Ohio Benefits Group

“How do I prove that I’m a Veteran?” It’s a question often asked by those who once served in the military. Many businesses offer discounts to Veterans for restaurants, hotels, stores, recreational activities and even home improvement, among other perks. Former service members will want to take advantage of those opportunities.
First, you’ll want to apply for VA’s Veteran ID Card (VIC), which is a digital photo ID you can use to get those discounts. Since September 2022, all new Veteran ID cards have been digital. A Veteran with a physical ID card can continue using it to get discounts. The VIC is separate from the VA health care ID, which a Veteran receives when enrolling in VA health care.
If you have any questions or need help, email VA’s VIC program at vetidcard@va.gov.
Click here to apply online and login using your existing Login.gov, ID.me, DS Logon or MyHealtheVet account. A Veteran without any of these accounts can create a free Login.gov or ID.me account. If you are unable to submit your VIC application through VA.gov, please use Access VA. 
When applying, make sure to have your social security number; a digital copy of your DD214, DD256, DD257 or NGB22 that you can upload; and a copy of a current and valid government-issued ID, such as a driver’s license, passport or state-issued identification card.
You’ll also need a digital color photo of yourself from the shoulders up. The photo should follow all of these standards:

• Show a full, front view of your face and neck with no hat, head covering or headphones covering or casting shadows on your hairline or face.
• Be cropped from your shoulders up much like a passport photo.
• Show you with your eyes open and in a neutral expression.
• Be taken in clothing you’d wear for a driver’s license photo.
• Be a square size and have a white or plain-color background with no scenery or other people in the photo.
• Show what you look like now, meaning a photo that is no older than 10 years old; it should be uploaded as a .jpeg, .png, .bmp or .tiff file.

A Veteran must meet certain criteria to be eligible for a VIC, including both of these requirements:

• Service on active duty, in the Reserve or in the National Guard, including the Coast Guard.
• Receipt of an honorable or general discharge under honorable conditions.

If the Veteran received an other-than honorable, bad conduct or dishonorable character of discharge, that person is not eligible for a Veteran ID card. If a Veteran has an uncharacterized or unknown discharge status, VA must verify that person’s eligibility before approving an application. The Veteran must provide a copy of his/her discharge papers when applying for a VIC to prove their character of discharge.
After a Veteran applies for a VIC, VA will check that person’s eligibility and verify that the character of discharge meets eligibility requirements, the ID submitted is valid and the image chosen to appear on the card meets photo requirements.
VA will then send an email letting the Veteran know the status of the application. If the Veteran has an unknown or uncharacterized discharge status, the application will take more time to process. VA may need to request your records from the National Personnel Records Center, part of the National Archives and Records Administration.
If a Veteran receives an email from VA asking for additional information or evidence to process the application, that person must sign in to AccessVA and update the application.
VA will send an email with the digital card attached if a Veteran is eligible for a Veteran ID Card.
For more information, email VA at vetidcard@va.gov. You can also click here.

​https://news.va.gov/117828/va-id-card-proof-discounts/?utm_id=19APR2023

Patients are getting blindsided by ‘facility fees,’ and states are taking actionAbout half of all patients are getting hit with facility fees, which are billed for doctor visits at hospital-owned clinics, as three in four physicians are now employed by hospitals, health systems or other corporate entities.By Markian Hawryluk | April 07, 2023


When Brittany Tesso’s then-3-year-old son, Roman, needed an evaluation for speech therapy in 2021, his pediatrician referred him to Children’s Hospital Colorado in Aurora. With in-person visits on hold due to the COVID-19 pandemic, the Tessos met with a panel of specialists via video chat.
The specialists, some of whom appeared to be calling from their homes, observed Roman speaking, playing with toys, and eating chicken nuggets. They asked about his diet.
Tesso thought the $676.86 bill she received for the one-hour session was pretty steep. When she got a second bill for $847.35, she assumed it was a mistake. Then she learned the second bill was for the costs of being seen in a hospital — the equipment, the medical records, and the support staff.
“I didn’t come to your facility,” she argued when disputing the charges with a hospital billing representative. “They didn’t use any equipment.”
This is the facility fee, the hospital employee told her, and every patient gets charged this.
“Even for a telehealth consultation?” Tesso laughed in disbelief, which soon turned into anger.
Millions of Americans are similarly blindsided by hospital bills for doctor appointments that didn’t require setting foot inside a hospital. Hospitals argue that facility fees are needed to pay for staff and overhead expenses, particularly when hospitals don’t employ their own physicians. But consumer advocates say there’s no reason hospitals should charge more than independent clinics for the same services.

“If there is no change in patient care, then the fees seem artificial at best,” said Aditi Sen, a Johns Hopkins University health economist.
At least eight states agree such charges are questionable. They have implemented limits on facility fees or are moving to clamp down on the charges. Among them are Connecticut, which already limits facility fees, and Colorado, where lawmakers are considering a similar measure. Together, the initiatives could signal a wave of restrictions similar to the movement that led to a federal law to ban surprise bills, which took effect last year.
“Facility fees are simply another way that hospital CEOs are lining their pockets at the expense of patients,” said Rep. Emily Sirota, the Denver Democrat who sponsored the Colorado bill.
Generally, patients at independent physician clinics receive a single bill that covers the physician’s fee as well as overhead costs. But when the clinic is owned by a hospital, the patient generally receives separate bills for the physician’s fee and the facility fee. In some cases, the hospital sends a single bill covering both fees. Medicare reduces the physician’s payment when a facility fee is charged. But private health plans and hospitals don’t disclose how physician and facility fees are set.
Children’s Hospital Colorado officials declined to comment on the specifics of Tesso’s experience but said that facility fees cover other costs of running the hospital.
“Those payments for outpatient care are how we pay our nurses, our child life specialists, or social workers,” Zach Zaslow, senior director of government affairs for Children’s Hospital said in a February call with reporters. “It’s how we buy and maintain our imaging equipment, our labs, our diagnostic tests, really all of the care that you expect when you come to a hospital for kids.”
Research suggests that when hospitals acquire physician practices and hire those doctors, the physicians’ professional fees go up and, with the addition of facility fees, the total cost of care to the patient increases, as well. Other factors are in play, too. For instance, health plans pay the rates negotiated with the hospital, and hospitals have more market power than independent clinics to demand higher rates.

Those economic forces have driven consolidation, as hospital systems gobble up physician clinics. According to the Physicians Advocacy Institute, 3 in 4 physicians are now employed by hospitals, health systems, or other corporate entities. And less competition usually leads to higher prices.
One study found that prices for the services provided by physicians increase by an average of 14% after a hospital acquisition. Another found that billing for laboratory tests and imaging, such as MRIs or CT scans, rise sharply after a practice is acquired.
Patients who get their labs drawn in a hospital outpatient department are charged up to three times what they would pay in an office, Sen said. “It’s very hard to argue that the hospital outpatient department is doing that differently with better outcomes,” she said.
Hospital officials say they acquire physician practices to maintain care options for patients. “Many of those physician practices are not viable and they were having trouble making ends meet, which is why they wanted to be bought,” said Julie Lonborg, a senior vice president for the Colorado Hospital Association.
States are considering limits on facility feesAlong with Colorado and Connecticut, other states that have implemented or are considering limits on facility fees are Indiana, Minnesota, New Hampshire, Ohio, Texas, and Washington. Those measures include collecting data on what facility fees hospitals charge, prohibiting add-on fees for telehealth, and requiring site-neutral payments for certain Medicaid services. A federal bill introduced in 2022 would require off-campus hospital outpatient departments to bill as physician providers, eliminating the possibility of charging facility fees.
Connecticut has gone the furthest, banning facility fees for basic doctor visits off-campus, and for telehealth appointments through June 2024. But the law’s application still has limitations, and with rising health care costs, the amount of facility fees in Connecticut continues to increase.
“It hasn’t changed much, partly because there’s so much money involved,” said Ted Doolittle, who heads the state’s Office of the Healthcare Advocate. “They can’t just painlessly take that needle out of their arm. They’re addicted to it.”
Bill would prohibit fees for primary careThe Colorado bill would prohibit facility fees for primary care visits, preventive care services that are exempted from cost sharing, and telehealth appointments. Hospitals would also be required to notify patients if a facility fee would apply. The ban would not apply to rural hospitals. The bill was scaled back from a much broader proposal after criticism from hospitals about its potential consequences.
Rural hospital executives, like Kevin Stansbury, CEO of Lincoln Health, a small community hospital in the eastern Colorado town of Hugo, had been particularly worried about the impact of a fee ban. The state hospital association estimated his hospital would lose as much as $13 million a year if facility fees were banned. The 37-bed hospital’s netted $22 million in patient revenue last year, resulting in a loss. It stays open only through local taxes, Stansbury said.
“This will still harm access to care — and especially essential primary and preventive care that is helping Coloradans stay healthier and out of the hospital,” Lonborg said of the revised approach. “It will also have a detrimental impact on access to specialty care through telehealth, which many Coloradans, especially in rural parts of the state, have come to depend on.”
The Colorado bill presents particular challenges for health systems such as UC Health and Children’s Hospital, which rely on the University of Colorado School of Medicine for staffing. For outpatient appointments, the medical school bills for the doctor’s fee, while the hospital bills a facility fee.
“The professional fee goes solely to the provider, and, very frequently, they’re not employed by us,” said Dan Weaver, vice president of communications for UC Health. “None of that supports the clinic or the staff members.”
Without a facility fee, the hospital would not receive any payment for outpatient services covered by the ban. Weaver said the combination of the clinicians’ and facility fees is often higher than fees charged in independent clinics because hospitals provide extra services that independent physician clinics cannot afford.
“Prohibiting facility fees for primary care services and for telehealth would still cause significant problems for patients throughout our state, forcing some clinics to close, and causing patients to lose access to the care they need,” he said.
Backers of the Colorado bill disagree.
“The data on their costs and their revenue paints a little different picture of their financial health,” said Isabel Cruz, policy manager for the Colorado Consumer Health Initiative, which backs the bill.
From 2019 through 2022, UC Health had a net income of $2.8 billion, including investment gains and losses.
The Colorado market is dominated by large health systems that can dictate higher rates to health plans. Plans pass on those costs through higher premiums or out-of-pocket costs.
“Unless the employers and patients that are incurring the prices are raising the alarm, there really isn’t a strong incentive for health plans to push against this,” said Christopher Whaley, a health care economist with the nonprofit think tank Rand Corp.
Consumer complaints helped pave the way for the federal No Surprises Act, which protects against unanticipated out-of-network bills. But far more people get hit with facility fees — about half of patients compared with 1 in 4 hospital patients who receive surprise bills, Whaley said.
Dr. Mark Fendrick, a University of Michigan health policy professor, said facility fees are also generally surprises but don’t fall under the definition of the No Surprises Act. And with the rise of high-deductible plans, patients are more likely to have to pay those fees out-of-pocket.
“It falls on the patient,” Fendrick said. “It’s a tax on the sick.”
Tesso held off paying the facility fee for her son’s visit as long as possible. And when her pediatrician again referred them to Children’s Hospital, she called to inquire what the facility fee would be. The hospital quoted a price of $994, on top of the doctor’s fee. She took her son to an independent doctor instead and paid a $50 copay.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

https://www.benefitspro.com/2023/04/07/patients-are-getting-blindsided-by-facility-fees-and-states-are-taking-action/?kw=Patients%20are%20getting%20blindsided%20by%20%27facility%20fees%2C%27%20and%20states%20are%20taking%20action&utm_source=email&utm_medium=enl&utm_campaign=bprodailynews&utm_content=20230410&utm_term=bpro&oly_enc_id=8686I4299356B7C

Texas judge strikes down ACA’s free preventive care requirementThe ruling, which applies nationwide and takes effect immediately, mandates that insurers and employers are not required to cover certain free preventive screenings for cancer, heart disease and other diseases under Obamacare.By Lynn Cavanaugh | March 30, 2023

The Earle Cabell Federal Bldg. houses the U.S. District Court for the Northern District of Texas.

Today, a federal judge in Texas struck down a key provision of the Affordable Care Act requirement that insurers and employers cover free preventive screenings for cancer, heart disease, HIV and other diseases. The decision, which applies nationwide and takes effect immediately, threatens access to over 100 million Americans who use these services, which include mammograms and STD testing.
Judge Reed C. O’Connor of the U.S. District Court for the Northern District of Texas –who previously struck down the entire ACA law before it was upheld by the Supreme Court – granted Braidwood Management Inc.’s request to block an ACA requirement for cost-sharing coverage of preventive services.
The ruling invalidates nationwide zero cost-sharing coverage requirements of preventive services recommended by the U.S. Preventive Services under the Affordable Care Act and finds that required coverage of PrEP for HIV violates the Religious Freedom Restoration Act. Cost sharing will likely deter patients from scheduling those procedures. The ruling won’t impact every preventive screening, as some recommendations predate the ACA, which was signed into law in 2010. More than 2,000 legal challenges have been filed in state and federal courts contesting parts for all of the Affordable Care Act (ACA) since it became law. Today’s case, Braidwood Management v. Becerra, involved the ACA’s requirement that most private insurance plans cover specific preventive care items and services — such as contraceptive care and supplies, as well as cancer screenings. The case could have long-term implications for millions of people who are covered by private insurance, according to Kaiser Family Foundation.
In Braidwood Management v. Becerra, two Christian-owned businesses and six individuals in Texas challenged the legality of the preventive care mandates on constitutional grounds. The plaintiffs also challenged the requirement to cover medication to prevent HIV, based on religious grounds.
In September 2022, Judge O’Connor ruled partly in favor of the plaintiffs and partly in favor of the Department of Health and Human Services (which defended the ACA).
While not surprised by Judge O’Connor’s decision, “It is imperative that these critical preventive services must continue for the health of our nation,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “We expect that the U.S. government will quickly act to stay this decision so that preventive services can continue nationwide, and appeal it. Preventive services are all critical and well-established medical services … While the appeals process moves forward, we call on health insurers to act on their own and continue to cover these preventive services without cost-sharing for the benefit of their enrollees.”
Related:  Texas court decision could change preventative medical services costsAs a result of the ruling, “the government may no longer be able to require insurance plans to cover certain preventive services and items at no cost to patients. Insurers and employers would once again have discretion over whether to cover preventive services, resulting in lower premiums in some cases but also a patchwork of coverage,” according to KFF. “Any rollback of the government’s ability to enforce these requirements could impact the millions of people covered by private insurance. The outcome of this case could also have broader ramifications for the authority of federal agencies to address a wide range of issues through regulation.”
It is likely that the Biden administration will appeal the ruling. KFF officials maintain that Braidwood Management v. Becerra has the potential to reach the U.S. Supreme Court.

https://www.benefitspro.com/2023/03/30/texas-judge-strikes-down-acas-free-preventive-care-requirement/

​As pharmacy benefit managers face scrutiny on Capitol Hill, a new Ohio lawsuit alleges Express Scripts and Prime Therapeutics used a Switzerland-based company to illegally drive up drug prices.By Alan Goforth | March 29, 2023

Public officials continue to turn up the heat on pharmacy benefit managers. Less than a week after a U.S. Senate committee approved PBM reform legislation, the Ohio Attorney General has sued Express Scripts and Prime Therapeutics, alleging that the companies conspired to illegally increase drug prices.
“PBMs are modern gangsters,” Attorney General David Yost said. “They were designed to protect and negotiate on behalf of employers and consumers after big pharma was criticized for overpricing medications, but instead they have absolutely destroyed transparency, scheming in the shadows to control drug prices on all sides of the market.”
The lawsuit alleges that Express Scripts, one of the country’s three largest PBMs, responded to criticism of its model by forming the group purchasing organization Ascent Health Services in 2019. It then granted Prime Therapeutics ownership in Ascent before moving its operations to Switzerland, which allowed it to further obfuscate its pricing models. The lawsuit also names Cigna Group, parent company of Express Scripts; Evernorth Health, another subsidiary of Cigna; Humana Pharmacy Solutions; Humana, parent company of Humana Pharmacy Solutions; and Ascent.
Express Scripts and Prime Therapeutics then used their shared stake in Ascent to share pricing, discount and rebate information with one another as well as with Humana Pharmacy Solutions, an Ascent customer, which drove up prices further, according to the lawsuit.
“Both drug buyers and sellers have little choice but to play the game by the PBMs’ rules, allowing PBMs to extract both monopoly profits from individuals and monopsony (a market situation where there is only one buyer) profits from the market,” Yost said.
Related: PBMs face scrutiny as House committee opens investigationThe suit alleges multiple violations of the Valentine Act, Ohio’s antitrust law, which prohibits price fixing, controlled sales and other agreements that restrain trade and hurt competition. The act is broader than its federal counterpart, the Sherman Act, in that the Ohio law prohibits market harms in addition to consumer harms. The lawsuit seeks seeks statutory fines and restitution of any illegals profits.
Yost has been a vocal critic of PBMs and the models they deploy to manage drug spending, particularly rebates and spread pricing. He has filed multiple lawsuits against different PBMs, making this week’s filing just the latest salvo in a lengthy war.
PBMs have been intensely scrutinized in the debate over who is at fault for rising drug costs, and pharmaceutical manufacturers typically blame PBMs for driving up expenses. In addition to congressional action, the Federal Trade Commission subpoenaed six of the largest PBMs – CVS Caremark; Express Scripts, OptumRx, Humana, Prime Therapeutics and MedImpact Healthcare Systems – last year.
https://www.benefitspro.com/2023/03/29/pbms-are-gangsters-ohio-ag-alleges-in-lawsuit-against-express-scripts-6-others/?printer-friendly

Releasing ownership data on Medicare-certified hospitals will boost healthcare transparency and promote competition, HHS says. By Jacqueline LaPointe
December 21, 2022 - HHS is releasing ownership data on all Medicare-certified hospitals in a bid to promote competition in a highly consolidated industry.
“At President Biden’s direction, this Administration puts consumers first – and we believe consumers deserve transparency,” HHS Secretary Xavier Becerra said in a recent announcement. “At HHS, we continue taking unprecedented action to deliver on President Biden’s vision. We are pulling back the curtain and letting the sunshine in on hospital and nursing home ownership because it is what the public deserves.”
“As we work to expand access to high-quality, affordable [healthcare], we will make sure there is transparency to ensure that facilities are held accountable and people can make the best-informed decisions on their care.”
Dig Deeper

• Experts Predict Strong Merger and Acquisition Activity for 2023
• Biden’s EO on US Competition Will Impact Hospital Mergers
• Increase in Cross-Market Hospital Systems May Hurt Market Competition

Detailed information on the ownership of more than 7,000 hospitals will be available for the public to view on CMS’ website. The information includes enrollment information, such as organization name, type, practice location addresses (e.g., off campus), National Provider Identifier (NPI), CMS Certification Number (CCN); detailed information about each owner, such as whether it is an organization or an individual and whether it is a direct owner or indirect owner (that is, there is at least one subsidiary between it and the provider); and a numerical associate ID for each owner to enable linkage to the enrollment file.
Making hospital ownership data publicly available will benefit researchers, enforcement agencies, and patients, according to HHS.
Researchers and other agencies will be able to use the data to identify common owners that have had histories of poor performance, for example. The federal department also said the information could be used to analyze data and trends on how market consolidation impacts consumers with increased costs, without necessarily improving quality of care, and to evaluate the relationships between ownership and changes in healthcare costs and outcomes.
HHS also plans to analyze the data to inform policy approaches that promote competition in healthcare.
Healthcare is a heavily consolidated industry as more organizations combine to achieve economies of scale and tap into greater innovation. However, industry stakeholders have criticized healthcare consolidation, saying it leads to less competition and higher prices for consumers. Patients may also face fewer options for healthcare services in concentrated markets, thereby limiting access to affordable care for consumers.
The American Hospital Association (AHA), however, has stood its ground in asserting that mergers and acquisitions help reduce hospital costs.
In 2021, AHA updated its analysis of hospital transactions and found that mergers and acquisitions were associated with a 3.3 percent reduction in operating expenses between 2009 and 2019. Based on this figure, acquired hospitals could save $9.5 million each year.
Although, research has shown that these deals do not improve quality and may even make it worse in some communities.
HHS has committed to increasing transparency in healthcare in an effort to promote competition. With greater competition, the federal department hopes to reduce healthcare costs for consumers without impacting the quality of care they receive.
HHS also said releasing hospital ownership data will allow patients to make more informed choices when it comes to selecting a healthcare provider.
CMS is expected to update the data on a monthly basis and provide it in a searchable format on data.cms.gov. Hospital ownership data will also be available in a flat Excel file.

​https://revcycleintelligence.com/news/hhs-releases-ownership-data-on-all-medicare-certified-hospitals

• September 27, 2022
• By InvestmentNews

Medicare beneficiaries will pay slightly lower Part B premiums and income-related surcharges next year as the Centers for Medicare & Medicaid Services partly reverses the sizable increases it put in place for 2022 in an effort to build reserves for expenses related to a new Alzheimer’s drug.
Individuals enrolled in Medicare Part B, which covers doctor visits and other outpatient services, will pay a monthly premium of $164.90 in 2023, which is down $5.20 from $170.10 in 2022.
In 2022, the Medicare Part B premium jumped $21.60, a 15% increase that was one of the largest in Medicare’s history, in part because CMS was required to accumulate reserves against the cost of the newly approved Alzheimer’s drug, Aduhelm.
While Aduhelm had been approved by the Food and Drug Administration, the approval was controversial, as was the drug’s initial price tag, at $56,000 per year. But last December, Aduhelm’s manufacturer, Biogen, said it would cut the drug’s cost by half, to $28,000 a year, as of Jan. 1.
In the wake of the price cut, CMS reassessed the 2022 Part B premium increase. It decided not to alter the 2022 premium in mid-year but said the lower price tag on Aduhelm was likely to mean a lower Medicare Part B premium for 2023.
Higher-income Medicare beneficiaries will also pay a little less next year. In 2023, individuals with modified adjusted gross income of $97,000 or more and married couples with MAGIs of $194,000 or more will pay additional surcharges ranging from an extra $65.90 per month to an extra $395.60 per month on top of the standard Part B premium. In 2023, those IRMAA surcharges ranged from $68.00 to $408.20 per month.
Married couples where both spouses are enrolled in Medicare pay twice as much.
Medicare Part B premiums and IRMAA surcharges are usually deducted directly from monthly Social Security benefits, although people who aren’t yet claiming Social Security are billed directly by Medicare. The cuts in the Part B premium and IRMAA surcharges come as the spike in U.S. inflation is expected to result in a large cost-of-living adjustment to Social Security benefits in 2023.
Earlier this month, Mary Johnson, Social Security analyst for the Senior Citizens League, projected Social Security benefits could increase by 8.7% next year, based on the August consumer price index.
The Social Security Administration is expected to announce the official cost-of-living adjustment for 2023 on Oct. 13, after the government releases September CPI. The COLA is based on the increase in the average CPI for the third quarter — July, August and September — over the previous year’s third quarter.

https://www.investmentnews.com/medicare-part-b-premium-irmaa-surcharges-to-decline-in-2023-227074www.investmentnews.com/medicare-part-b-premium-irmaa-surcharges-to-decline-in-2023-227074

17 May 2022
Military.com | By Patricia KimeAfter nearly 30 years of trying to prove a theory -- that an environmental toxin was responsible for sickening roughly 250,000 U.S. troops who served in the 1990-91 Persian Gulf War -- Dr. Robert Haley says new research confirms that sarin nerve gas caused Gulf War Illness.
Following the Gulf War, nearly one-third of all who deployed reported unexplained chronic symptoms such as rashes, fatigue, gastrointestinal and digestive issues, brain "fog," neuropathy, and muscle and joint pain. Federal agencies spent years broadly dismissing the idea that troops may have been suffering from exposure to chemical agents, with many veterans experiencing symptoms sent to mental health providers.
But a study published last week in the journal Environmental Health Perspectives used genetic research and survey data to determine that U.S. service members exposed to sarin were more likely to develop Gulf War Illness, and those who were exposed and had a weaker variant of a gene that helps digest pesticides were nine times more likely to have symptoms.
Read Next: Congress' First Military UFO Hearing in 50 Years Deflates Speculation on Alien Spacecraft
"Quite simply, our findings prove that Gulf War illness was caused by sarin, which was released when we bombed Iraqi chemical weapons storage and production facilities," said Haley, director of the Division of Epidemiology in the Internal Medicine Department at University of Texas Southwestern Medical Center.
"There are still more than 100,000 Gulf War veterans who are not getting help for this illness and our hope is that these findings will accelerate the search for better treatment," Haley said.
Originally developed as a pesticide, the chemical weapon sarin was known to have been stockpiled by Iraqi President Saddam Hussein prior to and after the 1990-91 Persian Gulf War. The synthetic nerve agent attacks the central nervous system and brain, killing victims by triggering an overreaction of neurotransmitters that causes convulsions and asphyxiation.
Thousands of coalition troops likely were exposed to sarin and cyclosarin, an organic phosphate also used as a chemical weapon, when the U.S. destroyed a bunker housing chemical weapons at the Khamisiyah Ammunition Storage Depot in southern Iraq, sending a plume of contaminants that spread across a 25-mile radius. Others may have been subjected to low levels of contaminants, as troops frequently reported that chemical weapons alarms went off in the absence of any apparent attack.
In the years following the war, veterans who sought medical help at the Department of Veterans Affairs were greeted with skepticism and sent to psychiatrists for mental health treatment. Health surveys conducted by the VA in the early 2010s of Gulf War veterans focused mainly on questions about psychological and psychiatric symptoms.
And in 2013, veterans' suspicions of the lack of concern at the VA were confirmed when VA whistleblower and epidemiologist Steven Coughlin came forward to say that the department buried or obscured research findings that would link physical ailments to military service -- a concerted effort to deny veterans health care and benefits.
Coughlin's charges were later confirmed by an email sent to staff from former Undersecretary for Benefits Allison Hickey expressing concern that changing what the VA still calls "chronic multisymptom illness" to "Gulf War illness" might "imply a causal link between service in the Gulf and poor health which could necessitate legislation for disability compensation for veterans who served in the Gulf."
Research Confirms Earlier, Smaller StudiesFor the new study into sarin, Haley and colleagues randomly selected 1,116 veterans who completed a U.S. Military Health Survey, including 508 who deployed and developed Gulf War Illness and 508 veterans who went but never developed symptoms. They collected blood and DNA samples from each participant and asked the veterans whether they heard nerve gas alarms during their deployment, and if so, how often.
The researchers also tested for variants of a gene that helps the body metabolize pesticides, called PON1. Some people have variants of this gene that are more effective in breaking down sarin while others have a variant that helps process chemicals like pesticides but is less efficient against sarin.
The study found that those who reported hearing nerve agent alarms and who also had the least robust form of the gene had a nine-fold chance of having Gulf War Illness. Those with a genotype that is a mix of the two variants had more than four times the chance of having Gulf War Illness, while those who just heard nerve agent alarms, which the researchers used as a proxy for exposure, raised the chance of developing the condition by nearly four times, although to a lesser degree of those who have a mix of genes.
According to the researchers, the data "leads to a high degree of confidence that sarin is a causative agent for Gulf War Illness."
"Our hypothesis was, if you have the strong form of the gene, then when you're exposed to low-level sarin, that gene makes a strong isoenzyme that destroys sarin in your blood. If you have the weak form of the gene, the enzyme that it makes is not very strong, so it goes through your blood into your brain and you get sick," Haley said in an interview with Military.com. "You've heard the expression 'correlation does not equal causation,' right? That's true, unless you are dealing with a gene-environment interaction."
A Mysterious MaladyThe mysterious symptoms experienced by thousands of service members, which came to be known as Gulf War Syndrome and, later, Gulf War Illness, generated hypotheses of the possible cause, including an additive in anthrax vaccines, preventive medicines given to troops such as the anti-nerve agent pyridostigmine bromide, ciprofloxacin, depleted uranium, and exposure to nerve gas, pesticides or smoke from oil well fires.
A congressional investigation in 1997 concluded that the Departments of Defense and Veterans Affairs had very little interest in finding a cause and blamed the symptoms as related to stress or other mental health disorders.
In its report, the Committee on Government Reform and Oversight found that the DoD and VA were "plagued by arrogant incuriosity and a pervasive myopia that sees a lack of evidence as proof" that the illness didn't exist.
"Sadly, when it comes to diagnosis, treatment and research for Gulf War veterans, we find the Federal Government too often has a tin ear, a cold heart and a closed mind," the report noted.
As Congress investigated the issue, Haley was studying possible causes, funded by Ross Perot, the Texas billionaire and Navy veteran known for donating to veterans' charities and resources, including efforts to help U.S. prisoners of war in Vietnam.
Haley's early work pointed to sarin as a possible cause, but other scientists, including the medical body of the National Academies of Sciences, Engineering and Medicine, found his studies to be insufficient in size and suffering from selection or "recall bias," meaning that vets may or may not remember whether they heard nerve gas alarms and how often.
Haley said the new research links veterans with Gulf War Illness with their genotype and "cannot be explained away by errors in recalling the environmental exposure or other biases in the data."
Others now concur. In an editorial accompanying the study, Marc Weisskopf, a professor of environmental epidemiology and psychology at the Harvard T.H. Chan School of Public Health, and Kimberly Sullivan, a research associate professor with Boston University School of Public Health, said the study makes a strong case for a causal link and explains, to some extent, why some troops got sick and some did not.
"The authors' exploration of a gene-environment interaction between presumed nerve agent exposure and the PON1 gene offers some strong arguments that there is a true causal effect at work," they wrote in their opinion piece.
The VA has established service connection for Gulf War veterans with certain chronic, unexplained symptoms, which the department calls "chronic multisymptom illness" or "undiagnosed illness."
Those who have certain symptoms, such as chronic fatigue syndrome, fibromyalgia and some gastrointestinal disorders, and served in the 1990-1991 conflict do not have to prove service connection and are eligible for benefits including a health exam, health care and disability compensation.
Historically, however, the VA has been strict in determining service connection. A 2017 Government Accountability Office report found the VA denied 83% of 102,000 claims filed for Gulf War Illness between 1994 and 2015.
New HopeHaley said the research could pave the way for more veterans to access health care and benefits and open up research into possible treatments. He said that the symptoms are caused by brain inflammation, which may be treatable once scientists figure out exactly how sarin works.
"Once we know, we could come up with treatments to reverse it," Haley said. "I really believe this is optimistic and that it means this is not brain damage. This is not loss of neurons and like a stroke or something that you're never going to recover from."
Among the veterans excited about the new study is Paul Sullivan, a Persian Gulf War veteran who works as director of veteran outreach at the law firm Bergmann & Moore and deployed to Iraq as an Army cavalry scout with the 1st Armored Division in 1991.
He said the results provide evidence that affected veterans need to access care from the VA.
"This landmark study provides a clear path for VA to presume sarin exposure for all 1991 Gulf War veterans," Sullivan said Thursday. "The study provides a compelling missing scientific link for treatment research for my fellow Gulf War Veterans disabled since our exposures during Desert Storm."
Haley said he has received letters from veterans asking if they could get tested for the different types of the PON1 gene and whether it would be helpful. Routine genetic testing does not include PON1, but further research may lead to a diagnostic test that would provide peace of mind to veterans, he said.
The research was conducted in collaboration with a survey research team from North Carolina-based RTI International and funded by the DoD and VA, both of which have funded thousands of studies on Gulf War Illness despite long-standing skepticism.
"This is the scientific process. Nobody's bad. Nobody's good. People have their theories. Skepticism is the name of the game. That is what makes it fun," Haley said.

​https://www.military.com/daily-news/2022/05/17/researchers-think-theyve-found-cause-of-gulf-war-illness.html?ESRC=mr_220523.nl

:Nevada dentist David White has seen diseased and rotted teeth in the mouths of patients who routinely put off checkups and avoided minor procedures such as fillings. While dental phobia is a factor, White said, the overriding reason people avoid treatment is cost.
To help patients lacking dental insurance, White in 2019 started offering a membership plan that looks much like an insurance policy — except it’s good only at his offices in Reno and Elko. Adults pay $29 a month — or $348 a year — and receive two free exams, two cleanings, X-rays and an emergency exam, services valued at $492. They also get a 20% discount on office procedures such as fillings and extractions.
About 250 of White’s patients have signed up, and it’s led many to visit more frequently for routine exams and get necessary treatment, he said. “It’s pushing patients toward better oral health,” White said.
He’s among a quarter of dentists nationwide offering memberships, according to a 2021 survey of 70,000 dentists by the American Dental Association.
These in-office plans are largely targeted to the 65 million Americans who lack dental insurance and have to pay out-of-pocket for all their care. Dentists also like the plans better than handling insurance plans because they don’t have to deal with insurers’ heavily discounted reimbursement rates, waits to get preapprovals to provide services and delays in getting their claims paid.


Lack of dental coverage contributes to the delaying or forgoing of dental care by 1 in 4 adults, according to a KFF analysis of a 2019 national survey.
Kleer, a Wayne, Pennsylvania, company started in 2018, has helped more than 5,000 dentists set up the offerings. “Patients on membership plans act like insured patients and come in as much as insured patients, but they pay less for coverage while dentists get paid more,” said CEO Dave Monahan. “All we are doing is cutting out the middleman,” he said.
Monahan said business has soared during the covid-19 pandemic as more dentists, confronted with higher costs for personal protective equipment and more patients without job-based coverage, saw the need for such plans.
Anthony Wright, executive director of consumer health advocacy group Access California, said he’s skeptical about the value of individual dental insurance but said patients also should be cautious about a dental membership plan because they are generally not overseen by states. “People should be aware that this is a generally unregulated field, so it’s buyer beware,” he said.
Before joining a membership plan, consumers should ask what the dentist charges for procedures so they know not just the discount but their actual out-of-pocket cost. In some cases, the membership plans are a viable option.
“If you are going to an established practice and if the costs are reasonable and within your budget, it may make some sense” to enroll, he said.
Vanessa Bernal, office manager at Winter Garden Smiles in central Florida, said many patients who are self-employed or work for small businesses have joined the practice’s membership plan.
“They don’t have employer coverage, and if they went to buy it on their own they would face a waiting period, whereas our discounts start immediately,” she said.
Winter Garden Smiles has enrolled more than 370 patients in its plan, which costs $245 a year for children and $285 for adults. The office has dropped out of three small insurance networks since starting its own plan.
Many of the plans being offered around the country look much like dental insurance. Patients pay the dental office typically $300 to $400 a year. In return, they receive certain preventive services at no charge and other procedures at a discount.
But the membership plans don’t have the annual deductibles or waiting periods that can make individually purchased dental insurance unattractive. Another deterrent to traditional insurance plans is their maximum benefit limits, usually $1,200 to $1,500 a year. In comparison, patients with memberships can use the discounts for unlimited treatment.
About half of Americans get dental coverage through their workplace. Those policies are generally the best buy for those with the benefit. But Medicare doesn’t offer dental coverage, and most state Medicaid programs don’t cover dental treatment for adults.
But for patients without a job-based plan, purchasing an independent dental policy is expensive and, unlike buying health insurance, it’s unclear whether the benefit outweighs the costs. That’s because dental costs are not as financially catastrophic as hospital bills, which can run into tens of thousands of dollars.
Annual dental insurance premiums typically range from $400 to $700. Most plans cover all the cost of preventive services, like cleanings. For minor procedures, like fillings, the plans generally pay 70% to 80%. For major procedures, such as crowns, the plans often pay about 50% of the cost, which is still more than what the membership plans cover. The insurance plans, however, often have negotiated prices with dentists, so plan members’ responsibility is reduced by that also.
Melissa Burroughs, who leads an oral-health-for-all campaign for the advocacy group Families USA, said the dental membership plans may help some people, but they don’t solve the problems of high dental costs and insurers treating coverage for teeth differently than for the rest of the body. “I don’t think these plans are the answer, and they definitely don’t meet the standard to make care truly affordable for many people,” she said.
Megan Lohman, CEO of Plan Forward, an Indianapolis company that helps set up membership plans, said many insurers haven’t raised reimbursement rates in years, encouraging dentists to offer their own plans. “We do not see dental insurance going away, but patients and dentists just needed an alternative,” she said.
Patients say they appreciate that services under the memberships are less expensive than when paying strictly out-of-pocket, and prepaying for services motivates them to seek preventive services.
“The membership plan keeps me on track, as it’s almost like I have a down payment on my care,” said Christina Campbell, 29, of Hamden, Connecticut. She had dental coverage under her mother’s policy until she was 26 and then started shopping for her own coverage.
When her dentist, Kevin D’Andrea, mentioned his plan, she decided it looked too good to pass up. With the membership, she said, she is back to getting twice-annual checkups and cleanings, and she no longer hesitates when it’s time for X-rays. Campbell, who manages a winery, pays $38 a month.
Holly Wyss, 59, of Greenwood, Indiana, found dental insurance too expensive, so she joined a $300-a-year membership plan through her dentist, David Wolf. The discounts saved her several hundred dollars on two crowns, she said. “For me, it’s a no-brainer,” said Wyss, a nurse practitioner. “It’s been a godsend to me, since everything I pay is out-of-pocket.”
Among the groups lacking dental insurance that have recently attracted attention are people covered by traditional Medicare. Many private Medicare Advantage plans, however, offer some dental benefits. These plans provide coverage only at certain dental offices, have a premium and often cover just a small portion of patients’ costs. The average limit on coverage is $1,300, and more than half of enrollees are in plans with a $1,000 cap on benefits, according to a report from KFF.
President Joe Biden and congressional Democrats have proposed adding a dental benefit to Medicare, along with other health care initiatives, as part of a $3.5 trillion human infrastructure plan those lawmakers are seeking to push through this fall. The bill released by the House Ways and Means Committee this month would still leave beneficiaries paying 20% of costs for preventive services such as checkups and between 50% to 90% of costs for certain procedures. And the law, if passed, could take five years or more to implement.
The need among older Americans is great.
Nearly half of Medicare beneficiaries, or 24 million people, had no dental coverage in 2019, according to KFF. In 2018, almost half of all Medicare beneficiaries had not visited a dentist within the past year (47%), with higher rates among African Americans (68%) and Hispanics (61%).
D’Andrea, the Hamden, Connecticut, dentist, said the membership plan he started in 2020 builds patient loyalty. “Patients know upfront what their out-of-pocket expenses are, and they don’t have to wait and see what their insurance will cover,” he said. “It’s like a game the insurers play, keeping us on hold for an hour to get preapprovals. We pull enough teeth in the office, and it’s the same getting information out of them.”

Auhors Link Click Here: khn.org/news/article/dentists-chip-away-at-uninsured-problem-by-offering-patients-membership-plans/view/republish/

TIAA-CREF Individual & Institutional Services LLC, a subsidiary of Teachers Insurance and Annuity Association of America (TIAA), agreed Tuesday to pay the Securities and Exchange Commission $97 million in restitution to settle charges of inaccurate and misleading statements related to rollovers.
TIAA was also charged with a failure to adequately disclose conflicts of interest to thousands of participants in TIAA record-kept employer-sponsored retirement plans (ESPs).
The $97 million includes a $9 million SEC civil penalty, plus reimbursement of a portion of the affected clients’ Portfolio Advisor account fees and interest on those fees. The payment settles both the SEC’s case and a parallel action announced the same day by the Office of the New York Attorney General.
According to the SEC’s order, from Jan. 1, 2013, through March 30, 2018, TC Services and its Wealth Management Advisers failed to “adequately disclose the full nature and extent of their conflicts of interest in recommending to clients that they roll over their retirement assets” into a managed account program called Portfolio Advisor.
The order finds that TC Services failed to adequately disclose compensation practices that incentivized the firm and its WMAs to recommend Portfolio Advisor for reasons other than a client’s particular investment needs.
“Over the course of six years, tens of thousands of customers were pressured by TIAA advisors to move their investments from low-cost, employer-sponsored retirement plans to higher-cost, individually-managed accounts,” the New York attorney general’s office said, adding that the Portfolio Advisor program “was significantly more expensive for clients and generated hundreds of millions of dollars in fees for TIAA.”
TIAA also agreed to undertake significant internal reforms, including:

• Subjecting all rollover recommendations to a strict fiduciary standard;
• Eliminating differential compensation for sales of managed accounts;
• Eliminating or fully disclosing other advisor conflicts of interests related to recommending managed accounts;
• Using plain language to disclose when advisors are not acting as fiduciaries; and
• Training advisors to offer a fair comparison between managed accounts and employer-sponsored plans.

According to the SEC’s order, “TC Services trained its WMAs to make, and its WMAs made, representations that they offered ‘objective’ and ‘non-commissioned’ advice, ‘put the client first,’ and acted in the client’s best interest while holding themselves out as fiduciaries. This was misleading because TC Services’ financial incentives for WMAs rendered their advice non-objective and TC Services did not ensure that WMA’s recommendations were, in fact, in the best interest of its clients.”
TC Services “simultaneously applied continual pressure to compel WMAs to prioritize the rollover of ESP assets into Portfolio Advisor over lower cost alternatives,” the SEC states.
The ‘hat switch’During the relevant period, “TIAA Services’ compliance training materials instructed advisors that they wore two hats: at times they were a fiduciary (when they acted as an investment adviser representative), and at other times they were not (when they acted as a registered broker-dealer representative,” according to the attorney general’s office.
“In practice, this distinction was counterintuitive and inherently misleading. TIAA Services applied an investment adviser fiduciary standard to all the preliminary stages of the Sales Process right up to but not including the moment when an Advisor provided an actionable investment recommendation,” the NY case states. “Many Advisors were themselves confused about their dual roles and did not fully understand when TIAA Services expected them to act as fiduciaries and when TIAA Services treated them only as broker-dealer registered representatives.”
At times, the case continues, “TIAA Services’ compliance training materials were in direct conflict with the firm’s Sales Process training materials.”
TC Services also failed to adopt and implement written policies and procedures reasonably designed to prevent violations of the Investment Advisers Act in connection with rollover recommendations, the SEC said.
Melissa Hodgman, acting director of the SEC Enforcement Division, added in a statement that “rollovers of ESPs are of paramount importance to investors seeking financial security in retirement, and advisers acting in a fiduciary capacity need to provide their clients with complete and accurate disclosure so that they may make fully informed investment decisions.”
Investment advisors “must clearly and accurately disclose their conflicts of interest. Here, TC Services’ disclosures and misleading statements downplayed and obscured financial incentives that created conflicts between it and its WMAs on one hand and its clients on the other,” added Adam Aderton, co-chief of the SEC Enforcement Division’s Asset Management Unit.
A TIAA spokesperson said Tuesday in a statement shared with BenefitsPRO’s sister site ThinkAdvisor that TIAA “cooperated with regulators, and we’re pleased to settle this matter that covers a time period that ended more than three years ago. We regret the times that we did not live up to our clients’ expectations of us.”
TIAA, the spokesperson added, has “learned some valuable lessons and have applied those lessons to enhancing our training, supervisory controls and disclosures.”

https://www.benefitspro.com/2021/07/14/tiaa-to-pay-97m-for-pressuring-investors-into-rollovers-412-118617/?kw=TIAA%20to%20pay%20%2497M%20for%20pressuring%20investors%20into%20rollovers&utm_source=email&utm_medium=enl&utm_campaign=retirementadvisorpro&utm_content=20210715&utm_term=bpro

Aluminum Is Intricately Associated with the Neuropathology of Familial Alzheimer’s Disease
​APRIL 9, 2021
Keele, UK – A new study published in the Journal of Alzheimer’s Disease Reports continues to support a growing body of evidence that aluminum contributes to the pathogenesis of Alzheimer’s disease (AD). Researchers found aluminum co-located with phosphorylated tau protein, which is an early initiator of AD. This study builds upon two earlier published studies (including Mold et al., 2020, Journal of Alzheimer’s Disease) from the same group. The new data demonstrate that aluminum is co-located with phosphorylated tau protein, present as tangles within neurons in the brains of early-onset or familial Alzheimer’s disease. “The presence of these tangles is associated with neuronal cell death, and observations of aluminum in these tangles may highlight a role for aluminum in their formation,” explained lead investigator Matthew John Mold, PhD, Birchall Centre, Lennard-Jones Laboratories, Keele University, Staffordshire, UK.


The earlier research highlighted widespread co-localization of aluminum and amyloid-β in brain tissue in familial AD. The researchers used a highly-selective method of immunolabelling in the current study, combined with aluminum-specific fluorescence microscopy. Phosphorylated tau in tangles co-located with aluminum in the brain tissue of the same cohort of Colombian donors with familial AD were identified. “It is of interest and perhaps significance with respect to aluminum’s role in AD that its unequivocal association with tau is not as easily recognizable as with amyloid-β. There are many more aggregates of aluminum with amyloid-β than with tau in these tissues and the latter are predominantly intracellular,” remarked co-author, Professor Christopher Exley.



George Perry, PhD, Editor-in-Chief of the Journal of Alzheimer’s Disease, comments: “Aluminum accumulation has been associated with Alzheimer’s disease for nearly half a century, but it is the meticulously specific studies of Drs. Mold and Exley that are defining the exact molecular interaction of aluminum and other multivalent metals that may be critical to formation of the pathology of Alzheimer’s disease.”
“The new data may suggest that the association of aluminum with extracellular senile plaques precedes that with intracellular aggregates of tau. These relationships with both amyloid-β and tau may account for the high levels of aluminum observed in the brain tissue of donors with familial AD versus those without a diagnosis of neurodegenerative disease,” said Dr. Mold. “Tau and amyloid-beta are known to act in synergy to produce neurotoxicity in AD and our data provide new evidence for a role of aluminum in this process.”
###

​https://www.iospress.nl/ios_news/aluminum-is-intricately-associated-with-the-neuropathology-of-familial-alzheimers-disease/?utm_source=join1440&utm_medium=email

1 Apr 2021
The Penny Hoarder | By Robin HartillIf you receive VA disability pay, Social Security or SSI and you haven't received your third stimulus check, your wait is almost over. The IRS just announced that payments to those receiving VA disability could be made in mid-April, while most payments for people who receive other federal benefits and aren't required to file a tax return will be made Wednesday, April 7.
The April 7 payment date applies to those who get benefits from Social Security retirement and disability, Supplemental Security Income and the Railroad Retirement System. A payment date for those who get VA benefits hasn't yet been announced.
Why Are VA Disability and Social Security Recipients Still Waiting?
If you file a tax return and receive benefits, chances are good that you're among the 127 million Americans who have already gotten their $1,400 stimulus checks. But about 30 million recipients of Social Security and other benefits are still waiting on stimulus money.
That's because the IRS is processing stimulus payments using 2019 and 2020 tax returns. But just as with the first two rounds of payments, the IRS didn't require recipients of Social Security and other benefits to file a tax return if they weren't otherwise required to. Instead, the IRS got the information it needed from the appropriate agency.
This time around, the IRS was waiting on Social Security and other agencies to provide updated direct deposit information and addresses for recipients. On March 25, after the House Ways and Means Committee issued a 24-hour ultimatum, the Social Security Administration provided the updated information. The VA and Railroad Retirement System provided the information earlier last week.
For recipients of VA benefits, the IRS news release announcing payment dates says: "The IRS continues to review data received for Veterans Affairs (VA) benefit recipients and expects to determine a payment date and provide more details soon. Currently, the IRS estimates that Economic Impact Payments for VA beneficiaries who do not regularly file tax returns could be disbursed by mid-April."
Do I Have to Do Anything to Get My Check?
Probably not. If you received the first two checks, you're probably in line to get this one, too. The only thing you can do right now is wait.
One exception: If you have dependents, you may need to file a tax return, because the IRS may not get dependent information directly from Social Security or another agency. This time around, you'll get $1,400 for each dependent, regardless of their age. If you have dependent children, submitting a return could also help you get a child tax credit of $3,600 for children younger than 6 or $3,000 for children 17 and younger.
You may not receive money on behalf of your dependent with your check. If you don't get it with your check, the IRS will send you the extra money once it processes your return.
You can expect to receive your third stimulus check however you get your federal benefits, either through direct deposit or a Direct Express Debit Mastercard. If you've closed the bank account the IRS has on file, your bank will reject the deposit and you'll get your payment in the mail.
Can I Track My Stimulus Check Yet?
If you receive federal benefits and don't file a tax return, not yet. The IRS Get My Payment tool will be updated the weekend of April 3-4 for benefit recipients who are getting paid on April 7.
The information is updated once a day. Avoid multiple log-ins, as you may get locked out for 24 hours.
This article was originally published by The Penny Hoarder.

https://www.military.com/daily-news/2021/04/01/heres-when-va-disability-social-security-ssi-recipients-will-get-their-1400-stimulus-checks.html?ESRC=army_210406nl

by Michael Millonig, LLC
​
The COVID-19 pandemic has been particularly devastating for nursing homes and their residents.  Aside from the tragically disproportionate loss of life, care for surviving residents has been delayed or interrupted due to infection, facility lockdowns or other health system disruptions.  In such cases, Medicare beneficiaries who qualified for skilled nursing facility (SNF) coverage may be eligible for an additional 100 days of coverage. Whether all qualified beneficiaries will actually get the extended coverage is another question.
Medicare does not pay for long-term care, just for "medical" care from a doctor or other health care professional or in a hospital. But there's a partial exception to this rule. Medicare will pay for up to 100 days of care per “spell of illness” in an SNF as long as the following two requirements are met:
1. Your move to an SNF followed a hospitalization of at least three days; and
2. You need and will be receiving skilled care.
After the 100 days of coverage ends, a new spell of illness can begin if the patient has not received skilled care, either in an SNF or a hospital, for a period of 60 consecutive days. The patient can remain in the SNF and still qualify as long as he or she does not receive a skilled level of care, but only custodial care, during that 60 days.
Following the declaration of a public health emergency this spring, the federal Centers for Medicare and Medicaid Services (CMS) issued a letter granting a waiver to allow Medicare beneficiaries coverage for an additional 100 days in an SNF, without satisfying the new spell of illness requirement, in certain COVID-19 related circumstances. The letter stated that the policy will apply only to skilled-care beneficiaries whose process of care was interrupted by the public health emergency. (The letter also waived the three-days-in-a-hospital rule in certain cases.)
Six months after that letter, however, there is still confusion about which COVID-19 related circumstances qualify for the waiver. Importantly, according to the Center for Medicare Advocacy, CMS recently confirmed that beneficiaries do not necessarily have to have a COVID-19 diagnosis to qualify for the additional 100 days of coverage. Rather, as described by Skilled Nursing News, “[t]he question is whether the emergency situation interrupted the patient’s path to 60 consecutive days of non-skilled, custodial care.”
In an August 26, 2020, memorandum, CMS attempted to clarify how it would determine whether a disruption in care was related to the public health emergency: “This determination basically involves comparing the course of treatment that the beneficiary has actually received to what would have been furnished absent the emergency. Unless the two are exactly the same, the provider would determine that the treatment has been affected by – and, therefore, is related to – the emergency.” 
However, in some cases, nursing homes do not understand how the waiver applies or are not inclined to help patients with a waiver application. The Center for Medicare Advocacy offers a detailed case example of an individual who appears to meet the criteria for additional Medicare coverage but who has encountered multiple barriers in getting it.   
In addition to confusion over who qualifies for the extended coverage, the Center for Medicare Advocacy has found that the “waiver that extends SNF benefits by up to 100 days does not appear to afford beneficiaries the same rights as the first 100 days of statutory coverage,” including rights to appeal coverage denials. The Center reports that it “has received an increasing number of requests for guidance on expanded Medicare coverage in skilled nursing facilities.” In response, the organization has compiled self-help materials to assist beneficiaries and their advocates. 
The Center is asking those with experiences pursuing coverage under the public health emergency rules, waivers, or guidance to contact it at Communications@MedicareAdvocacy.org

By Joel Anderson 
August 14, 2020 
Stretching your nest egg as far as possible is something that’s most likely front of mind for retirees who aren’t very wealthy. With no new sources of income aside from Social Security or possibly a pension, it’s important to find a place to retire that won’t drain your savings.
However, getting a clear sense of exactly how long your retirement savings will last requires understanding how much it costs to live in the state you’re calling home. As anyone trying to get by somewhere with a high cost of living can attest, even basic necessities can quickly start to winnow down your retirement account. And it only gets more complicated if you decide you don’t want to spend your entire retirement in the same place, as your costs won’t be consistent throughout your retirement.
That’s why GOBankingRates performed a study to compare the cost of living in every state and determine how long you can survive off of $100,000. Granted, $100,000 won’t buy you a lot of time in any state. But, these results will give you a sense of just how much you need to save.
Last updated: Dec. 9, 2019

Are You Retirement Ready?
Sponsors of 50. Hawaii

• Annual Expenditure: $85,243
• $100,000 Will Last: 1 year, 2 months, 3 days

To say that Hawaii is the most expensive state to live in is something of an understatement: Hawaiians pay over $20,000 more per year than the second-most expensive state, California. You’ll need over $2 million to survive retirement in this state — the most in the country.
49. California

• Annual Expenditure: $64,516
• $100,000 Will Last: 1 year, 6 months, 18 days

California’s not an easy place to stretch your retirement dollar, with the cost of housing coming in at more than double the average for the country.

Are You Retirement Ready?
Sponsors of 
xavierarnau / iStock.com48. New York

• Annual Expenditure: $61,267
• $100,000 Will Last: 1 year, 7 months, 17 days

Some might gripe that the only thing imperial about the Empire State is how much it costs to live there, with the average New Yorker needing more than $60,000 a year to cover expenses.
See: 10 Best Retirement Plan Options
47. Alaska

• Annual Expenditure: $59,895
• $100,000 Will Last: 1 year, 8 months

Costs in Alaska are generally high — particularly for healthcare and utilities — but there’s one area where the state won’t eat so far into your nest egg: Alaska is the most tax-friendly state for retirees.

Are You Retirement Ready?
Sponsors of 46. Maryland

• Annual Expenditure: $59,666
• $100,000 Will Last: 1 year, 8 months, 2 days

Maryland is one of the more expensive states for retirees to live in, but a lot of the older residents can afford it: It’s one of the states with the richest retirees.
45. Oregon

• Annual Expenditure: $59,483
• $100,000 Will Last: 1 year, 8 months

Oregon has a cost of living that’s 30% higher than the country as a whole. However, if you’re dead set on enjoying the beautiful coastlines of the Pacific Northwest in your golden years, consider making your home in Brandon. It’s the best city in the state to buy a home.

Are You Retirement Ready?
Sponsors of 44. Massachusetts

• Annual Expenditure: $58,385
• $100,000 Will Last: 1 year, 8 months, 16 days

Massachusetts is not a state that’s kind to your retirement savings, with sky-high housing costs playing the biggest part in making things difficult. It’s also the state where a comfortable retirement costs the most at about $65,000 a year.
43. Connecticut

• Annual Expenditure: $58,156
• $100,000 Will Last: 1 year, 8 months, 18 days

Not only is Connecticut one of the pricier states in the country to live in, but for many retirees, the source of their income might not be as stable as they would hope. Connecticut is the worst state for pensions in the U.S.

Are You Retirement Ready?
Sponsors of 42. Rhode Island

• Annual Expenditure: $55,914
• $100,000 Will Last: 1 year, 9 months, 13 days

If you’ve compiled an impressive nest egg over the course of your career, Rhode Island isn’t a great place to keep it protected.
41. New Jersey

• Annual Expenditure: $54,175
• $100,000 Will Last: 1 year, 10 months, 3 days

Like many of the most expensive states in the country, the main culprit for New Jersey’s high cost of living is housing, with New Jersey residents paying almost 50% more than the average American for a place to live.

Are You Retirement Ready?
Sponsors of 40. Vermont

• Annual Expenditure: $53,718
• $100,000 Will Last: 1 year, 10 months, 9 days

Not only is Vermont a tough place to maintain your nest egg, it’s also a pretty rough spot for building it up as well. The Green Mountain State is the state where it’s hardest to save $1 million for retirement, found another GOBankingRates study.
39. Maine

• Annual Expenditure: $53,214
• $100,000 Will Last: 1 year, 10 months, 15 days

It’s possible that the high cost of living in Maine has some residents thinking big in terms of what it means to be wealthy. In a GOBankingRates survey, the most common answer for what it meant to be “rich” in Maine was an income of $10 million a year or more, the highest answer for any state.

Are You Retirement Ready?
Sponsors of 38. New Hampshire

• Annual Expenditure: $51,247
• $100,000 Will Last: $1 year, 11 months, 12 days

If you’re dead set on living in New Hampshire in retirement but you’re looking to avoid some of those high costs, steer well clear of the 03854 ZIP code — home to New Castle Island. It’s the most expensive ZIP code in the state.
37. Nevada

• Annual Expenditure: $50,469
• $100,000 Will Last: $1 year, 11 months, 23 days

If you want to spend your golden years in the Silver State, prepare to spend a little more. Costs are at least 10% higher than the national average across every category except for utilities, where they’re actually 20% under what the rest of America pays.

Are You Retirement Ready?
Sponsors of 36. Washington

• Annual Expenditure: $49,554
• $100,000 Will Last: 2 years, 5 days

If you’re surprised to see Washington so far down this list, keep in mind that it’s home to Seattle, one of the most expensive cities in the country. To live comfortably in Seattle you need nearly $90,000 a year, which outpaces everywhere but the usual suspects in the San Francisco Bay Area, New York and Washington, D.C.
35. Delaware

• Annual Expenditure: $48,227
• $100,000 Will Last: 2 years, 25 days

Although Delaware might be on the higher side for costs, it can also offer some great ways to protect your nest egg: It’s one of the best states to retire rich in the country.

Are You Retirement Ready?
Sponsors of 34. Colorado

• Annual Expenditure: $47,540
• $100,000 Will Last: 2 years, 1 month, 5 days

The cost to live comfortably in Denver is over $77,000 a year, making it one of the most expensive cities in the country. If you want to stay in the Rocky Mountain State but don’t like the “mile high” costs in Denver, consider Colorado Springs where it’s over $10,000 a year cheaper.
33. Montana

• Annual Expenditure: $47,540
• $100,000 Will Last: 2 years, 1 month, 5 days

If you were hoping to keep your nest egg healthy after retiring to Montana by investing well, you might find it harder there than elsewhere. Montana is one of the worst states to grow your money, according to a separate GOBankingRates study.

Are You Retirement Ready?
Sponsors of 32. Virginia

• Annual Expenditure: $46,717
• $100,000 Will Last: 2 years, 1 month, 19 days

You’ll pay less for groceries, utilities and transportation than the average American if you opt to retire to Virginia, but there’s clearly more to the story. That would be the cost of housing, which is over 10% higher than the national average.
31. Pennsylvania

• Annual Expenditure: $46,305
• $100,000 Will Last: 2 years, 1 month, 26 days

Pennsylvania is the first state on this list where housing costs are actually below average when compared to the country as a whole. However, if you’re looking to stretch your retirement savings as far as possible, you can still do better, especially when Pennsylvanians pay more than average for groceries, utilities and transportation.

Are You Retirement Ready?
Sponsors of 30. South Dakota

• Annual Expenditure: $46,305
• $100,000 Will Last: 2 years, 1 month, 26 days

There’s one thing you don’t have to worry about in South Dakota: state income tax. That’s because it’s one of the seven states without any, which could make a significant difference in how long you can stretch that nest egg.
29. Minnesota

• Annual Expenditure: $45,848
• $100,000 Will Last: $2 years, 2 months, 6 days

No state is closer to the average cost of living than Minnesota, where costs are just 0.2% higher than the country as a whole. That’s not true statewide, though, as Minneapolis is among the more expensive major cities in the country. The cost to live comfortably there is $77,512 a year.

Are You Retirement Ready?
Sponsors of 28. North Dakota

• Annual Expenditure: $45,298
• $100,000 Will Last: 2 years, 2 months, 15 days

One place you probably won’t overspend in North Dakota is on housing. Even if the state’s most expensive ZIP code — the 58503 ZIP north of Bismarck — has a median home price of $339,600, that’s still less than half of what it is for Hawaii.
27. Florida

• Annual Expenditure: $45,253
• $100,000 Will Last: 2 years, 2 months, 16 days

Florida might only be middle-of-the-pack for stretching a six-figure retirement fund, but it’s still a popular destination for many retirees. And you have plenty of options to choose from in terms of which Florida city stacks up the best for you.
Take Action Now: How To Protect Your Retirement Savings During the Coronavirus Pandemic
26. South Carolina

• Annual Expenditure: $44,978
• $100,000 Will Last: 2 years, 2 months, 21 days

The question of how long $100,000 lasts in retirement might be especially apt for South Carolina. A GOBankingRates survey determined that most residents of the Palmetto State have about $50,000-$100,000 saved for retirement.
25. West Virginia

• Annual Expenditure: $44,292
• $100,000 Will Last: 2 years, 3 months, 3 days

West Virginians are paying less for housing and utilities than most Americans, but that’s counter-balanced by higher-than-average costs on groceries and “miscellaneous” expenses.
24. Illinois

• Annual Expenditure: $44,246
• $100,000 Will Last: 2 years, 3 months, 3 days

Illinois is the first state on the better half of this survey, with the average retiree being able to squeeze a full three months out of the third year on that initial $100,000. And if you decide you want to make the Windy City your home, you’ll have plenty of options in selecting from the many different suburbs around the city.
23. Utah

• Annual Expenditure: $44,200
• $100,000 Will Last: 2 years, 3 months, 4 days

Regardless of how long it lasts, Utah is doing plenty to help you build that retirement account. It’s the state where it’s easiest to save $1 million for retirement.
22. Wisconsin

• Annual Expenditure: $44,063
• $100,000 Will Last: 2 years, 3 months, 7 days

You can make $100,000 last over two years in retirement if you’re living in the Badger State. However, if you’re thinking you’ll just need to earn $100,000 in that last year before you hang it up, you should know that you only take home $67,124 from a $100,000 salary after taxes in Wisconsin.
21. Arizona

• Annual Expenditure: $43,285
• $100,000 Will Last: 2 years, 3 months, 22 days

Arizona’s costs are lower than the national average in every category except utilities, helping retirees stretch their savings.
20. North Carolina

• Annual Expenditure: $42,965
• $100,000 Will Last: 2 years, 3 months, 28 days

If you’re looking for a place to live in retirement where you’re not in the hustle and bustle of the city but also still close enough to take advantage of city living on occasion, North Carolina might be the place to look. Three of the best suburbs for retirement are in the Tarheel State: Bermuda Run, Fairfield Harbour and Sunset Beach.
19. Louisiana

• Annual Expenditure: $42,736
• $100,000 Will Last: 2 years, 4 months, 3 days

Not only is Louisiana among the better states for stretching your savings in retirement, it’s also the best state to grow your money, found a separate GOBankingRates study.
18. Nebraska

• Annual Expenditure: $42,736
• $100,000 Will Last: 2 years, 4 months, 3 days

Nebraska’s cost-of-living scores are either at or below the national average in every category except for transportation. However, at least some of the money you can save on things like groceries and housing will end up with the state government: Nebraska is the least tax-friendly state for retirees.
17. New Mexico

• Annual Expenditure: $42,507
• $100,000 Will Last: 2 years, 4 months, 7 days

If you enjoy life in the big city but can’t handle the high cost of living that usually comes with it, New Mexico might offer you the best compromise. You only need to make $53,384 a year to live comfortably in Albuquerque, one of the lowest figures among the 50 largest U.S. cities.
16. Ohio

• Annual Expenditure: $42,416
• $100,000 Will Last: 2 years, 4 months, 9 days

Housing is especially affordable in Ohio, coming in at almost 25% less than what the average American is paying. Add that to costs that are either below average or less than 2% over it, and it’s not hard to see why Ohio cracked the top 20 in this study.
15. Idaho

• Annual Expenditure: $42,416
• $100,000 Will Last: 2 years, 4 months, 9 days

Idaho’s scenic landscape could be considered incentive enough to retire there, but the state’s low costs are an additional perk, allowing you to last into the fifth month of your third year on $100,000.
Read: How To Roll Over Your 401(k)
14. Kentucky

• Annual Expenditure: $42,370
• $100,000 Will Last: 2 years, 4 months, 10 days

Kentucky’s biggest cost advantage over other states is in its housing, where you’ll pay almost 20% less than the national average. With a median home price of just $136,600, the cost of a home in this state is one many Americans can actually afford.
13. Iowa

• Annual Expenditure: $42,050
• $100,000 Will Last: 2 years, 4 months, 17 days

Like many states in the Midwest, Iowa boasts low housing costs that help push the overall cost of living down significantly. However, while it’s housing leading the charge, Iowa’s costs are below what the average American pays across the board.
12. Indiana

• Annual Expenditure: $41,867
• $100,000 Will Last: 2 years, 4 months, 20 days

Indiana offers retirees the chance to stretch their savings much further than most of the country; this is important to the Hoosier State, as Indiana is the state with the poorest retirees in the country.
11. Wyoming

• Annual Expenditure: $41,821
• $100,000 Will Last: 2 years, 4 months, 21 days

The cost of living in Wyoming is lower than it is for the country as a whole, but the high cost of healthcare for seniors could quickly erase much of that benefit. Employing either homemaker services or a home health aide will run you about $5,000 a year.
10. Texas

• Annual Expenditure: $41,775
• $100,000 Will Last: 2 years, 4 months, 22 days

Texas offers a range of advantages to its elderly residents when it comes to stretching retirement dollars. In fact, eight of the 30 best cities to retire on a budget of $1,000 a month or less are in the Lone Star State.
9. Georgia

• Annual Expenditure: $41,546
• $100,000 Will Last: 2 years, 4 months, 27 days

Low costs in Georgia mean a retiree can make $100,000 last them for almost two years and five months. Even if you’re living well by saving on basic costs, though, not everyone is in the same situation: Atlanta is among the places in the U.S. with the most income inequality.
8. Kansas

• Annual Expenditure: $40,952
• $100,000 Will Last: 2 years, 5 months, 9 days

Kansas is a great state to retire to if you want to stretch your nest egg as far as possible, and it’s even better if you’re living off of a pension funded by the state: Kansas is one of the best states for pensions.
7. Tennessee

• Annual Expenditure: $40,906
• $100,000 Will Last: 2 years, 5 months, 10 days

Whether it’s the Grand Ole Opry in Nashville or Beale Street in Memphis, Tennessee is a great state for American music. Of course, if you’re retired and living there, it’s the low costs that might be music to your ears.
6. Missouri

• Annual Expenditure: $40,677
• $100,000 Will Last: 2 years, 5 months, 15 days

Although most costs are lower in Missouri, the Show-Me State is especially affordable when it comes to housing. A year of a roof over your head costs an average of just $11,597, making it one of just five states where you can expect to pay under $12,000 per annum.
5. Alabama

• Annual Expenditure: $40,631
• $100,000 Will Last: 2 years, 5 months, 16 days

You can expect to stretch your retirement savings by retiring almost anywhere in the Yellow Hammer State, but that’s especially true if you decide to call the city of Birmingham home: It’s one of the cheapest places to retire in the entire country.
4. Arkansas

• Annual Expenditure: $40,631
• $100,000 Will Last: 2 years, 5 months, 16 days

The cost of a comfortable retirement in Arkansas is very low, coming in below any other state in the country save for Mississippi and its incredibly low cost of living.
3. Michigan

• Annual Expenditure: $40,586
• $100,000 Will Last: 2 years, 5 months, 17 days

The Great Lake State is as welcoming as it is scenic, and the low costs mean you can enjoy more of it with your nest egg.
2. Oklahoma

• Annual Expenditure: $40,403
• $100,000 Will Last: 2 years, 5 months, 21 days

Oklahoma has low costs statewide that will help you stretch $100,000 to almost a full two and a half years. And unlike many states, that extends to the state’s largest city as well: $1 million will last you 24 and a half years in retirement in Oklahoma City, making it one of the most affordable U.S. cities for retirees.
1. Mississippi

• Annual Expenditure: $38,435
• $100,000 Will Last: 2 years, 7 months, 6 days

No state has a lower cost for a comfortable retirement than Mississippi, where you can expect to pay almost a third less for housing than the country as a whole. All told, the cumulative cost of living in Mississippi is 16% lower than the national average.
How Long $100K in Retirement Will Last in Every StateStates on either coast might offer a lot in terms of great weather and loads of culture, but they certainly ask a lot in terms of your pocketbook. The 15 states where $100,000 stretches the least in retirement include all five states on the Pacific Ocean (Hawaii, California, Oregon, Washington and Alaska). On the East Coast, the worst states for your retirement nest egg are New York, Maryland, New Jersey and all six of the states that make up New England.
On the other end of the list, it’s hard to miss that states from the South and the Midwest have the lowest costs by far. Of the 15 states where your $100,000 in retirement savings goes the furthest, all but two (Idaho and Wyoming) are in one of those two regions.

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With COVID-19 cases rising across the country, there's not really much debate about whether the situation is getting worse or better in the United States. In fact, the only division among public health experts now is whether we're in a second wave, or whether the first wave never ended.
Sadly, things are probably going to continue getting worse, with some states re-closing, case counts rising, and hospitals in some parts of the country at risk of becoming overwhelmed. As the bad news mounts, there's a very real chance there will be significant economic consequences, including an extended recession and a possible repeat of this spring's market crash.
Retirees need to be prepared for this type of economic turmoil. Here are three key steps to take right now to get ready if a second coronavirus lockdown happens. 
 
1. Bulk up your emergency fundIf COVID-19 cases continue to spike and businesses begin re-closing en masse across the United States, the result will almost assuredly be economic chaos. This could have an impact on the stock market, potentially sending your investments plummeting again. And if consumer spending falls this quarter, you'll likely see no Social Security cost-of-living adjustment next year. 
If your investment account balance falls and your Social Security benefits stay stagnant, putting you at risk of losing buying power, you don't want to be in a position where you have to sell losing investments just to get money to cover your costs or cope with an emergency. Make sure you're prepared for both minor and major calamities by building up a hefty emergency fund in a high-yield savings account.
If you have liquid cash to cover several months of living expenses, you can wait out any market downturn and economic chaos a second wave causes without putting your future financial security in jeopardy.
2. Review your investment strategy and asset allocationRetirees should have some money invested in the market, but it needs to be an appropriate amount and in appropriate investment vehicles given your age and risk tolerance. It's important to make sure you aren't over-invested -- especially with the looming possibility the market could crash again.
To determine what percent of assets should be in the market, subtract your age from 110. So if you're 70, you'd want about 40% of your money in equities and the rest in more stable and secure holdings. You'll also want to ensure you've got a sound investment strategy that you're comfortable with so you're less likely to incur long-term losses in a bear market and so you won't be tempted to panic-sell if you see your portfolio balance start to fall.  
3. Review your medical coverageMost retirees have Medicare, but its coverage isn't as comprehensive as many think. To ensure you're not caught off guard by surprise expenses, review what's covered and what your coinsurance obligations are in case you get sick.
You can see details about Medicare Coronavirus coverage online, but this pandemic is an important reminder that you tend to become more medically vulnerable as you get older, so you also need to know what your insurance will cover if you develop other ailments.
For many seniors, it makes sense to opt for a Medicare Advantage or Medigap policy to get more comprehensive protection than traditional Medicare offers. Start looking into your options now so you'll be ready to make a change if needed when open enrollment comes around. 
Don't get caught unprepared for a second waveThe coronavirus has already sent the country into a recession, driven record-high unemployment, and caused trillions of dollars in (temporary) losses in the stock market. There's a very real chance a second wave could be worse if it necessitates more stay-at-home orders that last for a longer time.
While there's no guarantee economic disaster will result from rising COVID-19 cases, it's best to be prepared in case it does. Taking the three steps mentioned above will help ensure your retirement isn't derailed if things go wrong. And if everything turns out better than expected, having a little extra money saved for emergencies and ensuring your investments are wise ones will only make you more prepared for whatever happens in the future. 


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Cynthia Measom
July 9, 2020, 5:00 AM
How Far a Retirement Fund of Half a Million Dollars Stretches in the 7 Most Populous StatesExperts typically recommend having at least $1 million dollars saved up for retirement, but some people either don’t have the time or refuse to delay their retirement to reach that idealistic milestone. Fortunately, if your retirement nest egg is hovering around $300,000, you have options both stateside and abroad.
For example, if you move to Fort Wayne, Indiana, you can stretch your retirement stash out over more than a decade. If you choose to move to another country, however, you can stretch your funds even further — in the top-ranked country on this list, a $300,000 nest egg could last you 55 years.
To find out the best locations for people with $300,000 in retirement, GOBankingRates analyzed the population and annual expenditures in the top 100 U.S. cities and 50 of the top countries across the globe. Discover where you can retire well without $1 million in the bank.
Last updated: Nov. 7, 2019
How Long $300,000 Lasts in Retirement in These CitiesEven though a $300,000 retirement nest egg doesn’t seem that substantial, you might be surprised. There are U.S. cities where that sum of money can last almost 12 years. Here are 11 locations to consider.
11. Memphis, Tennessee

• How many years $300K will last for renters: 9.68
• Annual cost of rent: $10,890
• Annual grocery cost: $3,527.12
• Annual utilities cost: $3,576.58
• Annual healthcare cost: $8,716.70
• Annual transportation cost: $4,283.40

You’ll actually pay less for rent in Memphis, on average, than you will in half of the other cities on this list. On top of that, the Home of the Blues has the third-cheapest annual groceries.
What sets Memphis back on this list is its annual healthcare cost. At $8,716.70, Memphis not only has far and away the most expensive healthcare cost on this list, it was also the most expensive cost for healthcare among all of the U.S. cities analyzed.
10. Pensacola, Florida

• How many years $300K will last for renters: 9.69
• Annual cost of rent: $12,600
• Annual grocery cost: $3,589.61
• Annual utilities cost: $3,910.84
• Annual healthcare cost: $6,760.30
• Annual transportation cost: $4,096.49

One of the ways you’ll save hundreds in Pensacola is on groceries. The annual grocery cost is $316.69 less than the national average of $3,906. And even though the city landed on the lower half of this list, you could live almost a decade on $300,000 — with total cost of living expenses and rent coming in at just under $31,000 annually — which is a great deal in the Sunshine State.
9. Tulsa, Oklahoma

• How many years $300K will last for renters: 9.83
• Annual cost of rent: $11,940
• Annual grocery cost: $3,499.78
• Annual utilities cost: $3,550.58
• Annual healthcare cost: $7,416.90
• Annual transportation cost: $4,100.38

Tulsa retirees can rack up big savings on groceries and utilities. The city has the second-lowest annual grocery cost out of all of the cities on the list at $406.22 less than the national average. The city also has the fourth-lowest annual utilities cost, which rings up to $163.42 less than the national average.
Alternatively: See How Long $100,000 Will Last in Retirement in Every State
8. Kansas City, Missouri

• How many years $300K will last for renters: 9.84
• Annual cost of rent: $12,420
• Annual grocery cost: $3,628.67
• Annual utilities cost: $6,713.40
• Annual healthcare cost: $3,766
• Annual transportation cost: $3,960.20

In Kansas City, Missouri, the annual grocery cost is $277.33 less than the national average, allowing you to save hundreds each year. You can save thousands of dollars per year, however, on healthcare if you live here. The annual healthcare cost is a whopping $2,934 less than the national average of $6,700.
7. St. Louis

• How many years $300K will last for renters: 10.03
• Annual cost of rent: $12,000
• Annual grocery cost: $3,628.67
• Annual utilities cost: $3,558.01
• Annual healthcare cost: $6,284.60
• Annual transportation cost: $4,431.37

St. Louis has the fifth-lowest annual healthcare and utilities costs out of all of the cities on the list. Plus, annual grocery, utilities and healthcare costs are all below the national averages.
6. Mobile, Alabama

• How many years $300K will last for renters: 10.16
• Annual cost of rent: $11,142
• Annual grocery cost: $3,628.67
• Annual utilities cost: $3,621.15
• Annual healthcare cost: $7,148.90
• Annual transportation cost: $3,991.35

You can squeeze more than a decade out of $300,000 if you choose to live in Mobile. That’s because the cost of living here is much cheaper. The annual utilities cost, for example, is $92.85 less than the national average.
5. Indianapolis

• How many years $300K will last for renters: 10.44
• Annual cost of rent: $12,000
• Annual grocery cost: $3,542.74
• Annual utilities cost: $3,350.03
• Annual healthcare cost: $5,795.50
• Annual transportation cost: $4,041.97

Indianapolis has the lowest cost for annual utilities out of all of the cities on the list, which is $363.97 lower than the national average. The city also has the fifth-lowest annual grocery cost and fourth-lowest annual healthcare cost. In fact, the annual healthcare cost is $904.50 less than the national average.
4. Wichita, Kansas

• How many years $300K will last for renters: 10.79
• Annual cost of rent: $10,200
• Annual grocery cost: $3,531.02
• Annual utilities cost: $3,843.99
• Annual healthcare cost: $6,612.90
• Annual transportation cost: $3,613.63

Wichita’s annual cost of rent is third-cheapest out of all the cities on this list. The city also has the fourth-lowest annual grocery cost. When compared to the national average, you can save $374.98 annually on groceries here. The annual healthcare cost is also below the national average of $6,700.
3. Cleveland

• How many years $300K will last for renters: 10.89
• Annual cost of rent: $10,800
• Annual grocery cost: $3,632.58
• Annual utilities cost: $3,524.59
• Annual healthcare cost: $5,514.10
• Annual transportation cost: $4,088.70

Cleveland has the second-lowest annual healthcare cost on the list. Healthcare costs here total up to impressive savings — $1,185.90 below the national average. The city also has the third-lowest annual utilities cost, which is $159.71 under the national average. Annual grocery costs are also less here: $273.42 below the national average.
2. Toledo, Ohio

• How many years $300K will last for renters: 11.43
• Annual cost of rent: $ 9,540
• Annual grocery cost: $3,542.74
• Annual utilities cost: $3,610.01
• Annual healthcare cost: $5,748.60
• Annual transportation cost: $3,796.65

Out of all the cities on the list, Toledo has the cheapest rent, with median rent coming in at $795 a month. It also has the third-lowest annual healthcare cost and transportation cost on the list. A year in retirement will only cost you, on average, $26,238.
1. Fort Wayne, Indiana

• How many years $300K will last for renters: 11.79
• Annual cost of rent: $9,600
• Annual grocery cost: $3,464.62
• Annual utilities cost: $3,368.60
• Annual healthcare cost: $5,393.50
• Annual transportation cost: $3,621.42

There’s more than one reason why Fort Wayne landed in the top spot for U.S. cities. Out of all of the cities on this list, Fort Wayne has the lowest annual cost for groceries, as well as the lowest annual healthcare cost. In addition, it has the second-lowest annual utilities cost and the second-lowest annual cost of rent.
How Long $300,000 Lasts in Retirement in These CountriesIf you’re willing to go international in retirement, your options with a $300,000 retirement fund suddenly open up. Here are 11 attractive locations aboard where you can stretch your retirement savings farther than anywhere in the U.S.
11. Australia

• How many years $300K will last for renters: 14.44
• Annual cost of rent: $15,861.99
• Annual grocery cost: $3,251.28
• Annual utilities cost: $1,666.08

People interested in relocating to the land Down Under can refer to the Australian government’s Department of Home Affairs website detailing the pathway to permanent residency for eligible retirees. In this country characterized by a laid-back and relaxed vibe, the majority of Australians speak English. Move here, and you’ll find yourself among a population who values making the most of its leisure time.
10. Panama

• How many years $300K will last for renters: 20.07
• Annual cost of rent: $10,901.10
• Annual grocery cost: $2,960.16
• Annual utilities cost: $1,086.36

Spanish is the official language of Panama and the most widely spoken. English is only spoken by approximately 14% of the population. The U.S. Embassy in Panama recommends that you consult with an attorney in Panama if you are considering retirement there. Retirees seeking a relaxed lifestyle can find plenty of places to feel at home within this country, including the tourist-friendly Panama City.
Read: How Long $1 Million in Savings Will Last in Every State
9. Cyprus

• How many years $300K will last for renters: 21.94
• Annual cost of rent: $9,340.59
• Annual grocery cost: $2,719.08
• Annual utilities cost: $1,615.92

If you’re going to retire to the Mediterranean island of Cyprus and don’t plan on working, you’ll need to apply for a Category F permit to settle. You’ll also need to document a secure source of income, such as a pension or dividends from investments. Although Greek and Turkish are the official languages of Cyprus, 73% of the population speaks English. In this small country, most of the people are friendly and enjoy interacting.
8. Portugal

• How many years $300K will last for renters: 22.37
• Annual cost of rent: $9,751.65
• Annual grocery cost: $2,375.04
• Annual utilities cost: $1,283.16

Portugal has the fourth-lowest annual grocery cost of all of the other countries on the list. The country offers a fixed-residency visa for retirees who wish to stay in the country for more than one year. The majority of the country’s population speaks Portuguese, but English is the second-most widely spoken language among tourists and business people. English is also taught as a second language in schools.
7. Taiwan

• How many years $300K will last for renters: 24.68
• Annual cost of rent: $7,133.04
• Annual grocery cost: $4,128.36
• Annual utilities cost: $806.64

Taiwan has the fourth-lowest annual utilities cost of all of the countries on this list. To become a resident in this country, you’ll need to apply for a Republic of China Resident Visa, which is valid for three months. Resident Visa holders must apply for the Alien Resident Certificate and Re-entry Permit within 15 days of the day following their arrival in the country. The official language of Taiwan is Mandarin. English, which is taught in the country’s schools, is the most significant foreign language. As for the culture, Taiwan is more traditional and conservative than other countries on this list.
6. Costa Rica

• How many years $300K will last for renters: 27.23
• Annual cost of rent: $7,224.63
• Annual grocery cost: $2,858.16
• Annual utilities cost: $933.84

Costa Rica has the fifth-lowest annual utilities cost of all of the countries on this list. To gain a residence permit in this country as a retiree, you’ll need to have an income of at least $1,000 per month. Of all South American countries, Costa Rica is generally regarded as having one of the most stable and democratic governments. Spanish, the official language of the country, is used by the government, media and schools.
5. Uruguay

• How many years $300K will last for renters: 27.83
• Annual cost of rent: $6,896.73
• Annual grocery cost: $2,549.52
• Annual utilities cost: $1,333.44

Uruguay has the fifth-lowest annual grocery cost of all of the countries on this list. The country is recognized for its friendly and laid-back culture, with a year-round mild climate. Spanish is the official language, with minimal English spoken. Two residency options are available to foreigners: temporary residency and permanent legal residency. Residential eligibility is simple, as long as you meet the country’s standard requirements.
4. Greece

• How many years $300K will last for renters: 30.84
• Annual cost of rent: $5,167.50
• Annual grocery cost: $2,553.24
• Annual utilities cost: $2,006.52

Retiring in Greece will give you the advantage of living in a society steeped in culture, tradition and family values while enjoying nine months of glorious sunshine. To gain permission to reside in Greece, U.S. citizens should first obtain a visa from the Greek Consulate or Embassy in their area. Once in Greece, and before the visa expires, you will need to apply for a residence permit at the Decentralized Administration Office. Greek is the official language spoken by the majority of the population. English is typically reserved for business purposes but it’s also taught in schools.
3. Malaysia

• How many years $300K will last for renters: 40.52
• Annual cost of rent: $4,725
• Annual grocery cost: $2,141.16
• Annual utilities cost: $537.48

Malaysia has the third-lowest annual utilities cost of all of the countries on this list. The country also has the third-lowest annual grocery cost. Via the country’s Malaysia My Second Home (MM2H) Programme, foreigners who meet certain requirements can qualify to stay in the country on a multiple-entry social visit pass, which is initially issued for 10 years. Besides Malay, which is the official language of Malaysia, English is also commonly spoken in this country. In general, Malaysians have a laid-back and relaxed attitude, but the practice of drinking alcohol is not popular due to the large Muslim population living in the country.
2. Mexico

• How many years $300K will last for renters: 42.60
• Annual cost of rent: $4,783.11
• Annual grocery cost: $1,829.76
• Annual utilities cost: $429

Choosing Mexico as your retirement destination can help you stretch a $300,000 nest egg over decades. Mexico has the lowest annual utilities cost of all of the countries on the list and the lowest annual grocery cost. A monthly income of at least $2,000 — or a bank balance of at least $80,000 — can help retirees qualify for permanent residency. Although Mexico’s Constitution states that the country is multilingual — due to the different indigenous languages spoken there — Spanish is the most widely spoken.
1. Sri Lanka

• How many years $300K will last for renters: 55.01
• Annual cost of rent: $3,056.97
• Annual grocery cost: $1,943.40
• Annual utilities cost: $453.24

Sri Lanka has the second-lowest annual utilities cost of all of the countries on this list. The country also has the second-lowest annual grocery cost. With a $15,000 deposit, foreign nationals who are at least 55 years old and have a monthly income of at least $15,000 are eligible for Sri Lanka’s two-year renewable “dream home” visa. The two official languages of the country are Sinhalese and Tamil. Only around 10% of the country speaks English, which is primarily used for business purposes, but the people have a reputation for being warm and friendly.
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Chris Jennings contributed to the reporting for this article.
Methodology: GOBankingRates analyzed the top 100 U.S. cities in terms of population and 50 of the top countries across the globe in order to find how long $300,000 will last in retirement. 
For the top 100 U.S. cities, GOBankingRates found the annual expenditures for a consumer unit (1.8 people) 65 years and older in the following categories: (1) grocery (“food at home”), (2) healthcare (“Healthcare”), (3) utilities (“Utilities, fuels, & public services), and (4) transportation (“Gas, other fuels, & motor oils” + “Other vehicle expenses”), all sourced from the Bureau of Labor Statistics Consumer Expenditure Survey, 3rd Quarter 2017 through 2nd Quarter 2018. These annual expenditures were then factored for each city using Sperling’s Best Places Cost of Living indices. For each city, GOBankingRates found both the median list price and median rent, which were then extrapolated out to give an (5) annual mortgage cost using SmartAsset’s mortgage calculator (assuming a 30-year fixed-rate mortgage after a 20% down payment and a rate of 3.82% as sourced from the Federal Reserve Bank of St. Louis as of June 16, 2019) and (6) annual cost of rent, respectively. These four factors formed the annual cost of living total, which was then combined with the annual mortgage cost and annual rent cost to give both (7) annual cost of living for homeowners and (8) annual cost of living for renters for each city. The totals were then divided by $300,000 to see how many years into retirement that total would last, with the larger total being better.
For countries, GOBankingRates used Numbeo.com to source all annual expenditure data. The average monthly rent was determined by averaging the costs of one one-bedroom apartment in the city centre, one one-bedroom partment outside of the city centre, one three-bedroom partment in the city centre, and one three-bedroom apartment outside of the city centre for each country. This average monthly rent was extrapolated out to give an (9) annual cost of rent for each country. GOBankingRates then found the monthly cost of utilities and groceries for each country, extrapolating those costs out to get annual cost for both (10) groceries and (11) utilities. These two factors (groceries and utilities) were combined with annual cost of rent to give an (12) annual cost of living for renters in each country. This total was then divided by $300,000 to see how many years into retirement that total would last, with the larger total ranking higher.
Data is accurate as of July 25, 2019, and is subject to change.
This article originally appeared on GOBankingRates.com: Here’s How Long $300K Lasts in Retirement

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The BCBS companies alleged that CVS had offered lower prices for “hundreds” of generic drugs and later told insurers that the prices were much higher than they actually were.
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Blue Cross Blue Shield insurers in six states have sued CVS Health Corp. over an alleged scheme to overcharge them for generic drugs by submitting claims for payment at “inflated prices.”
The lawsuit, filed May 27 in the Rhode Island federal court, added to mounting pressure that CVS has been facing since 2015 over its cash discount programs, which it said were designed to compete with Walmart and other “big-box” discounted pharmacies.
According to the complaint, health insurers typically negotiate “lesser-of” contracts with pharmacy benefits middlemen to pay the lower cost of either the negotiated drug price or the cash price that insured patients would pay. But the BCBS companies alleged that CVS had offered lower prices for “hundreds” of generic drugs and later told insurers that the prices were much higher than they actually were.
 
“By intentionally submitting falsely inflated usual and customary prices, CVS knew that it was being overpaid for these generic drug transactions. In fact, as internal documents show, that was CVS’s plan all along,” BCBS’s attorneys from Partridge Snow & Hahn wrote in the 46-page complaint.
“CVS has now pocketed billions of dollars in ill-gotten gains through this unlawful scheme— including many millions from plaintiffs,” they said.
CVS, however, is not the only pharma firm to land in hot water over claims for prescription drug prices.
Last month, 50 independent pharmacies sued OptumRx, a major pharmacy benefit manager, in a proposed class action over its alleged failure to comply with state pharmacy claims reimbursement laws.
That suit claimed that OptumRx paid local pharmacies substantially less than it paid large chain retail pharmacies like CVS or Walgreens and knowingly reimbursed local pharmacies below wholesale cost to stock necessary generic prescription drugs.
Still, CVS is preparing for a planned trial later this year over substantially the same issue in the first class action to target the Woonsocket, Rhode Island-based company for overcharging for generic drugs.
CVS has said in financial filings that it is “defending itself against these claims.”
The BCBS suit has cited “internal documents” from public legal filings to argue that CVS concealed its alleged scheme from third-party payors for years.
“Had CVS been open and notorious about its fraudulent pricing scheme, it never would have succeeded—plaintiffs would have insisted that CVS submit the correct usual and customary price,” the complaint said. “Indeed, while carrying out this scheme, CVS internally feared that third party payors would learn of the deception and demand correction.”
The plaintiffs in the case, captioned Blue Cross and Blue Shield of Alabama v. CVS Health, are represented by Christian Jenner, Paul Kessimian and Phoebe Roth of Partridge Snow & Hahn.