. In some patients, antihistamines were administered to help resolve symptoms. We used standard methods kamagra gold vs kamagra to sequence all viral samples to determine the potential for resistance-associated treatment failure.

Accordingly, we assessed the prevalence of variants with resistance to LY-CoV555 that were predicted in preclinical studies. Such variants were present with an allele fraction of more than 20% in at least one sample at any time point in 8.2% of the patients in the LY-CoV555 group (6.3% in the 700-mg subgroup, 8.4% in the 2800-mg subgroup, and 9.9% in the 7000-mg subgroup) and in 6.1% of those in kamagra gold vs kamagra the placebo group. The clinical importance of the presence of these variants is not known.As erectile dysfunction continues its global spread, it’s possible that one of the pillars of erectile dysfunction treatment kamagra control — universal facial masking — might help reduce the severity kamagra gold vs kamagra of disease and ensure that a greater proportion of new s are asymptomatic.

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

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

Indeed, down-regulating immunopathology is one mechanism by which dexamethasone improves outcomes in severe erectile dysfunction treatment . As proof kamagra gold vs kamagra of concept of viral inocula influencing disease manifestations, higher doses of administered kamagra led to more severe manifestations of erectile dysfunction treatment in a Syrian hamster model of erectile dysfunction .4If the viral inoculum matters in determining the severity of erectile dysfunction , an additional hypothesized reason for wearing facial masks would be to reduce the viral inoculum to which the wearer is exposed and the subsequent clinical impact of the disease. Since masks can filter out some kamagra-containing droplets (with filtering capacity determined by mask type),2 masking might reduce the inoculum that an exposed person inhales.

If this theory bears out, population-wide masking, with any type of mask that increases acceptability and adherence,2 might contribute to increasing the proportion of erectile dysfunction s that are kamagra gold vs kamagra asymptomatic. The typical rate of asymptomatic with erectile dysfunction was estimated to be 40% by the CDC in mid-July, but asymptomatic rates are reported to be higher than 80% in settings with universal facial masking, which provides observational evidence for this hypothesis. Countries that have adopted population-wide masking have fared better in terms of rates of severe erectile dysfunction treatment-related illnesses and death, which, in environments with limited testing, suggests a shift kamagra gold vs kamagra from symptomatic to asymptomatic s.

Another experiment in the Syrian hamster model simulated surgical masking of the animals and showed that with simulated masking, hamsters were less likely to get infected, and if they did get infected, they either were asymptomatic or had milder symptoms than unmasked hamsters.The most obvious way to spare society the devastating effects of erectile dysfunction treatment is to promote measures to reduce both transmission and severity of illness. But erectile dysfunction is highly transmissible, cannot be contained by syndromic-based surveillance alone,1 and is proving difficult to eradicate, even in regions that implemented strict initial kamagra gold vs kamagra control measures. Efforts to increase testing and containment in the United States have been ongoing and variably successful, owing in part to the recent increase in demand for testing.The hopes for treatments are pinned not just on prevention.

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

In two kamagra gold vs kamagra recent outbreaks in U.S. Food-processing plants, where all workers were issued masks each day and were required to wear them, the proportion of asymptomatic s among the more than 500 people who became infected was 95%, with only 5% in each outbreak experiencing mild-to-moderate symptoms.3 Case-fatality rates in countries with mandatory or enforced population-wide masking have remained low, even with resurgences of cases after lockdowns were lifted.Variolation was a process whereby people who were susceptible to smallpox were inoculated with material taken from a vesicle of a person with smallpox, with the intent of causing a mild and subsequent immunity. Variolation was practiced only until the introduction of the variola treatment, kamagra gold vs kamagra which ultimately eradicated smallpox.

Despite concerns regarding safety, worldwide distribution, and eventual uptake, the world has high hopes for a highly effective erectile dysfunction treatment, and as of early September, 34 treatment candidates were in clinical evaluation, with hundreds more in development.While we await the results of treatment trials, however, any public health measure that could increase the proportion of asymptomatic erectile dysfunction s may both make the less deadly and increase population-wide immunity without severe illnesses and deaths. Re with erectile dysfunction kamagra gold vs kamagra seems to be rare, despite more than 8 months of circulation worldwide and as suggested by a macaque model. The scientific community has been clarifying for some time the humoral and cell-mediated components of the adaptive immune response to erectile dysfunction and the inadequacy of antibody-based seroprevalence studies to estimate the level of more durable T-cell and memory B-cell immunity to erectile dysfunction.

Promising data have been emerging in recent weeks suggesting that strong cell-mediated immunity results from even mild or asymptomatic erectile dysfunction ,5 so any public health strategy that could reduce the severity of disease should increase population-wide immunity as well.To test our hypothesis that population-wide masking is one of those kamagra gold vs kamagra strategies, we need further studies comparing the rate of asymptomatic in areas with and areas without universal masking. To test the variolation hypothesis, we will need more studies comparing the strength and durability of erectile dysfunction–specific T-cell immunity between people with asymptomatic and those with symptomatic , as well as a demonstration of the natural slowing of erectile dysfunction spread in areas with a high proportion of asymptomatic s.Ultimately, combating the kamagra will involve driving down both transmission rates and severity of disease. Increasing evidence suggests that population-wide facial masking might benefit both components kamagra gold vs kamagra of the response.erectile dysfunction treatment has created a crisis throughout the world.

This crisis has produced a test of leadership. With no good options to combat a novel pathogen, kamagra gold vs kamagra countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test.

They have taken a crisis kamagra gold vs kamagra and turned it into a tragedy.The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in erectile dysfunction treatment cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country kamagra gold vs kamagra with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000.

erectile dysfunction treatment is an overwhelming challenge, and many factors contribute to its severity. But the one we can control kamagra gold vs kamagra is how we behave. And in the United States we have consistently behaved poorly.We know that we could have done better.

China, faced with the first kamagra gold vs kamagra outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared kamagra gold vs kamagra with more than 500 per million in the United States. Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks.

And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating kamagra gold vs kamagra the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prekamagra level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.Why has the United States handled this kamagra so badly?. We have failed at almost kamagra gold vs kamagra every step.

We had ample warning, but when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way kamagra gold vs kamagra behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have.2 Moreover, a lack of emphasis on developing capacity has meant that U.S.

Test results are often long delayed, rendering the results useless for disease control.Although we tend to focus on technology, most of the interventions that have large effects are not kamagra gold vs kamagra complicated. The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing have in many places been lackadaisical at best, with loosening kamagra gold vs kamagra of restrictions long before adequate disease control had been achieved.

And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective control measures. The government has appropriately invested heavily in treatment development, but its kamagra gold vs kamagra rhetoric has politicized the development process and led to growing public distrust.The United States came into this crisis with enormous advantages. Along with tremendous manufacturing capacity, we have a biomedical research system that is the envy of the world.

We have enormous kamagra gold vs kamagra expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and even denigrate experts.The response of our nation’s leaders has kamagra gold vs kamagra been consistently inadequate.

The federal government has largely abandoned disease control to the states. Governors have varied in kamagra gold vs kamagra their responses, not so much by party as by competence. But whatever their competence, governors do not have the tools that kamagra gold vs kamagra Washington controls.

Instead of using those tools, the federal government has undermined them. The Centers for Disease Control and Prevention, which was the world’s leading disease response organization, has been eviscerated and has kamagra gold vs kamagra suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in treatment development but have been excluded from much crucial government decision making.

And the Food and Drug Administration has been shamefully kamagra gold vs kamagra politicized,3 appearing to respond to pressure from the administration rather than scientific evidence. Our current leaders have undercut trust in science and in government,4 causing damage that will certainly outlast them. Instead of relying on expertise, the administration has kamagra gold vs kamagra turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.Let’s be clear about the cost of not taking even simple measures.

An outbreak that has disproportionately affected communities of color has exacerbated the tensions associated with inequality. Many of our children are missing school at critical times in their social kamagra gold vs kamagra and intellectual development. The hard work of health care professionals, who have put their lives on the line, has not been used wisely.

Our current leadership takes pride in the economy, but while most of the world has opened up kamagra gold vs kamagra to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs. And more than 200,000 Americans have died. Some deaths kamagra gold vs kamagra from erectile dysfunction treatment were unavoidable.

But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a kamagra that has already killed more Americans than any conflict since World War II.Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for kamagra gold vs kamagra their actions. But this election gives us the power to render judgment.

Reasonable people will certainly disagree about kamagra gold vs kamagra the many political positions taken by candidates. But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent.

We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs..

Patients Figure buy kamagra online uk paypal 1. Figure 1 buy kamagra online uk paypal. Enrollment and Randomization. Of the 1114 patients who were assessed for eligibility, buy kamagra online uk paypal 1062 underwent randomization. 541 were assigned to the remdesivir group and 521 to the placebo group (intention-to-treat population) (Figure 1).

159 (15.0%) were categorized as having mild-to-moderate disease, and 903 (85.0%) were in the severe disease buy kamagra online uk paypal stratum. Of those assigned to receive remdesivir, 531 patients (98.2%) received the treatment as assigned. Fifty-two patients had remdesivir treatment discontinued before day 10 because of an adverse event or a buy kamagra online uk paypal serious adverse event other than death and 10 withdrew consent. Of those assigned to receive placebo, 517 patients (99.2%) received placebo as assigned. Seventy patients discontinued placebo buy kamagra online uk paypal before day 10 because of an adverse event or a serious adverse event other than death and 14 withdrew consent.

A total of 517 patients in the remdesivir group and 508 in the placebo group completed the trial through day 29, recovered, or died. Fourteen patients who received remdesivir buy kamagra online uk paypal and 9 who received placebo terminated their participation in the trial before day 29. A total of 54 of the patients who were in the mild-to-moderate stratum at randomization were subsequently determined to meet the criteria for severe disease, resulting in 105 patients in the mild-to-moderate disease stratum and 957 in the severe stratum. The as-treated population included 1048 patients who received the assigned treatment (532 in the remdesivir group, including one patient who had been randomly assigned to placebo buy kamagra online uk paypal and received remdesivir, and 516 in the placebo group). Table 1.

Table 1 buy kamagra online uk paypal. Demographic and Clinical Characteristics of the Patients at Baseline. The mean age of the patients was 58.9 years, and buy kamagra online uk paypal 64.4% were male (Table 1). On the basis of the evolving epidemiology of erectile dysfunction treatment during the trial, 79.8% of patients were enrolled at sites in North America, 15.3% in Europe, and 4.9% in Asia (Table S1 in the Supplementary Appendix). Overall, 53.3% buy kamagra online uk paypal of the patients were White, 21.3% were Black, 12.7% were Asian, and 12.7% were designated as other or not reported.

250 (23.5%) were Hispanic or Latino buy kamagra online uk paypal. Most patients had either one (25.9%) or two or more (54.5%) of the prespecified coexisting conditions at enrollment, most commonly hypertension (50.2%), obesity (44.8%), and type 2 diabetes mellitus (30.3%). The median number of days between symptom onset and randomization was 9 (interquartile buy kamagra online uk paypal range, 6 to 12) (Table S2). A total of 957 patients (90.1%) had severe disease at enrollment. 285 patients (26.8%) buy kamagra online uk paypal met category 7 criteria on the ordinal scale, 193 (18.2%) category 6, 435 (41.0%) category 5, and 138 (13.0%) category 4.

Eleven patients (1.0%) had missing ordinal scale data at enrollment. All these patients discontinued the study buy kamagra online uk paypal before treatment. During the study, 373 patients (35.6% of the 1048 patients in the as-treated population) received hydroxychloroquine and 241 (23.0%) received a glucocorticoid (Table S3). Primary Outcome buy kamagra online uk paypal Figure 2. Figure 2.

Kaplan–Meier Estimates of Cumulative buy kamagra online uk paypal Recoveries. Cumulative recovery estimates are shown in the overall population (Panel A), in patients with a baseline score of 4 on the ordinal scale (not receiving oxygen. Panel B), in those buy kamagra online uk paypal with a baseline score of 5 (receiving oxygen. Panel C), in those with a baseline score of 6 (receiving high-flow oxygen or noninvasive mechanical ventilation. Panel D), buy kamagra online uk paypal and in those with a baseline score of 7 (receiving mechanical ventilation or extracorporeal membrane oxygenation [ECMO].

Panel E).Table 2. Table 2 buy kamagra online uk paypal. Outcomes Overall and According to Score on the Ordinal Scale in the Intention-to-Treat Population. Figure 3 buy kamagra online uk paypal. Figure 3 buy kamagra online uk paypal.

Time to Recovery According to Subgroup. The widths of the confidence buy kamagra online uk paypal intervals have not been adjusted for multiplicity and therefore cannot be used to infer treatment effects. Race and ethnic group were reported by the patients.Patients in the remdesivir group had a shorter time to recovery than patients in the placebo group (median, 10 days, as compared with 15 days. Rate ratio buy kamagra online uk paypal for recovery, 1.29. 95% confidence interval [CI], 1.12 to 1.49.

P<0.001) (Figure buy kamagra online uk paypal 2 and Table 2). In the severe disease stratum (957 patients) the median time to recovery was 11 days, as compared with 18 days (rate ratio for recovery, 1.31. 95% CI, 1.12 to buy kamagra online uk paypal 1.52) (Table S4). The rate ratio for recovery was largest among patients with a baseline ordinal score of 5 (rate ratio for recovery, 1.45. 95% CI, buy kamagra online uk paypal 1.18 to 1.79).

Among patients with a baseline score of 4 and those with a baseline score of 6, the rate ratio estimates for recovery were 1.29 (95% CI, 0.91 to 1.83) and 1.09 (95% CI, 0.76 to 1.57), respectively. For those receiving mechanical ventilation or ECMO at enrollment (baseline ordinal score of 7), the rate ratio for recovery was buy kamagra online uk paypal 0.98 (95% CI, 0.70 to 1.36). Information on interactions of treatment with baseline ordinal score as a continuous variable is provided in Table S11. An analysis adjusting for baseline ordinal score buy kamagra online uk paypal as a covariate was conducted to evaluate the overall effect (of the percentage of patients in each ordinal score category at baseline) on the primary outcome. This adjusted analysis produced a similar treatment-effect estimate (rate ratio for recovery, 1.26.

95% CI, 1.09 buy kamagra online uk paypal to 1.46). Patients who underwent randomization during the first 10 days after the onset of symptoms had a rate ratio for recovery of 1.37 (95% CI, 1.14 to 1.64), whereas patients who underwent randomization more than 10 days after the onset of symptoms had a rate ratio for recovery of 1.20 (95% CI, 0.94 to 1.52) (Figure 3). The benefit of remdesivir was larger when given earlier in the illness, though the benefit persisted in most analyses of buy kamagra online uk paypal duration of symptoms (Table S6). Sensitivity analyses in which data were buy kamagra online uk paypal censored at earliest reported use of glucocorticoids or hydroxychloroquine still showed efficacy of remdesivir (9.0 days to recovery with remdesivir vs. 14.0 days to recovery with placebo.

Rate ratio, 1.28 buy kamagra online uk paypal. 95% CI, 1.09 to 1.50, and 10.0 vs. 16.0 days buy kamagra online uk paypal to recovery. Rate ratio, 1.32. 95% CI, buy kamagra online uk paypal 1.11 to 1.58, respectively) (Table S8).

Key Secondary Outcome The odds of improvement in the ordinal scale score were higher in the remdesivir group, as determined by a proportional odds model at the day 15 visit, than in the placebo group (odds ratio for improvement, 1.5. 95% CI, 1.2 to 1.9, adjusted for disease severity) buy kamagra online uk paypal (Table 2 and Fig. S7). Mortality Kaplan–Meier buy kamagra online uk paypal estimates of mortality by day 15 were 6.7% in the remdesivir group and 11.9% in the placebo group (hazard ratio, 0.55. 95% CI, 0.36 to 0.83).

The estimates by day 29 were buy kamagra online uk paypal 11.4% and 15.2% in two groups, respectively (hazard ratio, 0.73. 95% CI, 0.52 to 1.03). The between-group differences in mortality varied considerably according buy kamagra online uk paypal to baseline severity (Table 2), with the largest difference seen among patients with a baseline ordinal score of 5 (hazard ratio, 0.30. 95% CI, 0.14 to 0.64). Information on interactions of treatment with baseline buy kamagra online uk paypal ordinal score with respect to mortality is provided in Table S11.

Additional Secondary Outcomes Table 3. Table 3 buy kamagra online uk paypal. Additional Secondary buy kamagra online uk paypal Outcomes. Patients in the remdesivir group had a shorter time to improvement of one or of two categories on the ordinal scale from baseline than patients in the placebo group (one-category improvement. Median, 7 buy kamagra online uk paypal vs.

9 days. Rate ratio for recovery, 1.23 buy kamagra online uk paypal. 95% CI, 1.08 to 1.41. Two-category improvement buy kamagra online uk paypal. Median, 11 vs.

14 days buy kamagra online uk paypal. Rate ratio, 1.29. 95% CI, 1.12 to 1.48) buy kamagra online uk paypal (Table 3). Patients in the remdesivir group had a shorter time to discharge or to a National Early Warning Score of 2 or lower than those in the placebo group (median, 8 days vs. 12 days buy kamagra online uk paypal.

Hazard ratio, 1.27. 95% CI, 1.10 to buy kamagra online uk paypal 1.46). The initial length of hospital stay was shorter in the remdesivir group than in the placebo group (median, 12 days vs. 17 days) buy kamagra online uk paypal. 5% of patients in the remdesivir group were readmitted to the hospital, as compared with 3% in the placebo group.

Among the buy kamagra online uk paypal 913 patients receiving oxygen at enrollment, those in the remdesivir group continued to receive oxygen for fewer days than patients in the placebo group (median, 13 days vs. 21 days), and the incidence of new oxygen use among patients who were not receiving buy kamagra online uk paypal oxygen at enrollment was lower in the remdesivir group than in the placebo group (incidence, 36% [95% CI, 26 to 47] vs. 44% [95% CI, 33 to 57]). For the 193 patients receiving noninvasive ventilation or high-flow oxygen at buy kamagra online uk paypal enrollment, the median duration of use of these interventions was 6 days in both the remdesivir and placebo groups. Among the 573 patients who were not receiving noninvasive ventilation, high-flow oxygen, invasive ventilation, or ECMO at baseline, the incidence of new noninvasive ventilation or high-flow oxygen use was lower in the remdesivir group than in the placebo group (17% [95% CI, 13 to 22] vs.

24% [95% CI, 19 to buy kamagra online uk paypal 30]). Among the 285 patients who were receiving mechanical ventilation or ECMO at enrollment, patients in the remdesivir group received these interventions for fewer subsequent days than those in the placebo group (median, 17 days vs. 20 days), and the incidence buy kamagra online uk paypal of new mechanical ventilation or ECMO use among the 766 patients who were not receiving these interventions at enrollment was lower in the remdesivir group than in the placebo group (13% [95% CI, 10 to 17] vs. 23% [95% CI, 19 to 27]) (Table 3). Safety Outcomes In the as-treated population, serious adverse events occurred in 131 of 532 patients (24.6%) in the remdesivir group and in 163 of 516 patients (31.6%) in the placebo buy kamagra online uk paypal group (Table S17).

There were 47 serious respiratory failure adverse events in the remdesivir group (8.8% of patients), including acute respiratory failure and the need for endotracheal intubation, and 80 in the placebo group (15.5% of patients) (Table S19). No deaths buy kamagra online uk paypal were considered by the investigators to be related to treatment assignment. Grade 3 or 4 adverse events occurred on or before day 29 in 273 patients (51.3%) in the remdesivir group and in 295 (57.2%) in the placebo group (Table S18). 41 events were judged by the investigators to be related to buy kamagra online uk paypal remdesivir and 47 events to placebo (Table S17). The most common nonserious adverse events occurring in at least 5% of all patients included decreased glomerular filtration rate, decreased hemoglobin level, decreased lymphocyte count, respiratory failure, anemia, pyrexia, hyperglycemia, increased blood creatinine level, and increased blood glucose level (Table S20).

The incidence of buy kamagra online uk paypal these adverse events was generally similar in the remdesivir and placebo groups. Crossover After the data and safety monitoring board recommended that the preliminary primary analysis report be provided to the sponsor, data on a total of 51 patients (4.8% of the total study enrollment) — 16 (3.0%) in the remdesivir group and 35 (6.7%) in the placebo group — were unblinded. 26 (74.3%) of those in the placebo group whose data were unblinded were buy kamagra online uk paypal given remdesivir. Sensitivity analyses evaluating the unblinding (patients whose treatment assignments were unblinded had their data censored at the time of unblinding) and crossover (patients in the placebo group treated with remdesivir had their data censored at the initiation of remdesivir treatment) produced results similar to those of the primary analysis (Table S9).Patients Figure 1. Figure 1 buy kamagra online uk paypal.

Enrollment and Trial buy kamagra online uk paypal Design. Table 1. Table 1 buy kamagra online uk paypal. Characteristics of the Patients at Baseline. From June 17 through August 21, 2020, a total of 467 patients underwent randomization to receive either LY-CoV555 (317 patients) or placebo (150 patients), and the patients in the LY-CoV555 buy kamagra online uk paypal group were assigned to one of three dose subgroups.

Of the patients who had undergone randomization, 452 met the criteria for inclusion in the primary analysis (309 in the LY-CoV555 group and 143 in the placebo group). LY-CoV555 was administered to these patients in buy kamagra online uk paypal doses of 700 mg (101 patients), 2800 mg (107 patients), or 7000 mg (101 patients) (Figure 1). The two trial groups were well balanced regarding risk factors at the time of enrollment (Table 1). Nearly 70% of the patients had at least one risk factor — an age of 65 years or buy kamagra online uk paypal older, a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of 35 or more, or at least one relevant coexisting illness — for severe erectile dysfunction treatment. After undergoing randomization, patients received an infusion of LY-CoV555 or placebo within a median of 4 days after the onset of symptoms.

At the time of randomization, more than buy kamagra online uk paypal 80% of the patients had only mild symptoms. The observed mean PCR cycle threshold (Ct) value of 23.9 on the day of infusion (equating to approximately 2.5 million RNA equivalents) matched expectations that a recently diagnosed population would have a high viral burden. The conversion from Ct value buy kamagra online uk paypal to viral load is described in Section 6.10 of the statistical analysis plan. Primary Outcome Table 2. Table 2 buy kamagra online uk paypal.

Change from Baseline in Viral Load. By day 11, the majority of patients had a substantial trend toward viral clearance, buy kamagra online uk paypal including those in the placebo group. The observed mean decrease from baseline in the log viral load for the entire population was −3.81 (baseline mean, 6.36. Day 11 mean, buy kamagra online uk paypal 2.56). This value corresponded to a decrease by more than a factor of 4300 in the buy kamagra online uk paypal erectile dysfunction burden, for an elimination of more than 99.97% of viral RNA.

For patients who received the 2800-mg dose of LY-CoV555, the difference from placebo in the decrease from baseline was −0.53 (95% confidence interval [CI], −0.98 to −0.08. P=0.02), for a lower viral load by a factor of 3.4 buy kamagra online uk paypal (Table 2). However, smaller differences from placebo in the decrease from baseline were observed among the patients who received the 700-mg dose (−0.20. 95% CI, −0.66 to 0.25 buy kamagra online uk paypal. P=0.38) and the 7000-mg dose (0.09.

95% CI, −0.37 buy kamagra online uk paypal to 0.55. P=0.70). Secondary Viral Outcomes On day 3, among the patients who received the 2800-mg dose of LY-CoV555, the observed difference from placebo buy kamagra online uk paypal in the decrease from baseline in the mean log viral load was −0.64 (95% CI, −1.11 to −0.17) (Table 2). The other two doses of LY-CoV555 showed similar improvements in viral clearance at day 3, with a difference from placebo in the change from baseline of −0.42 (95% CI, −0.89 to 0.06) for the 700-mg dose and −0.42 (95% CI, −0.90 to 0.06) for the 7000-mg dose. The difference from placebo in the change from buy kamagra online uk paypal baseline for the pooled doses of LY-CoV555 was −0.49 (95% CI, −0.87 to −0.11).

Exploratory Measures of Viral Clearance Figure 2. Figure 2 buy kamagra online uk paypal. erectile dysfunction Viral Load in All Patients and According to Trial Group on Day 7. Panel A buy kamagra online uk paypal shows the erectile dysfunction viral load (as measured by the cycle threshold on reverse-transcriptase–polymerase-chain-reaction assay) for all the patients who received either LY-CoV555 or placebo and for whom viral-load data were available at the time of the interim analysis. The box plots indicate the patients who were not hospitalized, and the red squares indicate those who were hospitalized.

Such hospital buy kamagra online uk paypal contact was found to be associated with a high viral load on day 7. The boxes represent interquartile ranges, with the horizontal line in each box representing the median and the whiskers showing the minimum and maximum values (excluding outliers that were more than 1.5 times the values represented at each end of the box). Panel B shows the cumulative probability that patients in each trial group would have the indicated cycle threshold of viral load on day 7.In the pooled trial population, an association was observed between buy kamagra online uk paypal slower viral clearance and more hospitalization events. Figure 2A buy kamagra online uk paypal presents the absolute viral load among hospitalized patients (pooled across randomization strata) as well as a box plot of viral loads among nonhospitalized patients. On day 7, all the available measures of viral load among hospitalized patients were higher than the median values among the nonhospitalized patients.

Among the patients with a higher viral load on day 7, the frequency of hospitalization was 12% (7 of 56 patients) among those who had a buy kamagra online uk paypal Ct value of less than 27.5, as compared with a frequency of 0.9% (3 of 340 patients) among those with a lower viral load. (The erectile dysfunction N1 gene primer determines a Ct value that is equivalent to approximately 570,000 nucleic acid–based amplification tests per milliliter with the use of the erectile dysfunction reference panel of the Food and Drug Administration.) Since this difference was not anticipated and emerged from post hoc exploratory analysis, it is unclear whether it would be applicable to other populations. Figure 2B shows the cumulative buy kamagra online uk paypal probability that patients in each trial group would have the indicated cycle threshold of viral load on day 7. erectile dysfunction treatment–Related Hospitalization Table 3. Table 3 buy kamagra online uk paypal.

Hospitalization. At day 29, the percentage of patients who were hospitalized with erectile dysfunction treatment was 1.6% (5 of 309 patients) in the LY-CoV555 group buy kamagra online uk paypal and 6.3% (9 of 143 patients) in the placebo group (Table 3). The percentage of patients according to the LY-CoV555 dose who were hospitalized was similar to the overall percentage, with 1.0% (1 of 101) in the 700-mg subgroup, 1.9% (2 of 107) in the 2800-mg subgroup, and 2.0% (2 of 101) in the 7000-mg subgroup. In a post hoc analysis buy kamagra online uk paypal examining hospitalization among patients who were 65 years of age or older and among those with a BMI of 35 or more, the percentage who were hospitalized was 4% (4 of 95) in the LY-CoV555 group and 15% (7 of 48) in the placebo group. Only 1 patient in the trial (in the placebo group) was admitted to an intensive care unit.

Symptom Score Figure 3 buy kamagra online uk paypal. Figure 3. Symptom Scores buy kamagra online uk paypal from Day 2 to Day 11. Shown is the difference in the change from baseline (delta value) in symptom scores between the LY-CoV555 group and the placebo group from day 2 to day 11. The symptom scores ranged from 0 to buy kamagra online uk paypal 24 and included eight domains, each of which was graded on a scale of 0 (no symptoms) to 3 (severe symptoms).

The 𝙸 bars represent 95% confidence intervals. Details about the symptom-scoring methods are provided in the Supplementary Appendix.To assess the effect of treatment on erectile dysfunction treatment symptoms, we compared the change from baseline in symptom scores buy kamagra online uk paypal between the LY-CoV555 group and the placebo group (Figure 3 and Fig. S1 in the Supplementary Appendix) buy kamagra online uk paypal. The symptom score ranged from 0 to 24 and included eight domains that were graded from 0 (no symptoms) to 3 (severe symptoms). From day 2 to day 6, the change in the symptom score from baseline was better in the LY-CoV555 group than in the placebo group, with values of −0.79 (95% CI, −1.35 to −0.24) on day 2, −0.57 (95% CI, −1.12 to −0.01) on day 3, −1.04 (95% CI, −1.60 to −0.49) on day 4, −0.73 (95% CI, −1.28 to −0.17) buy kamagra online uk paypal on day 5, and −0.79 (95% CI, −1.35 to −0.23) on day 6.

The change from baseline in the symptom score continued to be better in the LY-CoV555 group than in the placebo group from day 7 to day 11, although by these time points most of the patients in the two groups had fully recovered or had only very mild symptoms. Safety Table 4 buy kamagra online uk paypal. Table 4. Adverse Events buy kamagra online uk paypal. Serious adverse events occurred in none of the 309 patients in LY-CoV555 group and in 0.7% (1 of 143 patients) in the placebo group (Table 4).

The percentage of buy kamagra online uk paypal patients who had an adverse event during treatment was 22.3% (69 of 309) in the LY-CoV555 group and 24.5% (35 of 143) in the placebo group. Diarrhea was reported in 3.2% of the patients (10 of 309) in the LY-CoV555 group and in 4.9% (7 of 143) in the placebo group. Vomiting was buy kamagra online uk paypal reported in 1.6% (5 of 309) and 2.8% (4 of 143), respectively. The most frequently reported adverse event in the LY-CoV555 group was nausea (3.9%), whereas diarrhea (4.9%) was the most frequent adverse event in the placebo group. Infusion-related reactions buy kamagra online uk paypal were reported in 2.3% of the patients (7 of 309) in the LY-CoV555 group and in 1.4% (2 of 143) in the placebo group.

Most of these events — which included pruritus, flushing, rash, and facial swelling — occurred during the infusion and were reported as mild in severity. No changes in vital signs were noted buy kamagra online uk paypal during these reactions, and the infusions were completed in all instances. In some patients, antihistamines were administered to help resolve symptoms. We used standard methods to sequence all viral samples to determine the potential buy kamagra online uk paypal for resistance-associated treatment failure. Accordingly, we assessed the prevalence of variants with resistance to LY-CoV555 that were predicted in preclinical studies.

Such variants were present with an allele fraction of more than 20% in at least one sample at any time point in 8.2% of the patients in the LY-CoV555 group (6.3% in the 700-mg subgroup, 8.4% in buy kamagra online uk paypal the 2800-mg subgroup, and 9.9% in the 7000-mg subgroup) and in 6.1% of those in the placebo group. The clinical importance of the presence of these variants is not known.As erectile dysfunction continues its global spread, it’s possible that one of the pillars of erectile dysfunction treatment kamagra control — universal facial masking — might help reduce the severity of disease and ensure that a greater proportion of new s are buy kamagra online uk paypal asymptomatic. If this hypothesis is borne out, universal masking could become a form of “variolation” that would generate immunity and thereby slow the spread of the kamagra in the United States and elsewhere, as we await a treatment.One important reason for population-wide facial masking became apparent in March, when reports started to circulate describing the high rates of erectile dysfunction viral shedding from the noses and mouths of patients who were presymptomatic or asymptomatic — shedding rates equivalent to those among symptomatic patients.1 Universal facial masking seemed to be a possible way to prevent transmission from asymptomatic infected people. The Centers for Disease Control and Prevention (CDC) therefore recommended on April 3 that the public wear cloth face coverings in areas with high rates of community transmission — buy kamagra online uk paypal a recommendation that has been unevenly followed across the United States.Past evidence related to other respiratory kamagraes indicates that facial masking can also protect the wearer from becoming infected, by blocking viral particles from entering the nose and mouth.2 Epidemiologic investigations conducted around the world — especially in Asian countries that became accustomed to population-wide masking during the 2003 SARS kamagra — have suggested that there is a strong relationship between public masking and kamagra control. Recent data from Boston demonstrate that erectile dysfunction s decreased among health care workers after universal masking was implemented in municipal hospitals in late March.erectile dysfunction has the protean ability to cause myriad clinical manifestations, ranging from a complete lack of symptoms to pneumonia, acute respiratory distress syndrome, and death.

Recent virologic, epidemiologic, and ecologic data have led to the hypothesis that facial masking may also reduce the severity of disease among people who buy kamagra online uk paypal do become infected.3 This possibility is consistent with a long-standing theory of viral pathogenesis, which holds that the severity of disease is proportionate to the viral inoculum received. Since 1938, researchers have explored, primarily in animal models, the concept of the lethal dose of a kamagra — or the dose at which 50% of exposed hosts die (LD50). With viral s in which host immune responses play a predominant role in viral pathogenesis, such as erectile dysfunction, high doses of viral inoculum can overwhelm and dysregulate innate immune defenses, increasing the buy kamagra online uk paypal severity of disease. Indeed, down-regulating immunopathology is one mechanism by which dexamethasone improves outcomes in severe erectile dysfunction treatment . As proof of concept of viral inocula influencing disease manifestations, higher doses of administered kamagra led to more severe manifestations of erectile dysfunction treatment in a Syrian hamster model of erectile dysfunction .4If the viral inoculum matters in determining the severity of erectile dysfunction , an additional hypothesized reason for wearing facial buy kamagra online uk paypal masks would be to reduce the viral inoculum to which the wearer is exposed and the subsequent clinical impact of the disease.

Since masks can filter out some kamagra-containing droplets (with filtering capacity determined by mask type),2 masking might reduce the inoculum that an exposed person inhales. If this theory bears out, population-wide masking, with any type of mask that increases acceptability and adherence,2 might contribute to increasing the proportion of erectile dysfunction s that are buy kamagra online uk paypal asymptomatic. The typical rate of asymptomatic with erectile dysfunction was estimated to be 40% by the CDC in mid-July, but asymptomatic rates are reported to be higher than 80% in settings with universal facial masking, which provides observational evidence for this hypothesis. Countries that have adopted population-wide masking have fared better buy kamagra online uk paypal in terms of rates of severe erectile dysfunction treatment-related illnesses and death, which, in environments with limited testing, suggests a shift from symptomatic to asymptomatic s. Another experiment in the Syrian hamster model simulated surgical masking of the animals and showed that with simulated masking, hamsters were less likely to get infected, and if they did get infected, they either were asymptomatic or had milder symptoms than unmasked hamsters.The most obvious way to spare society the devastating effects of erectile dysfunction treatment is to promote measures to reduce both transmission and severity of illness.

But erectile dysfunction is highly transmissible, cannot be contained by syndromic-based surveillance alone,1 and is proving difficult to eradicate, even buy kamagra online uk paypal in regions that implemented strict initial control measures. Efforts to increase testing and containment in the United States have been ongoing and variably successful, owing in part to the recent increase in demand for testing.The hopes for treatments are pinned not just on prevention. Most treatment trials include a secondary outcome of decreasing the severity of illness, since increasing the proportion of cases in which disease is mild or asymptomatic would be a public health victory buy kamagra online uk paypal. Universal masking seems to reduce the rate of new s. We hypothesize that by reducing the viral inoculum, it would also increase the proportion of infected people who remain asymptomatic.3In an outbreak on buy kamagra online uk paypal a closed Argentinian cruise ship, for example, where passengers were provided with surgical masks and staff with N95 masks, the rate of asymptomatic was 81% (as compared with 20% in earlier cruise ship outbreaks without universal masking).

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

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

With no good options to combat a novel pathogen, countries were buy kamagra online uk paypal forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.The magnitude of this buy kamagra online uk paypal failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in erectile dysfunction treatment cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the buy kamagra online uk paypal rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000.

erectile dysfunction treatment is an overwhelming challenge, and many factors contribute to its severity. But the one we can control is how buy kamagra online uk paypal we behave. And in the United States we have consistently behaved poorly.We know that we could have done better. China, faced buy kamagra online uk paypal with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and buy kamagra online uk paypal reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States.

Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has buy kamagra online uk paypal allowed that country to limit the time of closure and to largely reopen society to a prekamagra level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.Why has the United States handled this kamagra so badly?. We have failed at almost every buy kamagra online uk paypal step. We had ample warning, but when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public.

And we buy kamagra online uk paypal continue to be way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have.2 Moreover, a lack of emphasis on developing capacity has meant that U.S. Test results are often long delayed, buy kamagra online uk paypal rendering the results useless for disease control.Although we tend to focus on technology, most of the interventions that have large effects are not complicated. The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had buy kamagra online uk paypal been achieved.

And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective control measures. The government has appropriately invested heavily in treatment development, buy kamagra online uk paypal but its rhetoric has politicized the development process and led to growing public distrust.The United States came into this crisis with enormous advantages. Along with tremendous manufacturing capacity, we have a biomedical research system that is the envy of the world. We have enormous expertise in buy kamagra online uk paypal public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that national expertise resides in government institutions.

Yet our leaders have largely chosen buy kamagra online uk paypal to ignore and even denigrate experts.The response of our nation’s leaders has been consistently inadequate. The federal government has largely abandoned disease control to the states. Governors have buy kamagra online uk paypal varied in their responses, not so much by party as by competence. But whatever their competence, governors do not have the tools that Washington buy kamagra online uk paypal controls. Instead of using those tools, the federal government has undermined them.

The Centers for Disease Control and Prevention, buy kamagra online uk paypal which was the world’s leading disease response organization, has been eviscerated and has suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in treatment development but have been excluded from much crucial government decision making. And the Food and Drug Administration has buy kamagra online uk paypal been shamefully politicized,3 appearing to respond to pressure from the administration rather than scientific evidence. Our current leaders have undercut trust in science and in government,4 causing damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed “opinion buy kamagra online uk paypal leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.Let’s be clear about the cost of not taking even simple measures.

An outbreak that has disproportionately affected communities of color has exacerbated the tensions associated with inequality. Many of our buy kamagra online uk paypal children are missing school at critical times in their social and intellectual development. The hard work of health care professionals, who have put their lives on the line, has not been used wisely. Our current leadership takes pride in the economy, but while most of the world has opened up to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs buy kamagra online uk paypal. And more than 200,000 Americans have died.

Some deaths buy kamagra online uk paypal from erectile dysfunction treatment were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a kamagra that has already killed more Americans than any conflict since World War II.Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely buy kamagra online uk paypal claimed immunity for their actions. But this election gives us the power to render judgment. Reasonable people will certainly disagree about the many political buy kamagra online uk paypal positions taken by candidates.

But truth is neither liberal nor conservative. When it comes to the response to buy kamagra online uk paypal the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs..

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€œElectronic prescriptions will be a key for making virtual visits more efficient and effective, and this integration with the WELL EMR network can help create a better patient experience. I am very proud of our WELL EMR Group who has worked tirelessly to successfully achieve conformance approval from Infoway and our WELL Digital Health Apps team who have made the service available through the apps.health marketplace.”PrescribeIT® enhances clinical communications, e-renewals, kamagra oral privacy and security. Prescriptions can now be sent directly from within OSCAR Pro EMR in a secure electronic format to the patient's pharmacy of choice and pharmacies can electronically request prescription renewals from the patient's health care provider. Electronic prescriptions are key for virtual visits as the patient does not have to rely on kamagra oral faxing prescriptions to pharmacies.

Furthermore, patient safety is increased due to prevention of data entry errors at the pharmacy and prescription fraud is decreased through direct transmission of the prescription from the prescriber to the pharmacy through the PrescribeIT® service.“We are excited about this partnership with WELL to make PrescribeIT® available to prescribers who use the OSCAR Pro EMR software,” said Jamie Bruce, Executive Vice President, Infoway. €œPrescribeIT® makes kamagra oral prescribing safer, more secure, easier and more convenient. PrescribeIT® is also an increasingly important tool in the prescriber’s virtual care toolbox.”WELL HEALTH TECHNOLOGIES CORP.Per. “Hamed Shahbazi” Hamed ShahbaziChief Executive Officer, Chairman and DirectorAbout WELLWELL is an omni-channel digital health company whose overarching objective is to empower doctors to provide the best and most advanced care kamagra oral possible while leveraging the latest trends in digital health.

As such, WELL owns and operates 25 primary health care clinics, is Canada's third largest digital Electronic Medical Records (EMR) supplier serving over 2,000 medical clinics, operates a leading national telehealth service and is a provider of digital health, billing and cybersecurity related technology solutions. WELL is an acquisitive company that kamagra oral follows a disciplined and accretive capital allocation strategy. WELL is publicly traded on the Toronto Stock Exchange under the symbol "WELL" and the Company was recognized as a TSX Venture 50 Company three years in a row in 2018, 2019 and 2020. To access the Company's telehealth service, kamagra oral visit.

Tiahealth.com or kamagra oral virtualclinics.ca and for corporate information, visit. Www.well.company.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our investments, we help deliver better quality and access to care and more efficient delivery of health services kamagra oral for patients and clinicians. Infoway is an independent, not-for-profit organization funded by the federal government.

Visit www.infoway-inforoute.ca.About PrescribeIT®Canada Health Infoway is working with Health Canada, the provinces and territories, and industry stakeholders to develop, operate and kamagra oral maintain the national e-prescribing service known as PrescribeIT®. PrescribeIT® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriber’s electronic medical record (EMR) and the pharmacy management system (PMS) of a patient’s pharmacy of choice. PrescribeIT® will kamagra oral protect Canadians’ personal health information from being sold or used for commercial activities. Visit www.PrescribeIT.ca.Forward-Looking StatementsThis news release may contain "forward-looking statements" within the meaning of applicable Canadian securities laws, including, without limitation statements regarding.

Improvement to kamagra oral overall patient care through clinical messaging. And the belief that the launch will ensure patient privacy and security of information. Forward-looking statements are necessarily based upon a number of estimates and assumptions that, while considered reasonable by management, are inherently subject to significant business, economic and competitive uncertainties, and kamagra oral contingencies. These statements generally can be identified by the use of forward-looking words such as “may”, “should”, “will”, “could”, “intend”, “estimate”, “plan”, “anticipate”, “expect”, “believe” or “continue”, or the negative thereof or similar variations.

Forward-looking statements involve known and unknown risks, uncertainties and other factors that may cause future results, performance or achievements to be materially different from the estimated future results, performance or achievements expressed or implied by those forward-looking statements and the forward-looking statements are not kamagra oral guarantees of future performance. WELL’s statements expressed or implied by these forward-looking statements are subject to a number of risks, uncertainties, and conditions, many of which are outside of WELL 's control, and undue reliance should not be placed on such statements. Forward-looking statements are qualified in their entirety by kamagra oral inherent risks and uncertainties, including. Risks related to privacy and cyber security concerns.

Risks related to kamagra oral compatibility between the two platforms and solutions. And error kamagra oral free adoption, use and growth of the service. Except as required by securities law, WELL does not assume any obligation to update or revise any forward-looking statements, whether as a result of new information, events or otherwise.Neither the TSX nor its Regulation Services Provider (as that term is defined in policies of the TSX) accepts responsibility for the adequacy or accuracy of this release.-30-For further information:Pardeep S. SanghaVP Corporate kamagra oral Strategy and Investor RelationsWELL Health Technologies Corp.604.572.6392This email address is being protected from spambots.

You need JavaScript enabled to view it.Inquiries about PrescribeIT® Tania EnsorSenior Director, Marketing, Stakeholder Relations and Reputation Management, PrescribeIT®Canada Health Infoway416.707.6285Email UsFollow @PrescribeIT_CANew survey insights released to mark Digital Health Week 2020November 16, 2020 (Toronto) — Canadians and health care providers have met the unprecedented challenge of the erectile dysfunction treatment kamagra head-on by embracing change in the way health care is delivered — from in-person to virtual. This week is Digital Health Week and to mark the kamagra oral occasion Canada Health Infoway (Infoway) is sharing research conducted in partnership with Environics that digs into this substantial shift and what Canadians want for their digital health future. This latest research project, A Healthy Dialogue, is one of the largest public consultations about digital health ever conducted in Canada. The consultation reached more than 58,000 Canadians — including those underserved by the health system — who shared how they thought technology would impact their care experience.The research reveals[i]:An overwhelming majority (92%) of Canadians want technology that makes health care as convenient as other aspects of their lives.More than half (53%) of Canadians who have used health kamagra oral technology in the past year say it helped them avoid an in-person visit to a provider or an emergency room.Of those Canadians who received virtual care during the kamagra, 91% were satisfied with the experience, 86% agreed that virtual care tools can be important alternatives to seeing doctors in-person, and more than three-quarters (76%) are willing to use virtual care after the kamagra.“We’ve gone from talking about ways to further integrate digital health into everyday health care to living it.

The events of the past year have accelerated our digital health progress significantly and have proven to Canadians just how important and helpful digital health can be,” says Michael Green, President and CEO of Infoway. €œDigital Health Week is an important time to celebrate kamagra oral our progress and acknowledge the hard work of all those who have made it possible.”While technology can help reduce barriers and improve access to health care, the research also found that nearly six in 10 Canadians feel they don’t know enough about digital health apps and services. As Canada’s digital health agency, Infoway is committed to working with its partners to address these gaps through activities like Digital Health Week.About Infoway’s Commitment to ResearchA Healthy Dialogue is part of Infoway’s commitment to contributing to digital health research in Canada. To support health care organizations, clinicians, kamagra oral policy maker and patients, families and caregivers, Infoway conducts research into the value of digital health solutions as well as clinicians’ and Canadians’ attitudes and perceptions.

To learn more about the results from A Healthy Dialogue, please visit https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/3850-a-healthy-dialogue-executive-summary. To learn about Infoway’s other research initiatives, please visit www.infoway-inforoute.ca/en/what-we-do/research-and-insights.About Digital Health kamagra oral Week — #ThinkDigitalHealthDigital Health Week was created to celebrate how digital health is transforming care across the country and to increase awareness about the value and benefits of digital health for all Canadians. Digital Health Week is supported by 60+ organizations. Join the conversation and share your story kamagra oral.

#ThinkDigitalHealth.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our investments, we help deliver better quality and access to care and kamagra oral more efficient delivery of health services for patients and clinicians. Infoway is an independent, not-for-profit organization funded by the federal government. Visit www.infoway-inforoute.ca.[i] A national survey of about 6,900 Canadians was conducted from kamagra oral December 2019-February 2020, pre-erectile dysfunction treatment.

A follow-up survey was conducted in June 2020 with about 2,200 of the original 6,900, to see if their views had shifted since the kamagra began.-30-Media Inquiries.

Vancouver, B.C buy kamagra online uk paypal additional info. And Toronto, buy kamagra online uk paypal ON., December 11, 2020 - WELL Health Technologies Corp. (TSX.V. WELL) (the “Company” buy kamagra online uk paypal or “WELL”), a company focused on consolidating and modernizing clinical and digital assets within the primary health care sector, is pleased to announce it has partnered with Canada Health Infoway (“Infoway”) to integrate Infoway’s national e-prescribing service, PrescribeIT®, with WELL’s OSCAR Pro Electronic Medical Records (EMR) software.

Physicians and health care practitioners using OSCAR Pro are now able to easily create, renew and cancel prescriptions electronically, while improving overall patient care through secure clinician messaging. WELL is buy kamagra online uk paypal offering an end-to-end solution from virtual and on-site patient consultation to electronic prescription, resulting in a better physician and patient experience. By partnering with PrescribeIT®, health care practitioners, pharmacists and patients can have confidence that the solution ensures patient privacy and security of information. €œWe are buy kamagra online uk paypal very excited to launch our e-prescribing service with Infoway’s PrescribeIT®,” said Hamed Shahbazi, Chairman and CEO of WELL.

€œElectronic prescriptions will be a key for making virtual visits more efficient and effective, and this integration with the WELL EMR network can help create a better patient experience. I am very proud of our WELL EMR Group who has worked tirelessly to successfully achieve conformance approval from Infoway and our WELL Digital Health Apps team who have made the buy kamagra online uk paypal service available through the apps.health marketplace.”PrescribeIT® enhances clinical communications, e-renewals, privacy and security. Prescriptions can now be sent directly from within OSCAR Pro EMR in a secure electronic format to the patient's pharmacy of choice and pharmacies can electronically request prescription renewals from the patient's health care provider. Electronic prescriptions are key buy kamagra online uk paypal for virtual visits as the patient does not have to rely on faxing prescriptions to pharmacies.

Furthermore, patient safety is increased due to prevention of data entry errors at the pharmacy and prescription fraud is decreased through direct transmission of the prescription from the prescriber to the pharmacy through the PrescribeIT® service.“We are excited about this partnership with WELL to make PrescribeIT® available to prescribers who use the OSCAR Pro EMR software,” said Jamie Bruce, Executive Vice President, Infoway. €œPrescribeIT® makes prescribing safer, more secure, easier and buy kamagra online uk paypal more convenient. PrescribeIT® is also an increasingly important tool in the prescriber’s virtual care toolbox.”WELL HEALTH TECHNOLOGIES CORP.Per. “Hamed Shahbazi” Hamed ShahbaziChief Executive Officer, Chairman and DirectorAbout WELLWELL is an omni-channel digital health company whose overarching objective is to empower doctors buy kamagra online uk paypal to provide the best and most advanced care possible while leveraging the latest trends in digital health.

As such, WELL owns and operates 25 primary health care clinics, is Canada's third largest digital Electronic Medical Records (EMR) supplier serving over 2,000 medical clinics, operates a leading national telehealth service and is a provider of digital health, billing and cybersecurity related technology solutions. WELL is an acquisitive company that follows a disciplined and buy kamagra online uk paypal accretive capital allocation strategy. WELL is publicly traded on the Toronto Stock Exchange under the symbol "WELL" and the Company was recognized as a TSX Venture 50 Company three years in a row in 2018, 2019 and 2020. To access the Company's telehealth buy kamagra online uk paypal service, visit.

Tiahealth.com or virtualclinics.ca and for buy kamagra online uk paypal corporate information, visit. Www.well.company.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our buy kamagra online uk paypal investments, we help deliver better quality and access to care and more efficient delivery of health services for patients and clinicians. Infoway is an independent, not-for-profit organization funded by the federal government.

Visit www.infoway-inforoute.ca.About PrescribeIT®Canada Health Infoway is working with Health buy kamagra online uk paypal Canada, the provinces and territories, and industry stakeholders to develop, operate and maintain the national e-prescribing service known as PrescribeIT®. PrescribeIT® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriber’s electronic medical record (EMR) and the pharmacy management system (PMS) of a patient’s pharmacy of choice. PrescribeIT® will protect Canadians’ personal health information from being sold or used for commercial activities buy kamagra online uk paypal. Visit www.PrescribeIT.ca.Forward-Looking StatementsThis news release may contain "forward-looking statements" within the meaning of applicable Canadian securities laws, including, without limitation statements regarding.

Improvement to overall patient care through clinical messaging buy kamagra online uk paypal. And the belief that the launch will ensure patient privacy and security of information. Forward-looking statements buy kamagra online uk paypal are necessarily based upon a number of estimates and assumptions that, while considered reasonable by management, are inherently subject to significant business, economic and competitive uncertainties, and contingencies. These statements generally can be identified by the use of forward-looking words such as “may”, “should”, “will”, “could”, “intend”, “estimate”, “plan”, “anticipate”, “expect”, “believe” or “continue”, or the negative thereof or similar variations.

Forward-looking statements involve known and unknown risks, uncertainties and other factors that may cause future results, performance buy kamagra online uk paypal or achievements to be materially different from the estimated future results, performance or achievements expressed or implied by those forward-looking statements and the forward-looking statements are not guarantees of future performance. WELL’s statements expressed or implied by these forward-looking statements are subject to a number of risks, uncertainties, and conditions, many of which are outside of WELL 's control, and undue reliance should not be placed on such statements. Forward-looking statements are qualified in their entirety by inherent risks and uncertainties, buy kamagra online uk paypal including. Risks related to privacy and cyber security concerns.

Risks related to compatibility between the two platforms and solutions buy kamagra online uk paypal. And error free adoption, use and growth of the service buy kamagra online uk paypal. Except as required by securities law, WELL does not assume any obligation to update or revise any forward-looking statements, whether as a result of new information, events or otherwise.Neither the TSX nor its Regulation Services Provider (as that term is defined in policies of the TSX) accepts responsibility for the adequacy or accuracy of this release.-30-For further information:Pardeep S. SanghaVP Corporate Strategy and Investor RelationsWELL Health Technologies Corp.604.572.6392This email address is being protected from spambots buy kamagra online uk paypal.

You need JavaScript enabled to view it.Inquiries about PrescribeIT® Tania EnsorSenior Director, Marketing, Stakeholder Relations and Reputation Management, PrescribeIT®Canada Health Infoway416.707.6285Email UsFollow @PrescribeIT_CANew survey insights released to mark Digital Health Week 2020November 16, 2020 (Toronto) — Canadians and health care providers have met the unprecedented challenge of the erectile dysfunction treatment kamagra head-on by embracing change in the way health care is delivered — from in-person to virtual. This week is Digital Health Week and to mark the occasion Canada Health Infoway (Infoway) is sharing research conducted in partnership with Environics that digs into this substantial shift and what Canadians buy kamagra online uk paypal want for their digital health future. This latest research project, A Healthy Dialogue, is one of the largest public consultations about digital health ever conducted in Canada. The consultation reached more than 58,000 Canadians — including those underserved by the health system — who shared how they thought technology would impact their care experience.The research reveals[i]:An overwhelming majority (92%) of Canadians want technology that makes health care as convenient as other aspects of their lives.More than half (53%) of Canadians who have used health technology in the past year say it helped them avoid an in-person visit to buy kamagra online uk paypal a provider or an emergency room.Of those Canadians who received virtual care during the kamagra, 91% were satisfied with the experience, 86% agreed that virtual care tools can be important alternatives to seeing doctors in-person, and more than three-quarters (76%) are willing to use virtual care after the kamagra.“We’ve gone from talking about ways to further integrate digital health into everyday health care to living it.

The events of the past year have accelerated our digital health progress significantly and have proven to Canadians just how important and helpful digital health can be,” says Michael Green, President and CEO of Infoway. €œDigital Health Week is an important time to celebrate our progress and acknowledge the hard work of all those who have made it possible.”While technology can help reduce barriers and improve access to health care, the research also found that nearly six in 10 Canadians feel they don’t know enough about digital health apps and buy kamagra online uk paypal services. As Canada’s digital health agency, Infoway is committed to working with its partners to address these gaps through activities like Digital Health Week.About Infoway’s Commitment to ResearchA Healthy Dialogue is part of Infoway’s commitment to contributing to digital health research in Canada. To support health care organizations, clinicians, policy maker and patients, families and caregivers, Infoway conducts research into the value of digital health solutions as well buy kamagra online uk paypal as clinicians’ and Canadians’ attitudes and perceptions.

To learn more about the results from A Healthy Dialogue, please visit https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/3850-a-healthy-dialogue-executive-summary. To learn about Infoway’s other research initiatives, please visit www.infoway-inforoute.ca/en/what-we-do/research-and-insights.About Digital Health Week — #ThinkDigitalHealthDigital Health Week was created to celebrate how digital health is transforming buy kamagra online uk paypal care across the country and to increase awareness about the value and benefits of digital health for all Canadians. Digital Health Week is supported by 60+ organizations. Join the buy kamagra online uk paypal conversation and share your story.

#ThinkDigitalHealth.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our investments, we buy kamagra online uk paypal help deliver better quality and access to care and more efficient delivery of health services for patients and clinicians. Infoway is an independent, not-for-profit organization funded by the federal government. Visit www.infoway-inforoute.ca.[i] A national survey of about buy kamagra online uk paypal 6,900 Canadians was conducted from December 2019-February 2020, pre-erectile dysfunction treatment.

A follow-up survey was conducted in June 2020 with about 2,200 of the original 6,900, to see if their views had shifted since the kamagra began.-30-Media Inquiries.

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