Empire State Associates' product quality, experience and reach distinguish it in the plumbing and HVAC market.
Empire State Associates' (ESA) principals are highly aware of the struggles facing the wholesale distribution companies it serves. "Our vision, which we talk about all the time, is to remain pertinent and relevant to the wholesalers, engineers and contractors we do business with," says Bill Frenzel, one of the three principal owners of the Ballston Spa, N.Y.-based manufacturer's representative agency.
The company employs two technicians who offer technical training for wholesalers, contractors and engineers on the plumbing and HVAC products it represents. ESA's line card includes leading manufacturers of plumbing and heating products.
The addition of AO Smith to ESA's line card enabled ESA to stock and sell water heater parts directly to its wholesale customer base. The company also stocks parts on the behalf of two other manufacturers.
Equipment sold by ESA is used in both commercial and residential settings. National distributors make up a portion of ESA's business, with independent firms making up the balance. The company also works with engineers to get its products specified in projects including new construction, remodels and retrofits.
ESA's history dates back to the 1940s, when Eric Wellisch, a New York City resident who often traveled to upstate New York to make sales calls, started the firm. He was joined in the 1950s by partner Greg Magratten, and the company became known as Wellisch Magratten Associates. In 1974, Wellisch sold his share of the company to Dale Norris, who had formerly worked as a territory manager in upstate New York.
In 1979 Jim Martin, a veteran of the wholesale industry who previously started his own agency, joined the company. Martin brought to the company – then known as Magratten Norris Martin Associates – several product lines, including Cherne and Fernco. Frenzel, who previously worked in the plumbing wholesale business, joined the company after Magratten's retirement in 1986. The company the following year changed its name to Empire State Associates.
The company has quadrupled its sales since Frenzel joined the company. Today, ESA's principal owners are Frenzel, who covers a sales territory that includes Syracuse, Binghamton, Watertown and Utica, N.Y.; Bill Norris, Dale's son, who joined the agency in 1992 and manages a sales territory in eastern New York; and Adam Frenzel, Bill's son, who joined the company in April 2006 and has covered the Rochester, N.Y., area since May 2009.
Frenzel says the company prides itself on attracting and retaining highly qualified sales staff and other employees. "When it comes to salary and benefits, no one in our industry does for their employees what we do for ours," He says. "We don't turn staff over, and people like working for us.


vintage postcards ... LOCAL SHOWERS ..POSTCARD . ..
vintage POSTCARD paper & ephemera ... Wonderful POSTCARD - with a delightful saying on the front - Weather Forcast ... LOCAL SHOWERS - too funny image of child with puddle pants - POST CARD not stamped or written on - never used... antique SWEET! this single little beautiful greeting is so vintage darling to offer the perfect greeting with a great vintage get well gift or perfect for your multimedia crafting, scrapbooking, collages, mosaics and creative frenzy! Could be Framed or perfect for that special card to a dear friend!
PLEASE email me to gladly reserve an item while I quickly get you a shipping quote - then only one paypal transaction is necessary (if you do purchase without a shipping amount that is fine but then you will need to complete a second shipping payment following the quote) - sorry but with such a variety of items and multiple buys the quotes are specific to the unique order and each customer so impossible to pre-determine - it may take a little longer but it is to find you the best (multiple buy) shipping rates.
I ship on Wednesdays of each week.
As I offer vintage and custom merchandise all sales are final but if you are not happy please contact me.
I'm listing as quickly as I can - retro finds and vintage funk to add to your stash-mania!
Check back here often as I am madly stocking the Etsy shelves!
AND my ANTIQUE OFFICE at INKTIQUES at"
THANK YOU for shopping at DearNellieStationery on Etsy!
vintage postcards ... 2 FOR 5 .. POSTCARD . ..
vintage postcards ... DONKEY COMIC See My Way Clear .. POSTCARD . ..
Unfortunately this item got lost in the mail. But the seller did issue a refund.
Thanks! Very nice and arrived on time.
I love this cute get well card. My dad was a rancher and had steers so he will enjoy this as a get well card. Perfect transaction and seller.
Wonderful cards! Perfect for Christmas T.Y. notes. Great!!
Item must be paid within 24 hours, 1 business day, of purchase unless convo and other arrangement - if no correspndence/convo I will cancel the sale and relist the item.
all vintage and custom goods - sold as is final sale - but please if you are not happy do not hesitate to contact me.
Please contact me for shipping cost - I will quote given your location and your chosen method of shipping - I do not charge any handling fees.
If you have paid immediately on purchase without a shipping quote then you will have to make a second paypal payment when I invoice you for the quote on shipping.
I will will gladly combine multiple purchases across any of my 6 shops for best shipping cost.
Insurance optional and buyers choice at time of payment.
Shipping method as requested by buyer at time of purchase - least cost or fastest - your choice!
I generally ship once a week on Wednesdays.
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Notes Service
Home Movie Reviews Tomorrow War – The Capn's Take
Tomorrow War – The Capn's Take
I was damn well convinced this was a David S. Goyer film. It had all the trappings of one without actually being one. If that makes any sense.
He's hard to explain, David S. Goyer. He's mostly written and produced films, but has directed some. I think you might be more familiar with his Blade films.
I don't know why I'm going so deep into David S. Goyer when he didn't write or direct this. He did however produce it. Yeah, I kind of felt good about myself for predicting that when it was time for the end credits to start rolling.
Like, yup! Knew it!
So if David S. Goyer didn't direct this, who did?
That would be Chris McKay. He hasn't really done much other than some animated stop-motion work. He's done a lot of Adult Swim content and The Lego Batman movie. That's about it when it comes to directing features.
I'll just tell you right off that I loved this movie. It hit almost every sweet spot with me until the end, but we'll get to that later.
The best way to describe this film is well… it's actually a combo of a few different movies such as that little seen but much loved Tom Cruise film Edge of Tomorrow. Another film I loved by the way.
It also has some Starship Troopers mixed in there, one of my favorite films. And some Aliens. Fuck it, why not just toss some Quiet Place in there for good measure.
It also feels like not only did we get the first film in a trilogy but also the sequels as well. Sure, they could have stretched this thing out like The Quiet Place, taking a thin plotline and trying to get three movies out of it, but Tomorrow War said nah, we'll just give you the whole shabang with one go, so hold your butts for one hell of a ride!
I've always liked Christ Pratt and when I say always I mean going as far back to his days on Everwood.
So I've been a fan for many years. No one was more excited to see him blow up as I was.
The fact he's married to Arnold Schwarzenegger's daughter is also kind of hilarious to me for some reason.
I'm less thrilled about the Jurassic Park films, less to do about him and really everything else about those movies themselves. But he is perfect as Star Lord in the Guardians of the Galaxy films.
I also think he's good in Tomorrow War, not great but good. They do know how to play to his strengths like his comedic timing and his charm, but you start to lose me when he becomes an unstoppable killing machine. He's a goof that bumbles through things. That's kind of his main trait. His shtick.
The plot to Tomorrow War I found really intriguing. Maybe kind of dumb, but interesting.
Basically, people from about 30 years in the future are in an unwinnable war with an alien race that has infested Earth, killing everything that moves indiscriminately.
So the people of the future use a scrapped together time machine to go back in the past to help recruit soldiers to fight this pretty much unwinnable war.
I found it interesting, what can I say!
I'm a sucker for time travel and Chris Pratt, not to mention Starship Troopers. This movie was tailed made for me.
Chris Pratt plays Dan Forester, an ex soldier now turned highschool science teacher. He's feeling down about himself as he just lost out on getting this job at some top research center.
The self pity soon ends because immediately we are introduced to our time travelers begging the past for help.
Dan has a wife and daughter, the wife isn't really all that important to the story, she might as well not exist, but the daughter is pretty important as you'll learn later.
The theme of this movie is family. Dan and his father, played by JK Simmons, are estranged from one another, as he abandoned Dan and his mother when he was young.
His character James really wishes to have a relationship with his granddaughter Muri. A name I don't think I've ever heard before.
Since the mortality rate is so high for anyone willing to go to the future to fight this invasion, a worldwide draft has been started.
Enter Dan, who turns out to be the perfect candidate. Not because of his military expertise, but because he dies in 7 years.
That is the criteria for any candidate. They can't have a future.
So they strap on this arm band and give you 24 hours to say your goodbyes. After that you get basic training. And by basic, I mean basic like in how to hold your gun upright and that's about it.
Dan meets fellow scientist Charlie who comments just how slapdash this whole thing is. They don't even have uniforms, just whatever they walked off the street in. Even one guy who was still wearing a chef's hat.
Before Dan and Charlie even have time to get to know each other, they are tossed into the future. And I mean literally tossed, as the time machine they use shoots everyone about 30 feet into the sky, over a city where the only safe landing is a rooftop swimming pool.
So about 80% of the new recruits die immediately. No, I doubt the dude wearing the chef's hat made it sadly.
Charlie and Dan did, along with a few others we quickly get to know like the team of returning badasses that have done this before and lived to tell the tale.
The veterans, Dan and Charlie and a few of the other remaining survivors are tasked immediately on a rescue mission to save a group of scientists and their research on the aliens they call "whitespikes". Called this because they are bone white and shoot spikes from their many viper-like tails.
This research team has been collecting data on a toxin that will kill the whitespikes, so it's vital Dan and his team get there before the whole city is leveled by jets carpet bombing the place.
Of course when they get there all the scientists are already dead. These whitespikes have almost impenetrable skin, only vulnerable under their chins and bellies.
Barking orders at Dan is someone leading this whole operation, played by Yvonne Strahovski from Handmaid's Tale. And Chuck, but I doubt anyone remembers that show.
Dan and his team gather as much research as they can, but get ambushed by whitespikes that have made a nest of the research building they're in.
Dan, Charlie and the leader of the veterans Dorian who much like Dan will be dead in a few years due to cancer. He figures if he's going out, it might as well be killing these alien monsters.
I really like the alien's design. They do kind of remind me of the aliens from The Quiet Place, but if they had these nasty looking tails that would shoot spikes at you like a gun.
After that disaster of a first mission, Dan meets the one who was barking orders at him, his now grown daughter.
So I pretty much called this immediately, even in the trailers I kind of figured that's who she was going to end up being. Told you, the theme for this movie is family.
She's actually kind of pissed at future him because in a few years he leaves his family, divorcing her mother and dying in a car crash. They kind of imply either drunk driving or suicide. I'll leave that up to you guys to decide.
Part I didn't really care for was splitting up Dan and his pal Charlie.
Charlie has to go straight out for a new mission with Dorian and we never see them again until later in the film.
I wanted them to stick together, damn it!
But maybe they figure it would be hard to do while also trying to build this bond between Dan and his future grown up daughter.
Grown up Muri has a new mission for him anyway, as they need to capture a queen whitespike. The toxin they developed kills the males, but has no effect on the females, who reproduce rapidly.
They have one cornered but getting it inside the cage is damn near impossible, since they are not only larger but can call on other male whitespikes to help defend it.
So they have to work quick.
When they do capture it, I think getting everyone killed in the process, Dan is taken to the main headquarters where the time travel device is and their main research facility.
It's basically this massive tanker on the ocean, surrounded by walls. Unlike the aliens in Quiet Place, these things can swim.
Muri finally comes up with a toxin that will kill the queen, but it calls out to the other whitespikes to rescue her.
Now the facility is overrun by these creatures.
Dan only has to wait a few minutes before he is recalled back to the past, but he knows that once he does, future Muri is all but done for.
But before she dies and before he leaves, she hands him the toxin so maybe the past can stop it before the invasion starts.
So here is kind of where things hit a snag when it comes to the plot department.
They hang a lot on this toxin, setting up the most of the first and all of the second act on it. However, as you'll see, it ultimately means nothing to the plot.
So Dan makes it back to his present, the whitespikes have destroyed the relay station that brings others into the future, now dooming a whole generation.
Dan has this toxin that can kill the whitespikes, but in his time it's useless since the aliens haven't arrived yet. Or so they think.
Apparently these seemingly mindless creatures that only think of feeding and have no arms built a spaceship, and flew it to Earth.
Right away that didn't pass the smell test. I was actually hoping for a bigger twist than what we got, being the whitespikes are just this bio weapon used by another alien race.
Anyway, their ship landed in the arctic, where in about 30 years the ice melts, releasing them all.
Dan, Charlie, Dorian and Dan's estranged father head out to find this crashed ship where they plan on injecting the aliens with the toxin that will kill them.
They do kill a few, but it's then revealed the ship has hundreds of thousands of whitespikes onboard, so essentially making the whole toxin thing pointless when in the end they do what they should have done in the first place and just blow the fucking ship up.
The second act should have ended with all hope being put on this toxin, but in the last minute not only does Dan lose his daughter but also the toxin.
That would have really brought home our character in his most defeated moment, bring us into the third act of him struggling to overcome it.
They do find ways to kind of use the toxin when Dan and his father band together to take out the last queen. But it really isn't essential, they could have done anything at this point.
Again, this whole toxin thing wouldn't be an issue if not for the fact the whole plot is setup around it. I guess it's a MacGuffin by every definition of the word but still. Have some pay off!
Even though I had a huge issue with that last act, I still really loved this movie. Is it as good as Starship Troopers? Fuck no! But it's just as fun I thought.
Next to Kong vs Godzilla, it's kind of the most fun I had while watching a movie this year. I highly recommend checking out Tomorrow War on Amazon. Unlike Netflix's original films, this actually feels like something you'd watch in the theater.
So check it out!
I give Tomorrow War a SEE IT!
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Providing a Step in the Write Direction

redpajama_set_name: RedPajamaCommonCrawl


This page describes how to create notifications for a watch. This page also describes how to provide additional content for each notification that is bridged to the watch from a connected phone.
Notifications on watches have the same structure as notifications on phones. Additionally, to give users the best experience, Wear OS by Google provides APIs for adding wearable-specific features to notifications.
When you issue a notification from your app, each notification appears as a card on the Notification Stream.
Figure 1. The same notification displayed on a phone and on a watch.
Both the watch and the phone can be sources of notifications. Use the NotificationCompat.Builder class to create notifications for wearables. When you build notifications with this class, the system takes care of displaying notifications properly.
Note: Notifications using RemoteViews are stripped of custom layouts and the wearable only displays the text and icons. However, you can create custom notifications that use custom card layouts by creating a wearable app that runs on the watch.
The v4 support library allows you to create notifications using the latest notification features such as action buttons and icons, while remaining compatible with Android 1.6 (API level 4) and higher.
Note: Starting in Android 8.0 (API level 26), you need to create notification channels for each type of notification you want to display.
Create an instance of NotificationCompat.Builder.
// The channel ID of the notification.
// (API level 25) and lower.
Issue the notification by passing the Notification object with a notification ID to notify().
// Issue the notification with notification manager.
When this notification appears on a phone, the user can invoke the PendingIntent specified by the setContentIntent() method by touching the notification. When this notification appears on a wearable, it appears in the notification stream. For bridged notifications, the user can click the notification to view the expanded notification and trigger any defined action, such as open action. Usually, these actions opens an Activity on your phone app.
Expanded notifications provide substantial additional content and actions for each notification. When you specify additional content pages and actions for a notification, those are available to the user within the expanded notification. Each expanded notification follows Material Design for Wear OS, so the user gets an app-like experience.
If the first action in the expanded notification has a RemoteInput (for example, a Reply action), then the choices you set with setChoices() appear within the expanded notification below the first action.
The notification is generated by an app on the paired phone and bridged to Wear.
The notification does not have a contentIntent.
Note: An app-specific background color set for a notification with the setColor() method is shown only when you expand the notification.
All notifications bridged from the paired phone to the Wear device will use expanded notifications.
If a notification is generated by an app running locally on Wear, you should make the touch target of your notification launch Notification object with a notification ID within your app by calling setContentIntent(). We recommend that you do not use expanded notifications for notifications generated by an app running locally on Wear.
Expanded Notifications allow you to include additional content and actions for a notification. You choose the level of detail that your app's notifications will provide; however, be judicious with the amount of detail you include in a notification.
To show additional text in your expanded notification, use the BigTextStyle.
To add images in your expanded notification, you can use the BigPictureStyle. If you want to add more than one image in your expanded notification, use the addPage() method along with the BigPictureStyle.
The expanded notification will contain one primary action, which is the first action in the notification unless a different action is specified using setContentAction().
To specify additional actions, use addAction() or addActions(). The action drawer of the expanded notification contains all available actions.
In addition to the primary content action defined by setContentIntent(), you can add other actions by passing a PendingIntent to the addAction() method.
For example, the following code shows the same type of notification from above, but adds an action to view the event location on a map.
On a phone, the action appears as an additional button attached to the notification. On a wearable, the action appears in the expanded notification after the content text. When the user taps the action, the associated intent is invoked on the phone.
Tip: If your notifications include a "Reply" action (such as for a messaging app), you can enhance the behavior by enabling voice input replies directly from the wearable. For more information, read Adding Voice Input as a notification action.
Inline action allows users to take actions on a notification from within the notification stream card. On Wear, the inline action appears as an additional button displayed at the bottom of the notification.
Inline actions are optional but recommended for cases in which users are likely to take an action on a notification after viewing the contents in the notification stream card (without going to the expanded notification). Examples of good use cases for inline action on a notification include: replying to a text message, stopping a fitness activity, and archiving an email message.
A notification can provide only one inline action. To display the inline action as an additional button in the notification, set the setHintDisplayActionInline() method to true. When a user taps the inline action, the system invokes the intent that you specified in the notification action.
The following code snippet adds a hint to display an action inline, and uses the addAction method to add the inline action to a notification.
//Wear OS requires a hint to display the reply action inline.
Create an instance of a WearableExtender, setting the wearable-specific options for the notication.
Create an instance of NotificationCompat.Builder, setting the desired properties for your notification as described earlier in this lesson.
Call extend() on the notification and pass in the WearableExtender. This applies the wearable options to the notification.
Call build() to build the notification.
Note: If you use the framework's NotificationManager, some features from NotificationCompat.WearableExtender do not work, so make sure to use NotificationCompat.
You can sync dismissals (cancellations) of notifications across the user's devices. To enable a dismissal to be synced, use the setDismissalId() method. For each notification, pass a globally unique ID, as a string, when you call the setDismissalId() method. When the notification is dismissed, all other notifications with the same dismissal ID are dismissed on the watch(es) and on the companion phone. To retrieve a dismissal ID, use getDismissalId().
Note: The setBackground() method is not supported on Wear 2.0. You can use NotificationCompat.BigPictureStyle for notifications that include images.
The setHintHideIcon() method is also not supported on Wear 2.0.
If you want the actions available on the wearable to be different from those on the phone, then use WearableExtender.addAction(). Once you add an action with this method, the wearable does not display any other actions added with NotificationCompat.Builder.addAction(). The actions added with WearableExtender.addAction() appear only on the wearable and they do not appear on the phone.
Voice actions are an important part of the wearable experience. To create an action that supports voice input, create an instance of RemoteInput.Builder that you can add to your notification action. This class's constructor accepts a string that the system uses as the key for the voice input, which you'll later use to retrieve the text of the input in your phone app.
const val EXTRA_VOICE_REPLY = "extra_voice_reply"
In addition to allowing voice input, you can provide up to five text responses that the user can select for quick replies. Call setChoices() and pass it a string array.
To receive the user's transcribed message in the activity you declared in the reply action's intent, call getResultsFromIntent(), passing in the "Reply" action's intent. This method returns a Bundle that contains the text response. You can then query the Bundle to obtain the response.
Note: Do not use Intent.getExtras() to obtain the voice result, because the voice input is stored as ClipData. The getResultsFromIntent() method provides a convenient way to receive a character sequence without having to process the ClipData yourself.
* get the associated voice input string.
Creating notifications from a standalone watch app is no different from creating bridged notifications. Notifications sourced from a standalone Wear app look similar to bridged notifications but they behave slightly differently. If no contentIntent is set or if the notification is bridged from a paired phone, then tapping the notification opens an expanded notification. Whereas, if the notification is originating from a standalone watch app, then tapping the notification fires the contentIntent to open your Wear app. To learn how to create notifications from a standalone app and mimic the expanded notification behavior, see the Wear Notifications sample.
By default, notifications are bridged from an app on a companion phone to the paired watch. If you build a standalone watch app and you have a companion phone app, the apps may create duplicate notifications. For information on handling the problem of duplicate notifications, see Bridging Mode for Notifications.


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text:
Diplodus – rodzaj morskich ryb z rodziny prażmowatych. Ryby zaliczane do tego rodzaju wyróżnia obecność tnących siekaczy umożliwiających odgryzanie części roślin.

Klasyfikacja
Gatunki zaliczane do tego rodzaju :

 Diplodus annularis – prażma
 Diplodus argenteus –
 Diplodus bellottii
 Diplodus bermudensis
 Diplodus capensis
 Diplodus cervinus –
 Diplodus fasciatus
 Diplodus holbrookii –
 Diplodus hottentotus
 Diplodus noct
 Diplodus omanensis
 Diplodus prayensis
 Diplodus puntazzo – dubiel
 Diplodus sargus – sargus
 Diplodus striatus
 Diplodus vulgaris – amarel

Przypisy

Prażmowate

redpajama_set_name: RedPajamaWikipedia


2016 – Year of the Monkey!
This year will welcome in the year of the monkey, part of an ancient tradition in which the Chinese zodiac attaches animal signs to each lunar year in a cycle of 12 years. The Chinese zodiac is separated into 12 blocks, each of which have a time-length of one year instead of one month like the western equivalent. The monkey is the ninth animal in the cycle, which will not take place again until 2028.
Well, people born in the year of the monkey are believed to be energetic, versatile, bright, mischievous, quick-witted, sociable and self-assured, particularly when it comes to making decisions about their careers and finances.
So here's hoping that the Year of the Monkey brings you all good fortune and prosperity throughout 2016!


text:
ON-DEMAND WEBCAST: 2020 ESG Trends to Watch
ESG themes are long-term, but some can emerge with sudden force. In this webcast, MSCI dives into five trends they believe will unfold in 2020 to catapult ESG investing into the new decade.
Why should you listen to the webcast?
The resurgence of stakeholder capitalism means that shareholders are no longer alone in finding channels to hold companies accountable.
Whether it's accessing capital or embarking on a workforce makeover, the top echelon of corporate management will find that deft management of ESG issues becomes a critical core competency.
Climate change accelerates as an investment theme, driving a looming re-valuation for "brown" properties and a search by investors for opportunities through mining alternative data sources.
Download the webcast to learn more.
Lee Souter
Vice President, Analytics Specialist
FactSet
Linda-Eling Lee
Managing Director and Global Head of ESG Research
Vice President, Analytics Specialist | FactSet
Mr. Lee Souter is a VP, Analytics Specialist who is responsible for FactSet's analytics sales and client relationship management in Canada. In this role, he focuses on providing content, analytics, and attribution solutions to clients across equities, fixed income, and multi-asset class strategies. Prior to this role, Mr. Souter was a Sales Specialist on FactSet's Fixed Income Analytics team in the Americas and began his career at FactSet as an investment management consultant. Mr. Souter earned a B.S. in Mathematics from the University of Vermont and an M.S. in Actuarial Science and Mathematical Finance from Boston University. He is a CFA charterholder and Certified Financial Risk Manager.
Managing Director and Global Head of ESG Research | MSCI
As Global Head of Research for MSCI's ESG Research group, Linda-Eling Lee oversees all ESG-related content and methodology. MSCI ESG Research is the largest provider of ESG Rating and analytics to global institutional investors. Linda leads one of the largest teams of research analysts in the world who are dedicated to identifying risks and opportunities arising from material ESG issues. She and her team have been widely recognised as the best SRI/ESG researchers by market surveys and awards.
Linda joined MSCI in 2010 following the acquisition of RiskMetrics, where she led ESG ratings research and was head of consumer sector analysis. Linda joined RiskMetrics Group in 2009 through the acquisition of Innovest. Prior to joining Innovest, Linda was the Research Director at the Center for Research on Corporate Performance, developing academic research at Harvard Business School into management tools to drive long-term corporate performance. Previously, she was a strategy consultant with Monitor Group in Europe and in Asia, where she worked with Fortune 500 clients in industries ranging from beverages to telecommunications.
Linda received her AB from Harvard, MSt from Oxford, and PhD in Organizational Behavior from Harvard University. Linda has published research both in management journals such as the Harvard Business Review and MIT's Sloan Management Review, as well as in top academic peer-reviewed journals such as Management Science and Journal of Organizational Behavior. She is frequent media commentator on ESG topics and sustainable investing in outlets including the Financial Times, Wall Street Journal, Forbes and the New York Times.


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text:
Budget Amendments - SB29 (Floor Approved)
Bill Order » Item 306 #1s
Intensive In-Home Services Rate Reduction (language only)
Item 306 #1s
Health And Human Resources
Medical Assistance Services, Department of
Page 167, after line 9, insert:
"VVV. The Department of Medical Assistance Services shall work with the Department of Behavioral Health and Developmental Services and the Virginia Association of Community Services Boards to establish rates for the Intensive In-Home Service based on quality indicators and standards such as the use of evidence-based practices."
(This amendment directs the Department of Medical Assistance Services to work with the Department of Behavioral Health and Developmental Services and the Virginia Association of Community Services Boards to ensure that the new rates to be established for intensive in-home services are based on certain parameters.)
Medicaid Program Services (45600) $5,641,851,202 $6,335,672,231
Reimbursements to State-Owned Mental Health and Mental Retardation Facilities (45607) FY2009 $203,128,980 FY2010 $203,128,980
Reimbursements for Mental Health and Mental Retardation Services (45608) FY2009 $438,911,093 FY2010 $493,468,370
Reimbursements for Professional and Institutional Medical Services (45609) FY2009 $3,282,206,910 FY2010 $3,796,909,127
Reimbursements for Long-Term Care Services (45610) FY2009 $1,717,604,219 FY2010 $1,842,165,754
Dedicated Special Revenue FY2009 $310,288,118 FY2010 $303,819,489
Federal Trust FY2009 $3,120,355,069 FY2010 $3,714,472,625
Authority: Title 32.1, Chapters 9 and 10, Code of Virginia; P.L. 89-87, as amended, Title XIX, Social Security Act, Federal Code.
A. It is the intent of the General Assembly to develop and cause to be developed appropriate, fiscally responsible methods for addressing the issues related to the cost and funding of long-term care. It is the further intent of the General Assembly to promote home-based and community-based care for individuals who are determined to be in need of nursing facility care.
B.1. The Director, Department of Medical Assistance Services shall seek the necessary waivers from the United States Department of Health and Human Services to authorize the Commonwealth to cover health care services and delivery systems, as may be permitted by Title XIX of the Social Security Act, which may provide less expensive alternatives to the State Plan for medical assistance.
2. The director shall promulgate such regulations as may be necessary to implement those programs which may be permitted by Titles XIX and XXI of the Social Security Act, in conformance with all requirements of the Administrative Process Act.
C.1. The appropriation includes $101,564,490 the first year from the general fund and $101,564,490 from the federal trust fund and $101,564,490 $99,663,148 the second year from the general fund and $101,564,490 $159,808,729 from the federal trust fund for reimbursement to the institutions within the Department of Mental Health, Mental Retardation and Substance Abuse Services Behavioral Health and Developmental Services.
2. The appropriation includes the first year $218,021,775 from the general fund and $218,021,775 from the federal trust fund, and the second year $226,975,468 from the general fund and $230,769,187 from the federal trust fund for estimated reimbursements for habilitative services provided to individuals on the Mental Retardation Waiver, the Mental Retardation Day Support Waiver, or the Individual and Family Developmental Disabilities Support waiver.
D. Out of this appropriation, the Department of Medical Assistance Services shall provide coverage of intensive assisted living care to residents of licensed Adult Care Residences who are Auxiliary Grant recipients. Individuals entitled to benefits under this section are not entitled to benefits under Item 308.
E. If any part, section, subsection, paragraph, clause, or phrase of this Item or the application thereof is declared by the United States Department of Health and Human Services or the Centers for Medicare and Medicaid Services to be in conflict with a federal law or regulation, such decisions shall not affect the validity of the remaining portions of this Item, which shall remain in force as if this Item had passed without the conflicting part, section, subsection, paragraph, clause, or phrase. Further, if the United States Department of Health and Human Services or the Centers for Medicare and Medicaid Services determines that the process for accomplishing the intent of a part, section, subsection, paragraph, clause, or phrase of this Item is out of compliance or in conflict with federal law and regulation and recommends another method of accomplishing the same intent, the Director of the Department of Medical Assistance Services, after consultation with the Attorney General, is authorized to pursue the alternative method.
F.1. Included in this appropriation is $59,042,780 from the general fund and $59,042,780 from nongeneral funds in the first year and $67,328,586 $63,023,937 from the general fund and $67,328,586 $67,328,586 from nongeneral funds in the second year to reimburse the Virginia Commonwealth University Health System for indigent health care costs. This funding is comprised of disproportionate share hospital (DSH) payments, indirect medical education (IME) payments, and any Medicaid profits realized by the Health System. Payments made from the federal DSH fund shall be made in accordance with 42 USC 1396r-4.
2. Included in this appropriation is $37,306,516 from the general fund and $37,306,516 from nongeneral funds in the first year and $42,157,704 $37,166,122 from the general fund and $42,157,704 $39,861,473 from nongeneral funds in the second year to reimburse the University of Virginia Health System for indigent health care costs. This funding is comprised of disproportionate share hospital (DSH) payments, indirect medical education (IME) payments, and any Medicaid profits realized by the Health System. Payments made from the federal DSH fund shall be made in accordance with 42 USC 1396r-4.
G. The department shall establish a program to more effectively manage those Medicaid recipients who receive the highest cost care. To implement the program, the department shall establish uniform criteria for the program, including criteria for the high cost recipients, providers and reimbursement, service limits, assessment and authorization limits, utilization review, quality assessment, appeals and other such criteria as may be deemed necessary to define the program. The department shall seek any necessary approval from the Centers for Medicare and Medicaid Services, and shall promulgate such regulations as may be deemed necessary to implement this program.
H. The Department of Medical Assistance Services and the Virginia Department of Health shall work with representatives of the dental community: to expand the availability and delivery of dental services to pediatric Medicaid recipients; to streamline the administrative processes; and to remove impediments to the efficient delivery of dental services and reimbursement thereof. The Department of Medical Assistance Services shall report its efforts to expand dental services to the Chairmen of the House Appropriations and Senate Finance Committees and the Department of Planning and Budget by December 15 each year.
I. The Department of Medical Assistance Services shall implement continued enhancements to the prospective drug utilization review (pro-DUR) program. The Department shall continue the Pharmacy Liaison Committee and the pro-DUR Committee. The department shall continue to work with the Pharmacy Liaison Committee to implement initiatives for the promotion of cost-effective services delivery as may be appropriate. The department shall report on the Pharmacy Liaison Committee's and the pro-DUR Committee's activities to the Board of Medical Assistance Services and to the Chairmen of the House Appropriations and Senate Finance Committees and the Department of Planning and Budget no later than December 15 each year of the biennium.
J. It is the intent of the General Assembly that the medically needy income limits for the Medicaid program are adjusted annually to account for changes in the Consumer Price Index.
K. The Department of Medical Assistance Services shall not require dentists who agree to participate in the delivery of Medicaid pediatric dental care services, or services provided to enrollees in the Family Access to Medical Insurance Security (FAMIS) Plan or any variation of FAMIS, to also deliver services to subscribers enrolled in commercial plans of the managed care vendor, unless the dentist is a willing participant in the commercial managed care plan.
L. It is the intent of the General Assembly that the use of the new atypical medications to treat seriously mentally ill Medicaid recipients should be supported by the formularies used to reimburse claims under the Medicaid fee-for-service and managed care plans.
M.1. The Department of Medical Assistance Services shall have the authority to seek federal approval of changes to its MEDALLION waiver and its Medallion II waiver.
2. In order to conform the state regulations to the federally approved changes and to implement the provisions of this act, the department shall promulgate emergency regulations to become effective within 280 days or less from the enactment of this act. The department shall implement these necessary regulatory changes to be consistent with federal approval of the waiver changes.
N. The Department of Medical Assistance Services shall develop and pursue cost saving strategies internally and with the cooperation of the Department of Social Services, Virginia Department of Health, Office of the Attorney General, Comprehensive Services Act program, Department of Education, Department of Juvenile Justice, Department of Mental Health, Mental Retardation and Substance Abuse Services, Virginia Department for the Aging, Department of the Treasury, University of Virginia Health System, Virginia Commonwealth University Health System Authority, Department of Corrections, federally qualified health centers, local health departments, local school divisions, community service boards, local hospitals, and local governments, that focus on optimizing Medicaid claims and cost recoveries. Any revenues generated through these activities shall be transferred to the Virginia Health Care Fund to be used for the purposes specified in this Item.
O. The Department of Medical Assistance Services shall retain the savings necessary to reimburse a vendor for its efforts to implement paragraph N of this Item. However, prior to reimbursement, the Department shall identify for the Secretary of Health and Human Resources each of the vendor's revenue maximization efforts and the manner in which each vendor would be reimbursed. No reimbursement shall be made to the vendor without the prior approval of the above plan by the Secretary.
P. The Department of Medical Assistance Services in cooperation with the State Executive Council, shall provide semi-annual training to local Comprehensive Services Act teams on the procedures for use of Medicaid for residential treatment and treatment foster care services, including, but not limited to, procedures for determining eligibility, billing, reimbursement, and related reporting requirements. The department shall include in this training information on the proper utilization of inpatient and outpatient mental health services as covered by the Medicaid State Plan.
Q. Contingent upon approval by the Centers for Medicare and Medicaid Services to implement a new Independence Plus Home and Community Based Services Waiver, the Department of Medical Assistance Services shall promulgate emergency regulations to become effective within 280 days or less from the enactment date of this act. The department shall implement these necessary regulatory changes to be consistent with federal approval of the waiver application developed by the department and stakeholders. In the event a recipient of a waiver slot under the Independence Plus Home and Community Based Services Waiver exits the program, funding for the slot shall revert to the waiver program from which the recipient came.
R.1. Notwithstanding § 32.1-331.12 et seq., Code of Virginia, the Department of Medical Assistance Services, in consultation with the Department of Mental Health, Mental Retardation and Substance Abuse Services, shall amend the State Plan for Medical Assistance Services to modify the delivery system of pharmaceutical products to include a Preferred Drug List. In developing the modifications, the department shall consider input from physicians, pharmacists, pharmaceutical manufacturers, patient advocates, and others, as appropriate.
2.a. The department shall utilize a Pharmacy and Therapeutics Committee to assist in the development and ongoing administration of the Preferred Drug List program. The Pharmacy and Therapeutics Committee shall be composed of 8 to 12 members, including the Commissioner of the Department of Mental Health, Mental Retardation and Substance Abuse Services, or his designee. Other members shall be selected or approved by the department. The membership shall include a ratio of physicians to pharmacists of 2:1 and the department shall ensure that at least one-half of the physicians and pharmacists are either direct providers or are employed with organizations that serve recipients for all segments of the Medicaid population. Physicians on the Committee shall be licensed in Virginia, one of whom shall be a psychiatrist, and one of whom specializes in care for the aging. Pharmacists on the Committee shall be licensed in Virginia, one of whom shall have clinical expertise in mental health drugs, and one of whom has clinical expertise in community-based mental health treatment. The Pharmacy and Therapeutics Committee shall recommend to the Department (i) which therapeutic classes of drugs should be subject to the Preferred Drug List program and prior authorization requirements; (ii) specific drugs within each therapeutic class to be included on the preferred drug list; (iii) appropriate exclusions for medications, including atypical anti-psychotics, used for the treatment of serious mental illnesses such as bi-polar disorders, schizophrenia, and depression; (iv) appropriate exclusions for medications used for the treatment of brain disorders, cancer and HIV-related conditions; (v) appropriate exclusions for therapeutic classes in which there is only one drug in the therapeutic class or there is very low utilization, or for which it is not cost-effective to include in the Preferred Drug List program; and (vi) appropriate grandfather clauses when prior authorization would interfere with established complex drug regimens that have proven to be clinically effective. In developing and maintaining the preferred drug list, the cost effectiveness of any given drug shall be considered only after it is determined to be safe and clinically effective.
b. The Pharmacy and Therapeutics Committee shall schedule meetings at least quarterly and may meet at other times at the discretion of the Chairperson and members. At the meetings, the Pharmacy and Therapeutics committee shall review any drug in a class subject to the Preferred Drug List that is newly approved by the Federal Food and Drug Administration, provided there is at least thirty (30) days notice of such approval prior to the date of the quarterly meeting.
3. The department shall establish a process for acting on the recommendations made by the Pharmacy and Therapeutics Committee, including documentation of any decisions which deviate from the recommendations of the Committee.
4. The Preferred Drug List program shall include provisions for (i) the dispensing of a 72-hour emergency supply of the prescribed drug when requested by a physician and a dispensing fee to be paid to the pharmacy for such supply; (ii) prior authorization decisions to be made within 24 hours and timely notification of the recipient and/or the prescribing physician of any delays or negative decisions; (iii) an expedited review process of denials by the department; and (iv) consumer and provider education, training and information regarding the Preferred Drug List prior to implementation, and ongoing communications to include computer access to information and multilingual material.
5. The Preferred Drug List program shall generate savings as determined by the department that are net of any administrative expenses to implement and administer the program.
6. Notwithstanding § 32.1-331.12 et seq., Code of Virginia, to implement these changes, the Department of Medical Assistance Services shall promulgate emergency regulations to become effective within 280 days or less from the enactment of this act. With respect to such state plan amendments and regulations, the provisions of § 32.1-331.12 et seq., Code of Virginia, shall not apply. In addition, the department shall work with the Department of Mental Health, Mental Retardation, and Substance Abuse Services to consider utilizing a Preferred Drug List program for its non-Medicaid clients.
7. The Department of Medical Assistance Services shall exempt antidepressant and antianxiety medications used for the treatment of mental illness from the Medicaid Preferred Drug List program. The Director of the Department of Medical Assistance Services, in cooperation with the Department of Mental Health, Mental Retardation and Substance Abuse Services, shall provide a report to the Chairmen of the House Appropriations and Senate Finance Committees by December 1, 2008, on the impact on patient care and costs of including these medications in the Preferred Drug List in the future.
8. The department shall provide to the Governor; the House Committees on Appropriations, and Health, Welfare and Institutions; the Senate Committees on Finance, and Education and Health; and the Joint Commission on Health Care a report on the Preferred Drug List (PDL) Program no later than November 1 of each year. The report shall include the direct savings attributed to the PDL for the prior fiscal year, an estimated savings of the program for the next fiscal year, and the cost to administer the PDL.
S. The Department of Medical Assistance Services shall reimburse school divisions who sign an agreement to provide administrative support to the Medicaid program and who provide documentation of administrative expenses related to the Medicaid program 50 percent of the Federal Financial Participation by the department.
T. In the event that the Department of Medical Assistance Services decides to contract for pharmaceutical benefit management services to administer, develop, manage, or implement Medicaid pharmacy benefits, the Department shall establish the fee paid to any such contractor based on the reasonable cost of services provided. The Department may not offer or pay directly or indirectly any material inducement, bonus, or other financial incentive to a program contractor based on the denial or administrative delay of medically appropriate prescription drug therapy, or on the decreased use of a particular drug or class of drugs, or a reduction in the proportion of beneficiaries who receive prescription drug therapy under the Medicaid program. Bonuses cannot be based on the percentage of cost savings generated under the benefit management of services.
U.1. The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to modify the reimbursement methodology used to reimburse for generic drug products. The new methodology shall reimburse for the product cost based on a Maximum Allowable Cost list to be established by the department. Such amendments shall be effective within 280 days or less from the enactment of this act.
2. In developing the maximum allowable cost (MAC) reimbursement rate for generic pharmaceuticals, the department shall: (i) if publicly available, publish the factors used to set state MAC rates, including the identity of the reference product used to set the MAC rate; the GCN number of the reference product; the factor by which the MAC rate exceeds the reference product price, which shall be not less than 110 percent of the lowest-published wholesale acquisition cost for products widely available for purchase in the state, and included in national pricing compendia; and the identity and date of the published compendia used to determine the reference product and set the MAC rate; (ii) identify three different suppliers that are able to supply the product and from whom pharmacies are able to purchase sufficient quantities of the drug. The drugs considered must be listed as therapeutically and pharmaceutically equivalent in the FDA's most recent version of the "Orange Book"; (iii) identify that the use of a MAC rate is lower than the Federal Upper Limit (FUL) for the drug, or the development of a MAC rate that does not have a FUL will not result in the use of higher-cost innovator brand name or single source drugs in the Medicaid program; and (iv) distribute the list of state MAC rates to pharmacy providers in a timely manner prior to the implementation of MAC rates and subsequent modifications.
3. The department shall: (i) review and update the list of MAC rates at least quarterly; (ii) implement and maintain a procedure to eliminate products from the list, or modify MAC rates, consistent with changes in the marketplace; and (iii) provide an administrative appeals procedure to allow a dispensing provider to contest a listed MAC rate.
4. The department shall conduct an analysis of the fiscal impact of the implementation of "Average Manufacturer Price" (AMP), as required by the federal Deficit Reduction Act of 2005, Public Law 109-171. Upon the later of April 15, 2008, or 90 days after the effective date of the regulation that the United States Secretary of Health and Human Services must promulgate under Section 6001(c)(3) of the 'Deficit Reduction Act of 2005,' Pub. L. No. 109-171, the department shall report to the Governor and the chairmen of the Senate Finance and House Appropriations Committees the amount of savings anticipated in the Medicaid Forecast as a result of this change in federal law. In the event that anticipated pharmacy savings exceed the amount of savings assumed in the Medicaid Forecast, the department shall make recommendations concurrently with the report regarding the adjustment of pharmacy dispensing fees based on the impact of changes in local pharmacy reimbursements.
V. 1. Out of this appropriation, the dedicated special fund appropriation for Medical Assistance Services includes $310,288,118 the first year and $303,819,489 $288,995,296 the second year from the Virginia Health Care Fund.
2. Notwithstanding any other provision of law, the State Comptroller shall deposit 50 percent of the Commonwealth's allocation of the Strategic Contribution Fund payment pursuant to the Master Settlement Agreement with tobacco product manufacturers into the Virginia Health Care Fund.
W. The Department of Medical Assistance Services shall ensure that in the process of developing the Preferred Drug List, the Pharmacy and Therapeutics Committee considers the value of including those prescription medications which improve drug regimen compliance, reduce medication errors, or decrease medication abuse through the use of medication delivery systems that include, but are not limited to, transdermal and injectable delivery systems.
X. The Department of Medical Assistance Services, in cooperation with the Department of Social Services' Division of Child Support Enforcement, shall identify and initiate third party recovery actions where there is a medical support order requiring a noncustodial parent to contribute to the medical cost of a child who is enrolled in the Medicaid or Family Access to Medical Insurance Security (FAMIS) Programs.
Y.1. Within the limits of this appropriation, the Department of Medical Assistance Services shall work with its contracted managed care organizations and fee-for-service health care providers to: (i) raise awareness among the providers who serve the Medicaid population about the health risks of chronic kidney disease; (ii) establish effective means of identifying patients with this condition; and (iii) develop strategies for improving the health status of these patients. The Department shall work with the National Kidney Foundation to prepare and disseminate information for physicians and other health care providers regarding generally accepted standards of clinical care and the benefits of early identification of individuals at highest risk of chronic kidney disease.
2. Effective July 1, 2006, the department shall request any clinical laboratory performing a serum creatinine test on a Medicaid recipient over the age of 18 years to calculate and report to the physician the estimated glomerular filtration rate (eGFR) of the patient and shall report it as a percent of kidney function remaining.
Z.1. The Director, Department of Planning and Budget is authorized to transfer amounts, as needed, from Medicaid Program Services (program 45600) to Administrative and Support Services (program 49900) to fund administrative expenditures associated with contracts between the Department of Medical Assistance Services and companies providing disease state and chronic care management programs services for Medicaid recipients. The department shall have the authority to promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
2. The department shall report on its efforts to contract for and implement disease state and chronic care management programs in the Medicaid program by November 1 of each year of the biennium, to the Chairmen of the Senate Finance and House Appropriations Committees and the Department of Planning and Budget. The report shall include estimates of savings that may result from such programs.
AA.1. Notwithstanding the provisions of § 32.1-325.1:1, Code of Virginia, upon identifying that an overpayment for medical assistance services has been made to a provider, the Director, Department of Medical Assistance Services shall notify the provider of the amount of the overpayment. Such notification of overpayment shall be issued within the earlier of (i) four years after payment of the claim or other payment request, or (ii) four years after filing by the provider of the complete cost report as defined in the Department of Medical Assistance Services' regulations, or (iii) 15 months after filing by the provider of the final complete cost report as defined in the Department of Medical Assistance Services' regulations subsequent to sale of the facility or termination of the provider.
2. Notwithstanding the provisions of § 32.1-325.1, Code of Virginia, the director shall issue an informal fact-finding conference decision concerning provider reimbursement in accordance with the State Plan for Medical Assistance, the provisions of § 2.2-4019, Code of Virginia, and applicable federal law. The informal fact-finding conference decision shall be issued within 180 days of the receipt of the appeal request. If the agency does not render an informal fact-finding conference decision within 180 days of the receipt of the appeal request, the decision is deemed to be in favor of the provider. An appeal of the director's informal fact-finding conference decision concerning provider reimbursement shall be heard in accordance with § 2.2-4020 of the Administrative Process Act (§ 2.2-4020 et seq.) and the State Plan for Medical Assistance provided for in § 32.1-325, Code of Virginia. Once a final agency case decision has been made, the director shall undertake full recovery of such overpayment whether or not the provider disputes, in whole or in part, the informal fact-finding conference decision or the final agency case decision. Interest charges on the unpaid balance of any overpayment shall accrue pursuant to § 32.1-313, Code of Virginia, from the date the Director's agency case decision becomes final.
BB. Any hospital that was designated a Medicare-dependent small rural hospital, as defined in 42 U.S.C. §1395ww (d) (5) (G) (iv) prior to October 1, 2004, shall be designated a rural hospital pursuant to 42 U.S.C. §1395ww (d) (8) (ii) (II) on or after September 30, 2004.
CC.1. The Department of Medical Assistance Services may amend the State Plan for Medical Assistance Services to modify the delivery system of pharmaceutical products to include a specialty drug program. In developing the modifications, the department shall consider input from physicians, pharmacists, pharmaceutical manufacturers, patient advocates, the Pharmacy Liaison Committee, and others as appropriate.
2. In developing the specialty drug program to implement appropriate care management and control drug expenditures, the department shall contract with a vendor who will develop a methodology for the reimbursement and utilization through appropriate case management of specialty drugs and distribute the list of specialty drug rates, authorized drugs and utilization guidelines to medical and pharmacy providers in a timely manner prior to the implementation of the specialty drug program and publish the same on the department's website.
3. In the event that the Department of Medical Assistance Services contracts with a vendor, the department shall establish the fee paid to any such contractor based on the reasonable cost of services provided. The department may not offer or pay directly or indirectly any material inducement, bonus, or other financial incentive to a program contractor based on the denial or administrative delay of medically appropriate prescription drug therapy, or on the decreased use of a particular drug or class of drugs, or a reduction in the proportion of beneficiaries who receive prescription drug therapy under the Medicaid program. Bonuses cannot be based on the percentage of cost savings generated under the benefit management of services.
4. The department shall: (i) review, update and publish the list of authorized specialty drugs, utilization guidelines, and rates at least quarterly; (ii) implement and maintain a procedure to revise the list or modify specialty drug program utilization guidelines and rates, consistent with changes in the marketplace; and (iii) provide an administrative appeals procedure to allow dispensing or prescribing provider to contest the listed specialty drugs and rates.
5. The department shall report on savings and quality improvements achieved through the implementation measures for the specialty drug program to the Chairmen of the House Appropriations and Senate Finance Committees, the Joint Commission on Health Care, and the Department of Planning and Budget by November 1 of each year.
6. The department shall have authority to enact emergency regulations under § 2.2-4011 of the Administrative Process Act to effect these provisions.
DD. The Department of Medical Assistance Services has the authority to implement cost-based reimbursement for special education health services furnished by school division providers effective July 1, 2006. School division providers shall file annual cost reports for these services and the department shall settle reimbursement to actual costs. Reimbursement to school divisions shall continue to be subject to the provisions of § 32.1-326.3(A)(1) of the Code of Virginia that only the federal share shall be reimbursed for special education health services and that local governments fund the state match for special education health services provided by school divisions.
EE. The Department of Medical Assistance Services shall work with representatives of the nursing home provider associations to develop a revised cost-reporting methodology which improves the timeliness and efficiency of the current process. A specific goal of such an enhanced process would be to decrease by one year the look-back period used within the biennial cost ceiling rebase determination.
FF. The Department of Medical Assistance Services shall have the authority to amend the State Plan of Medical Assistance Services, the Virginia Plan for Title XXI of the Social Security Act and the Family Access to Medical Insurance Security Plan to implement modifications to the Medicaid program to comply with the mandated provisions of the federal Deficit Reduction Omnibus Reconciliation Act of 2005 Children's Health Insurance Program Reauthorization Act of 2009. This authorization shall apply only to those provisions the states are required to implement within 280 days of enactment of this Appropriation Act. The department shall have the authority to enact emergency regulations under § 2.2-4011 of the Administrative Process Act to effect this provision. The department shall notify the Chairmen of the House Appropriations and Senate Finance Committees no less than 30 days prior to the submission of amendments to the State Plan of Medical Assistance Services.
GG. The Department of Medical Assistance Services, in consultation with the appropriate stakeholders, shall develop a long-range blueprint for the development and implementation of an integrated acute and long-term care system. This plan shall: (i) explain how the various community and state level stakeholders will be involved in the development and implementation of the new program model(s); (ii) describe the various steps for development and implementation of the program model(s), including a review of other states' models, funding, populations served, services provided, education of clients and providers, and location of programs; (iii) describe how the existing system is funded and how integration will impact funding; and (iv) describe the evaluation methods that will be used to ensure that the program provides access, quality, and consumer satisfaction.
HH. The Department of Medical Assistance Services shall implement one or more Program for All Inclusive Care for the Elderly (PACE) programs.
II. The Department of Medical Assistance Services shall amend its State Plan for Medical Assistance Services to develop and implement a regional model for the integration of acute and long-term care services. This model would be offered to elderly and disabled clients on a mandatory basis. The Department shall promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
JJ.1. The Director, Department of Medical Assistance Services shall seek the necessary waiver from the United States Centers for Medicare and Medicaid Services to expand eligibility for Medicaid coverage of family planning services to individuals with a family income up to 133 percent of the federal poverty level. For the purposes of this section, family planning services shall not cover payment for abortion services and no funds shall be used to perform, assist, encourage or make direct referrals for abortions. The Department of Medical Assistance Services shall promulgate emergency regulations to implement this amendment within 280 days or less from the enactment date of this act.
2. The Department of Medical Assistance Services shall, if feasible and consistent with federal requirements, seek the necessary waiver from the Centers for Medicare and Medicaid Services to expand eligibility for Medicaid coverage of family planning services to individuals with a family income above 133 percent of the federal poverty level up to an eligibility level that will not compromise federal budget neutrality for the waiver, but not to exceed 200 percent of the federal poverty level.
KK.1. Contingent upon approval by the Centers for Medicare and Medicaid Services as part of the Money Follows the Person demonstration grant, the Department of Medical Assistance Services shall seek federal approval for necessary changes to home and community-based 1915(c) waivers to allow individuals transitioning from institutions to receive care in the community. The Department of Medical Assistance Services shall promulgate any necessary emergency regulations within 280 days or less from the enactment date of this act.
2. The Department of Medical Assistance Services shall amend the Individual and Family Developmental Disabilities Support (DD) Waiver to add 30 new slots (15 each fiscal year) and the Mental Retardation (MR) Waiver to add 220 new slots (110 each fiscal year) which will be reserved for individuals transitioning out of institutional settings through the Money Follows the Person Demonstration. The Department of Medical Assistance Services shall seek federal approval for necessary changes to the DD and MR waiver applications to add the additional slots. Additionally, the department shall have authority to implement the Money Follows the Person Demonstration prior to the completion of any regulatory process undertaken in order to affect the program.
LL. The Department of Medical Assistance Services shall have the authority to amend the managed care waiver to allow the department to enroll adoption assistance recipients into managed care organizations as defined in 12 VAC 30-120-360 through 12 VA 30-120-420. In addition, the department shall have the authority to amend the State Plans for Titles XIX (Medical Assistance) and XXI (Family Access to Medical Insurance Security Plan – FAMIS) of the Social Security Act, as required by applicable statute and regulations to provide managed care services to adoption assistance recipients. The Department of Medical Assistance Services shall have the authority to promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
MM. The Department of Medical Assistance Services shall be authorized, in collaboration with the Virginia Commonwealth University Health System (VCUHS), to seek a waiver from the Centers for Medicare and Medicaid Services (CMS) to permit use of Disproportionate Share Hospital (DSH) funds to allow the VCUHS (Hospital and Physician Practice) to continue the existing partnership with community physicians and with any community hospitals who are providing less costly health care services to eligible indigent patients for VCUHS. As part of the waiver application process the parties shall develop estimates of the cost of the program to the state and federal governments, and shall report the findings to the Governor and to the Chairman of the House Appropriations and the Senate Finance Committees. If the Director, Department of Planning and Budget, determines that the waiver program would not require additional state funds, the program shall be implemented upon receiving CMS approval. If additional state funding is needed, the program shall not be implemented until such funding is authorized through the budget process.
NN. The Department of Medical Assistance Services shall, at the direction of the Secretary of Health and Human Resources, amend the State Plan for Medical Assistance to treat all life estates in the determination of Medicaid eligibility in the same manner as in effect under the State Plan for Medical Assistance on July 1, 2008. The department shall have the authority to promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
OO. The Department of Medical Assistance Services shall have the authority to implement prior authorization and utilization review for community-based mental health services for children and adults. The department shall have the authority to promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
PP. The Department of Medical Assistance Services shall amend the State Plan of Medical Assistance Services to implement a "site of service" reimbursement differential using Medicare facility relative value units (RVUs) for facility-based services instead of non-facility RVUs, as defined in the Resource Based Relative Value System (RBRVS) methodology prescribed in 12VAC30-80-190, state agency fee schedule for RBRVS. The implementation of facility RVUs shall be budget neutral. The department shall reallocate changes in expenditures from implementing this site of service payment policy proportionately to all physician services. The site of service differential shall be implemented over a four-year period, effective July 1, 2008. The department shall have the authority to promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
QQ. The Department of Medical Assistance Services shall have the authority to seek federal approval of changes to its managed care waiver to limit the Primary Case Management program to localities of the state with only one participating managed care organization. The department shall have the authority to promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
RR. The Department of Medical Assistance Service shall realign the rates paid for individual supported employment provided under the Medicaid home- and community-based waivers to the same level paid by the Department of Rehabilitative Services (DRS) to employment services organizations. The Department shall implement this change effective July 1, 2008, and subsequently whenever the DRS rates for employment services organizations are changed. The Department shall modify state regulations to make this change permanent.
SS. The Department of Medical Assistance Services (DMAS) shall develop a plan to amend the State Plan for Medical Assistance or submit a research and demonstration project waiver pursuant to Section 1115 of Title XIX of the Social Security Act, as amended, to implement a system of monetary incentives for Medicaid recipients to make healthy decisions and to engage in self-management of their healthcare, and the deposit of incentive funds in enhanced benefits accounts to be accessed by enrollees to purchase healthcare services or items that are not covered under Virginia Medicaid and which will assist enrollees in being personally responsible for their own healthcare. The plan shall include the development of necessary changes in funding, law or regulations for the implementation of the changes. The plan is to be submitted to the Governor, the Secretary of Health and Human Resources, the Joint Commission on Health Care, and the Chairmen of the House Appropriations and Senate Finance Committees by October 30, 2008, for consideration in the development of amendments to the 2008-10 Appropriations Act.
TT. Out of this appropriation, $5,000,000 the first year and $2,777,777 the second year from the general fund and $5,000,000 the first year and $2,777,777 the second year from nongeneral funds shall be used to increase reimbursement rates paid to providers of congregate residential group home services for individuals in the Mental Retardation Home and Community-based Waiver Program. In the first year, the rates shall be set 3.6 percent higher than the rates in effect June 30, 2008, and in the second year shall be set 2.0 percent higher than the rates in effect June 30, 2008. That is, the rates in the second year shall be lower than the rates in the first year, but higher than the rates effective on June 30, 2008 .
UU. Effective July 1, 2008, and ending after June 30, 2010, the Department shall reduce prospective inpatient hospital payment rates by 2.683 percent below the rates that otherwise would be in effect. The Department shall amend the State Plan to authorize this change, and shall have the authority to implement this reimbursement change effective July 1, 2008, and prior to the completion of any regulatory process undertaken in order to effect such change. The Department shall not replace through other payment mechanisms the losses of Type One hospitals from this reimbursement change. However, the department can reimburse, only federal funds, if the Type One hospital is able to certify the public expenditure.
VV. Effective July 1, 2008, and ending after June 30, 2009, the Department of Medical Assistance Services shall reduce nursing facility direct and indirect care payment rates by 1.329 percent below the rates that otherwise would be in effect. The Department of Medical Assistance Services shall amend the State Plan to authorize this change, and shall have the authority to implement these reimbursement changes effective July 1, 2008 and July 1, 2009, and prior to the completion of any regulatory process undertaken in order to effect such change.
WW. The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to decrease the dispensing fee paid to pharmacists from $4.00 to $3.75 per prescription per month. Such amendments to the State Plan shall become effective July 1, 2009.
XX. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to convert the current reimbursement methodology for rehabilitation agencies to a statewide prospective rate for individual and group services to achieve estimated savings of $185,909 the second year in general funds and $185,909 the second year in nongeneral funds. The department shall have the authority to promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act. This shall not apply to rehabilitation services furnished by the Community Services Boards.
YY. The Department of Medical Assistance Services shall ensure that the FY 2010 capitation rate increase for Medallion II does not exceed seven percent. If other provider rate limitations required by this act result in corresponding downward adjustments to the FY 2010 capitation rates, this seven percent limit shall be reduced by the amount of the impact on Medallion II rates of those downward adjustments. The department shall apply the same limit to the calculation of rates for FAMIS.
ZZ. Effective July 1, 2009, the department shall have the authority to amend the State Plan for Medical Assistance to eliminate reimbursement for hospital acquired conditions in a manner similar to the Medicare initiative implemented October 1, 2008. The department shall have the authority to implement this reimbursement change effective July 1, 2009, and prior to the completion of any regulatory process undertaken in order to effect such change. The department shall also revise its medical necessity criteria to be consistent with Medicare national coverage determinations as part of the overall Medicare initiative.
AAA. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to clarify that existing family healthcare coverage is a factor in the determination of cost effectiveness under the Health Insurance Premium Payment program. Cases which result in a determination that participation is not cost effective shall be denied premium assistance. The department shall promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.
BBB. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to reduce reimbursement to long-stay hospitals to achieve savings in the second year of $990,000 general fund and $990,000 nongeneral fund. The department shall promulgate regulations to implement this amendment no more than 280 days from the enactment of this act.
CCC. The Department of Medical Assistance Services shall increase fees paid for personal care services paid under the department's home and community- based care waivers by three percent effective July 1, 2009. Personal care includes personal care, respite care and companion care services provided in the EDCD, HIV/AIDS, MR and DD waivers.
DDD. Pursuant to Section 4-1.05.a.4. of this act, $1,399,287 of the June 30, 2008, general fund balances required to be reappropriated have been transferred to the general fund.
EEE. Pursuant to Section 4-1.05.a.4. of this act, $9,217,697 of the June 30, 2008, Virginia Health Care Fund balances required to be reappropriated have been transferred to the general fund.
FFF. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance governing Medicaid reimbursements for freestanding psychiatric hospitals, licensed as hospitals, to rebase rates using FY 2005 base year data and an adjustment factor of 100 percent. Going forward, rates for freestanding psychiatric hospitals shall be rebased on the same schedule as other hospitals. The department shall have the authority to implement this reimbursement change effective July 1, 2009, and prior to the completion of any regulatory process undertaken in order to effect such change.
GGG. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to reduce hospital capital reimbursement from 80 percent of cost to 75 percent of cost for Type Two hospitals. This does not apply to Type Two hospitals whose Virginia Medicaid utilization, which is defined as patient days, exceeds 50 percent. The department shall have the authority to implement this reimbursement change effective July 1, 2009, and prior to the completion of any regulatory process undertaken in order to effect such change.
HHH. The Department of Medical Assistance Services shall not adjust rates or the rate ceiling of residential psychiatric facilities for inflation in FY 2010.
III. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to reduce by 50 percent the inflation adjustment that became effective January 1, 2009, for home health rates, make the next inflation adjustment July 1, 2010, and make future annual inflation adjustments effective on July 1. The department shall have the authority to implement this reimbursement change effective July 1, 2009, and prior to the completion of any regulatory process undertaken in order to effect such change.
JJJ. Beginning with the last quarter of FY 2009, the Department of Medical Assistance Services shall delay the last quarterly payment of certain quarterly amounts paid to hospitals, from the end of each state fiscal year to the first quarter of the following year. Quarterly payments that shall be delayed from each June to each July shall be Disproportionate Share Hospital payments, Indirect Medical Education payments, and Direct Medical Education payments. The department shall have the authority to implement this reimbursement change effective upon passage of this act, and prior to the completion of any regulatory process undertaken in order to effect such change.
KKK. Beginning with the June 2009 monthly capitation payment to managed care organizations, the Department of Medical Assistance Services shall make payment for the member months of each month in the first week of the subsequent month. The department shall have the authority to implement this reimbursement schedule change effective upon passage of this act, and prior to the completion of any regulatory process undertaken in order to effect such change.
LLL. Beginning in June 2009, and every June thereafter, the remittance that would normally be paid to providers on the last remittance date of the state fiscal year shall be delayed one week longer than is normally the practice. This change shall apply to the remittances of Medicaid and FAMIS providers. This change does not apply to providers who are paid a per-month capitation payment. The department shall have the authority to implement this reimbursement change effective upon passage of this act, and prior to the completion of any regulatory process undertaken in order to effect such change.
MMM. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to eliminate the FY 2010 adjustment for inflation of hospital operating rates, disproportionate share hospital payments and graduate medical education payments. The department shall not replace through other payment mechanisms the losses of Type One hospitals from this reimbursement change. However, the department can reimburse, only federal funds, if the Type One hospital is able to certify the public expenditure. This reimbursement change does not apply to hospitals operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services. The department shall have the authority to implement this reimbursement change effective July 1, 2009, and prior to the completion of any regulatory process undertaken in order to effect such change.
NNN. Effective July 1, 2009, the Department of Medical Assistance Services shall amend the State Plan for Medical Assistance to eliminate the adjustment for inflation of nursing facility operating rates and ceilings and specialized care rates and ceilings for days of service in FY 2010. Providers with fiscal years in progress will have the most recent year's inflation eliminated from the rate effective July 1, 2009. Providers with fiscal periods starting July 1, 2009, will not have inflation applied to the rate for that period. This reimbursement change does not apply to nursing facilities operated by the Department of Mental Health, Mental Retardation and Substance Abuse Services and government-operated nursing facilities with 85 percent or greater Medicaid utilization in their provider fiscal year ending in calendar year 2007. The department shall have the authority to implement this reimbursement change effective July 1, 2009, and prior to the completion of any regulatory process undertaken in order to effect such change.
OOO. The Department of Medical Assistance Services shall examine the methodology for reimbursing durable medical equipment. The Department may consider proposals from CGI Technologies Solutions, Inc. to effectuate savings as part of its review. The Department shall report its findings to the Chairmen of the House Appropriations and Senate Finance Committees by November 1, 2009 including the specific strategies recommended to effectuate savings.
PPP. Upon approval by the Centers for Medicare and Medicaid Services of the application for renewal of the Mental Retardation Waiver, expeditious implementation of any revisions shall be deemed an emergency situation pursuant to § 2.2-4002 of the Administrative Process Act. Therefore, to meet this emergency situation, the Department of Medical Assistance Services shall promulgate emergency regulations to implement the provisions of this act.
QQQ. The Department of Medical Assistance Services, to the extent permissible under federal law, shall enter into an agreement with local Healthy Families sites so that qualifying funds may be used at the discretion of each site for obtaining matching nongeneral funds when available.
RRR. The Department of Medical Assistance Services shall conform its requirements for hospice provided personal care to federal requirements for Medicare Conditions of Participation for beneficiaries participating in the Elderly or Disabled with Consumer Direction Waiver program. The department shall have the authority to implement this regulatory change effective July 1, 2009 and prior to the completion of any regulatory process undertaken in order to effect such change.
SSS. The Department of Medical Assistance Services shall provide information to personal care agency providers regarding the options available to meet staffing requirements for personal care aides including the completion of provider-offered training or DMAS Personal Care Aide Training Curriculum.
TTT. The Department of Medical Assistance Services, in consultation with the Department of Mental Health, Mental Retardation and Substance Abuse Services, shall amend the State Plan for Medical Assistance Services in order to comply with the payor of last resort requirements of Part C of the Individuals with Disabilities Education Act (IDEA) of 2004. The Department of Medical Assistance Services shall promulgate regulations to become effective within 280 days or less from the enactment date of this act. The Department shall implement these necessary regulatory changes to be consistent with federal requirements for the Part C program.
UUU. The Department of Medical Assistance Services shall have authority to amend the Virginia State Plan for Title XXI of the Social Security Act and the Virginia Health Insurance Flexibility and Accountability (HIFA) Waiver to require that Family Access to Medical Insurance Security (FAMIS) and FAMIS MOMS applicants and enrollees furnish their Social Security numbers as a condition of eligibility in order to have citizenship and identity verified by the Social Security Administration, unless the applicant is otherwise exempt from this requirement. The department shall have the authority to implement this change effective upon the signing of this act, and prior to the completion of any regulatory process undertaken in order to effect such change.


These couplers are made for use with Grade 80 or Grade 100 chain. They attach to chain fittings--primarily master links--with an "Engineered Flat". They assemble and disassemble with no special tools required. Made from alloy steel, Quenched and Tempered. Individually proof-tested at 2-1/2 times the Working Load Limit with certification. Safety factor of 4:1.


The German testing company Stiftung Warentest has The best child seat ever is made by Recaro - the new Privia!
The latest child safety seat test from Stiftung Warentest resulted in a clear winner: the new Recaro Privia infant carrier with the Recaro fix base. With a total rating of 1.3 the Recaro Privia when paired with the Isofix-base received the best test rating ever given for a child safety seat by the Stiftung Warentest. In the latest edition of the "test" magazine (Issue 6/2014) a total of 28 seats were tested for safety, handling, ergonomics and hazardous materials.
With the result of "very good" the Recaro Privia in use with the Recaro fix base is the undisputed test winner in the category Group 0/0+. With a rating of 1.3 Recaro was awarded the best test result ever given by the Stiftung Warentest, who has since 2007 tested over 200 child safety seats from various manufacturers.