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Start Preamble Office of the Assistant Secretary for Health, Office of the Secretary, Department of cipro prices walmart Health and Human Services. Notice. As stipulated by the Federal Advisory Committee Act, the Department of Health and Human Services (HHS) is hereby giving notice cipro prices walmart that two meetings are scheduled to be held for the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB). The meetings will be open to the public via WebEx and teleconference. A pre-registered public comment session will be cipro prices walmart held during both meetings.

Pre-registration is required for members of the public who wish to attend the meetings via WebEx/teleconference. Individuals who wish to send in their written public comment should send an email to CARB@hhs.gov. Registration information is available on the website http://www.hhs.gov/âpaccarb and must be cipro prices walmart completed by October 1, 2021 for the October 6, 2021 virtual Public Meeting. And, by November 29, 2021 for the November 30-December 1, 2021 virtual Public Meeting. Additional information about registering for the meeting and providing public comment can be obtained at http://www.hhs.gov/âpaccarb cipro prices walmart on the Upcoming Meetings page.

The October meeting is scheduled to be held on October 6, 2021, from 10:00 a.m. To 11:00 a.m cipro prices walmart. ET (times are tentative and subject to change). The November/December meeting is scheduled to be held on November 30, 2021 from 10:00 a.m. To 3:00 cipro prices walmart p.m.

And December 1, 2021, from 10:00 a.m. To 3:00 p.m cipro prices walmart. ET (times are tentative and subject to change). The confirmed times and agenda items for both meetings will be posted on the website for the PACCARB at http://www.hhs.gov/âpaccarb when this information becomes available. Pre-registration for attending the meeting is strongly suggested and should be completed no later than October 1, 2021 for the October meeting and November 29, 2021 for the cipro prices walmart November/December meeting.

Instructions regarding attending this meeting virtually will be posted at least one week prior to the meeting at. Http://www.hhs.gov/âpaccarb. Start Further Info Jomana Musmar, M.S., Ph.D., Designated Federal Officer, Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Room L616, Switzer Building, 330 C St. SW, Washington, DC 20024.

Phone. 202-746-1512. Email. CARB@hhs.gov. End Further Info End Preamble Start Supplemental Information The Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB), established by Executive Order 13676, is continued by Section 505 of Public Law 116-22, the cipro and All-Hazards Preparedness and Advancing Innovation Act of 2019 (PAHPAIA).

Activities and duties of the Advisory Council are governed by the provisions of the Federal Advisory Committee Act (FACA), Public Law 92-463, as amended (5 U.S.C. App.), which sets forth standards for the formation and use of federal advisory committees. The PACCARB shall advise and provide information and recommendations to the Secretary regarding programs and policies intended to reduce or combat antibiotic-resistant bacteria that may present a public health threat and improve capabilities to prevent, diagnose, mitigate, or treat such resistance. The PACCARB shall function solely for advisory purposes. Such advice, information, and recommendations may be related to improving.

The effectiveness of antibiotics. Research and advanced research on, and the development of, improved and innovative methods for combating or reducing antibiotic resistance, including new treatments, rapid point-of-care diagnostics, alternatives to antibiotics, including alternatives to animal antibiotics, and antimicrobial stewardship activities. Surveillance of antibiotic-resistant bacterial s, including publicly available and up-to-date information on resistance to antibiotics. Education for health care providers and the public with respect to up-to-date information on antibiotic resistance and ways to reduce or combat such resistance to antibiotics related to humans and animals. Methods to prevent or reduce the transmission of antibiotic-resistant bacterial s.

Including stewardship programs. And coordination with respect to international efforts in order to inform and advance the United States capabilities to combat antibiotic resistance. The October 6, 2021 public meeting will be held virtually and is dedicated to deliberation and vote of the letter with recommendations from the Immediate Action Subcommittee of the Advisory Council. The meeting agenda will be posted on the PACCARB website at http://www.hhs.gov/âpaccarb when it has been finalized. All agenda items are tentative and subject to change.

The November 31, 2021 and December 1, 2021 public meeting will be held virtually and will be dedicated to addressing the current situation regarding antimicrobial resistance as well as to a presentation from the National Academies of Sciences, Engineering, and Medicine on their report, Examining the Long-term Health and Economic Effects of Antimicrobial Resistance in the United States. The meeting agenda will be posted on the PACCARB website at http://www.hhs.gov/âpaccarb when it has been finalized. All agenda items are tentative and subject to change. Instructions regarding attending both meetings virtually will be posted one Start Printed Page 49552week prior to each meeting at. Http://www.hhs.gov/âpaccarb.

Members of the public will have the opportunity to provide comments live during the October meeting via conference line by pre-registering online at http://www.hhs.gov/âpaccarb. Pre-registration is required for participation in this session with limited spots available. Written public comments can also be emailed to CARB@hhs.gov by midnight October 1, 2021 and should be limited to no more than one page. All public comments received prior to October 1, 2021, will be provided to Advisory Council members. Members of the public will have the opportunity to provide comments live during the November 30, 2021 and December 1, 2021 public meeting via conference line by pre-registering online at http://www.hhs.gov/âpaccarb.

There will be two separate sessions available for public comment. An Innovation Spotlight will be held on November 30, 2021 where companies and/or organizations involved in combating antibiotic resistance have an opportunity to present their work to members of the Advisory Council. And on December 1, 2021, where all members of the general public are welcome to provide oral comment during this separate session. Pre-registration is required for participation in these sessions with limited spots available. Further information about these two sessions can be found online at http://www.hhs.gov/âpaccarb.

Written public comments can also be emailed to CARB@hhs.gov by midnight November 29, 2021 and should be limited to no more than one page. All public comments received prior to November 29, 2021, will be provided to Advisory Council members. Start Signature Dated. August 26, 2021. Jomana F.

Musmar, Designated Federal Officer, Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria, Office of the Assistant Secretary for Health. End Signature End Supplemental Information [FR Doc. 2021-19027 Filed 9-2-21. 8:45 am]BILLING CODE 4150-44-P.

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Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled foods to avoid with cipro and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed foods to avoid with cipro him a bill for his co-pay. Now Joe has a bill that he canât pay.

Read below to find out -- SHORT ANSWER. QMB or Medicaid will pay foods to avoid with cipro the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of foods to avoid with cipro service.

However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers. Providers may not know they are foods to avoid with cipro not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article.

CMS foods to avoid with cipro is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here. See pp foods to avoid with cipro. 53, 86.

1. To Which Providers will QMB or Medicaid foods to avoid with cipro Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2 foods to avoid with cipro.

How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges for a QMB beneficiary, even if the service is normally not foods to avoid with cipro covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C.

Â§ 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance foods to avoid with cipro using a â16â code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3. For a foods to avoid with cipro Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016.

In the proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how foods to avoid with cipro much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service. Part foods to avoid with cipro A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay.

Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has foods to avoid with cipro been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here.

Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved foods to avoid with cipro charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the foods to avoid with cipro deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down.

In the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays foods to avoid with cipro toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage. If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider foods to avoid with cipro receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service.

For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following foods to avoid with cipro services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32).

SSL 367-a, subd foods to avoid with cipro. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers foods to avoid with cipro from being willing to treat them. SSL 367-a, subd.

1(d)(iv), added 2016. EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules. The Medicare rate for Mary's specialist visit is $185.

The Medicaid rate for the same service is $120. Current rules (since 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment.

Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget.

. 4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997.

42 U.S.C. Â§ 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.

This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing.

Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?.

It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Agingâs Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services.

CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017).

QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card does not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB.

See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. What Codes the Provider Sees in eMedNY &. EPACES Medicaid eligibility system - see GIS 16 MA/005 - Changes to eMedNY for Certain Medicaid Recipient Coverage Codes (PDF) âââââââRecipient Coverage Code "09" is defined as "Medicare Savings Program only" (MSP) and is used along with an eMedNY Buy-in span and MSP code of "P" to define a Qualified Medicare Beneficiary (QMB). Providers will receive the following eligibility messages when verifying coverage on EMEVS and ePaces.

"Medicare coinsurance and deductible only" for individuals with Coverage Code 06 and an MSP code of P. *Code 06 is "provisional Medicaid coverage" for Medicaid recipients found provisionally eligible for Medicaid, subject to meeting the spend-down. See more about provisional coverage here. "Family Planning Benefit and Medicare Coinsurance and Ded" for individuals with Coverage Code 18 and an MSP code of P. "Code 18" is for Medicare beneficiaries who are enrolled in the Family Planning Benefit Program (FPBP), who are also income eligible for QMB.

6. If you are Billed -â Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.âââ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice. Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26. 2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372.

TTY/TDD users can call 1-855-729-2372. Medicare Advantage members should complain to their Medicare Advantage plan. In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. Â§ 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs. Toolkit to Help Protect QMB Rights ââIn July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans.

Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link. Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author. Cathy Roberts.

Author. Geoffrey Hale This article was authored by the Empire Justice Center.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP). The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people. Some people are not eligible for an MSP even though they have full Medicaid with no spend down.

This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits. MIPP reimburses them for their Part B premium because they have âfull Medicaidâ (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program. In this article.

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

Sam is age 50 and has Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income.

This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP. 2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as âMAGI-like budgeting.â Under MAGI rules income can be up to 138% of the FPLâagain, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL.

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

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

Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during buy antibiotics emergency their case may remain with NYSoH for more than 12 months. See here.

See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note. During the buy antibiotics emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on buy antibiotics eligibility changes 4.

Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article.

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

See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &. 1619B. 5.

When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences.

MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as.

A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V).

If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov.

If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin.

Under Medicare Part B, his co-insurance cipro prices walmart is 20% of the Medicare-approved Propecia pharmacy prices charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he canât pay. Read cipro prices walmart below to find out -- SHORT ANSWER.

QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New cipro prices walmart York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service.

However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing cipro prices walmart Part B medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them.

These rights and the ramifications of these QMB rules are explained cipro prices walmart in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook cipro prices walmart here.

See pp. 53, 86. 1 cipro prices walmart. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?.

"Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" cipro prices walmart the QMB recipient for the coinsurance. 2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?.

If beneficiary has Original Medicare -- The provider bills Medicaid - even if the cipro prices walmart QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges for a QMB beneficiary, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C cipro prices walmart.

Â§ 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a â16â code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3 cipro prices walmart. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?.

The answer to this question has changed by laws enacted in 2015 and 2016. In the cipro prices walmart proposed 2019 State Budget, Gov. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans.

The answer also differs based on cipro prices walmart the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are cipro prices walmart reduced if the beneficiary has a Medicaid spend-down.

For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See cipro prices walmart more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020.

For example, Dr. John charges $500 for cipro prices walmart a visit, for which the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down.

In cipro prices walmart the 2019 proposed state budget, Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays cipro prices walmart in NYS is different for Original Medicare and Medicare Advantage.

If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same cipro prices walmart service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate.

ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities cipro prices walmart operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is.

This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case cipro prices walmart. This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd. 1(d)(iv), added 2016 cipro prices walmart.

EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in cipro prices walmart the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules. The Medicare rate for Mary's specialist visit is $185.

The Medicaid rate for the same service is $120. Current rules (since cipro prices walmart 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50.

The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of cipro prices walmart that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because cipro prices walmart the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148).

For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. . 4.

May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C.

Â§ 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.

QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals.

See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN.

The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Agingâs Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services.

2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card does not indicate QMB eligibility.

Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly.

What Codes the Provider Sees in eMedNY &. EPACES Medicaid eligibility system - see GIS 16 MA/005 - Changes to eMedNY for Certain Medicaid Recipient Coverage Codes (PDF) âââââââRecipient Coverage Code "09" is defined as "Medicare Savings Program only" (MSP) and is used along with an eMedNY Buy-in span and MSP code of "P" to define a Qualified Medicare Beneficiary (QMB). Providers will receive the following eligibility messages when verifying coverage on EMEVS and ePaces. "Medicare coinsurance and deductible only" for individuals with Coverage Code 06 and an MSP code of P.

*Code 06 is "provisional Medicaid coverage" for Medicaid recipients found provisionally eligible for Medicaid, subject to meeting the spend-down. See more about provisional coverage here. "Family Planning Benefit and Medicare Coinsurance and Ded" for individuals with Coverage Code 18 and an MSP code of P. "Code 18" is for Medicare beneficiaries who are enrolled in the Family Planning Benefit Program (FPBP), who are also income eligible for QMB.

16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.âââ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice. Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26.

2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372. Medicare Advantage members should complain to their Medicare Advantage plan.

In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. Â§ 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs. Toolkit to Help Protect QMB Rights ââIn July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans. Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs.

Links to their webinars and other resources is at this link. Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author. Cathy Roberts.

Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits. MIPP reimburses them for their Part B premium because they have âfull Medicaidâ (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid).

Instead, these consumers can have their Part B premium reimbursed through the MIPP program. In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP.

Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example. Sam is age 50 and has Medicare and MBI-WPD.

She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income.

This is referred to as âMAGI-like budgeting.â Under MAGI rules income can be up to 138% of the FPLâagain, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP.

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

AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS. The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd.

4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during buy antibiotics emergency their case may remain with NYSoH for more than 12 months. See here.

See GIS 20 MA/04 or this article on buy antibiotics eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit.

If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums.

See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP. If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11.

Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &. 1619B. 5.

Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check.

MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility.

There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment.

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

If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program. The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS).

What may interact with Cipro?

Do not take Cipro with any of the following:

cisapride
droperidol
terfenadine
tizanidine

Cipro may also interact with the following:

antacids
caffeine
cyclosporin
didanosine (ddI) buffered tablets or powder
medicines for diabetes
medicines for inflammation like ibuprofen, naproxen
methotrexate
multivitamins
omeprazole
phenytoin
probenecid
sucralfate
theophylline
warfarin

This list may not describe all possible interactions. Give your health care providers a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

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A fourth wave of the opioid epidemic is coming, a national expert on drug use and policy said during a virtual panel discussion this week hosted by the Berkshire County, Massachusetts, District Attorneyâs Office and the can i buy cipro online Berkshire Opioid Addiction Prevention Collaborative.Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco (UCSF) School of Medicine, said the next wave in the countryâs opioid health can i buy cipro online emergency will focus on stimulants like methamphetamine and cocaine, and drug combinations where stimulants are used in conjunction with opioids.âThe use of methamphetamines is back and itâs back big time,â said Ciccarone, whose most recent research has focused on heroin use.Previously, officials had said there were three waves of the opioid epidemic â the first being prescription pills, the second being heroin, and the third being synthetic drugs, like fentanyl.Now, Ciccarone said, what federal law enforcement and medical experts are seeing is an increase in the use of stimulants, especially methamphetamines.The increase in deaths due to stimulants may be attributed to a number of causes. The increase in supply, both imported and domestically produced, as well as the increase of the drugsâ potency.âMethâs purity and potency has gone up to historical levels,â he said.

ÂAs of 2018, weâve reached unseen heights of 97 percent potency and 97 can i buy cipro online percent purity. In a prohibitionist world, we should not be seeing such high quality. This is almost pharmaceutical quality.âAdditionally, law can i buy cipro online enforcement and public health experts like Ciccarone are seeing an increase in the co-use of stimulants with opioids, he said.

Speedballs, cocaine mixed with heroin, and goofballs, methamphetamines used with heroin or fentanyl, are becoming more common from the Midwest into Appalachia and up through New England, he said.Federal law enforcement officials are recommending local communities prepare for the oncoming rise can i buy cipro online in illegal drugs coming into their communities.âSome people will use them both at the same time, but some may use them in some combination regularly,â he said. ÂThey may use meth in the morning to go to work, and use heroin at night to come down.âThe co-use, he said, was an organic response to the fentanyl overdose epidemic.âSome of the things that we heard â¦ is that meth is popularly construed as helping to decrease heroin and fentanyl use. Helping with heroin withdraw symptoms and helping with heroin overdoses,â can i buy cipro online he said.

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supply reduction, demand reduction and harm reduction. But not focus on only one single drug.Additionally, he said that by addressing issues within communities and by healing communities socially, economically and spiritually, communities can begin to reduce demand.âWeâve got to fix the cracks can i buy cipro online in our society, because drugs fall into the cracks,â he said.Shutterstock U.S. Rep.

Annie Kuster (D-NH) recently held two virtual roundtables addressing how buy antibiotics has affected New Hampshireâs healthcare industry.âThe health and economic crisis caused by buy antibiotics has created significant challenges for Granite State healthcare, mental health, and substance use treatment providers â at the same time, we are seeing increases in substance abuse and mental illness across New Hampshire,â Kuster said. ÂFrom the transition to telehealth care and cancellations of elective procedures to a lack of personal protective equipment and increasing health needs of our communities â providers have overcome a multitude of obstacles due to buy antibiotics in recent months. I was glad to hear from these hard-working Granite Staters, whose insights will continue to guide my work in Congress as we respond to this cipro.

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A fourth wave of the opioid epidemic is coming, cipro prices walmart a national expert on drug use and policy said during a virtual panel discussion this week hosted by the Berkshire County, Massachusetts, District Attorneyâs Office and the Berkshire Opioid Addiction Prevention Collaborative.Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco (UCSF) School of Medicine, said the next wave in the countryâs opioid health emergency will focus on stimulants like methamphetamine and cocaine, and drug combinations where stimulants are used in conjunction with opioids.âThe use of methamphetamines is back and itâs back big time,â said Ciccarone, whose most recent research has focused on heroin use.Previously, officials had said there were three waves of the opioid epidemic â the first being prescription pills, the second being heroin, and the third being synthetic drugs, like fentanyl.Now, Ciccarone said, cipro prices walmart what federal law enforcement and medical experts are seeing is an increase in the use of stimulants, especially methamphetamines.The increase in deaths due to stimulants may be attributed to a number of causes. The increase in supply, both imported and domestically produced, as well as the increase of the drugsâ potency.âMethâs purity and potency has gone up to historical levels,â he said.

ÂAs of 2018, weâve reached cipro prices walmart unseen heights of 97 percent potency and 97 percent purity. In a prohibitionist world, we should not be seeing such high quality. This is almost pharmaceutical quality.âAdditionally, law enforcement and public cipro prices walmart health experts like Ciccarone are seeing an increase in the co-use of stimulants with opioids, he said.

Speedballs, cocaine mixed with heroin, and goofballs, methamphetamines used with heroin or fentanyl, are becoming more common from the Midwest into Appalachia and up through New England, he said.Federal law enforcement officials are recommending local communities prepare cipro prices walmart for the oncoming rise in illegal drugs coming into their communities.âSome people will use them both at the same time, but some may use them in some combination regularly,â he said. ÂThey may use meth in the morning to go to work, and use heroin at night to come down.âThe co-use, he said, was an organic response to the fentanyl overdose epidemic.âSome of the things that we heard â¦ is that meth is popularly construed as helping to decrease heroin and fentanyl use. Helping with cipro prices walmart heroin withdraw symptoms and helping with heroin overdoses,â he said.

ÂWe debated this for many years that people were using stimulants to reverse overdoses â weâre hearing it again.ââSupply is up, purity is up, price is down,â he said. ÂWe know from economics that when drug patterns go in that direction, use is going up.âCiccarone said that there should not be deaths because of stimulants, but that heroin/fentanyl is the deadly element in the equation.His recommendations cipro prices walmart to communities were not to panic, but to lower the stigma surrounding drug use in order to affect change. Additionally, he cipro prices walmart said, policies should focus on reduction.

supply reduction, demand reduction and harm reduction. But not focus on only one single drug.Additionally, he said that by addressing issues within communities and by healing communities socially, economically and spiritually, communities can begin to reduce demand.âWeâve got to fix the cracks in our society, because drugs fall cipro prices walmart into the cracks,â he said.Shutterstock U.S. Rep.

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Weâre still learning how deep that impact was from closing schools and kids being home for a year.â Reports emerged during the cipro, the report said, that remote learning was taking a toll on students. Clark County, Nevada schools re-opened after 18 students took their lives between March and December 2020 â twice the rate of the previous year. Most suicide prevention starts cipro 500mg uses in schools when mental health issues typically first emerge. The report found that rural school districts found it harder to continue providing services during the cipro, than their urban counterparts did.

To address the rural/urban suicide gap, Mallinson said, rural communities need more funding and more resources to provide prevention programs. ÂIn a privatized healthcare system, like what we have in a lot of rural counties, thereâs been a cipro 500mg uses lot of healthcare consolidation,â he said. ÂAnd consolidation has brought closures. Those closures tend to be in rural areas.

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Proposed rule. In this document, the Federal Communications Commission proposes to require covered text providers to support text messaging to 988, the 3-digit dialing code to reach the National Suicide Prevention Lifeline. We seek comment on this proposal and related issues, such as the text message formats that covered text providers must transmit to cipro 500mg uses 988 and the timeframe for implementation. Comments are due on or before July 12, 2021, and reply comments are due on or before August 10, 2021.

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FCC504@fcc.gov or phone. 202-418-0530 or TTY. 202-418-0432. For detailed instructions for submitting comments and additional information on the rulemaking process, see the SUPPLEMENTARY INFORMATION section of this document.

Start Further Info Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388, Michelle.Sclater@fcc.gov. End Further Info End Preamble Start Supplemental Information This is a summary of the Commission's further notice of proposed rulemaking (FNPRM) in WC Docket No. 18-336, adopted on April 22, 2021 and released on April 23, 2021. The full text of the document is available at https://docs.fcc.gov/âpublic/âattachments/âFCC-21-47A1.pdf.

To request materials in accessible formats for people with disabilities (e.g., braille, large print, electronic files, audio format, etc.) or to request reasonable accommodations (e.g., accessible format documents, sign language interpreters, CART, etc.), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice) or (202) 418-0432 (TTY). Synopsis I. Further Notice of Proposed Rulemaking A.

Text-to-988 Can Save Lives 1. In this FNPRM, we tentatively conclude that text-to-988 functionality will greatly improve consumer access to the National Suicide Prevention Lifeline (Lifeline), particularly for at-risk populations, and thereby save lives. We seek comment on this tentative conclusion, and on the benefits of text messaging as a means to facilitate access to the critical mental health resources offered by the Lifeline generally. 2.

We tentatively conclude that ensuring that Americans in crisis can text 988 is likely to save lives. In the 988 notice of proposed rulemaking, the Commission observed that âAmericans, particularly younger Americans, increasingly rely on texting to communicate,â and sought comment on how to account for this fact in establishing 988 as a nationwide 3-digit code for the Lifeline. In response, numerous experts in mental health and other fields have submitted comments in this proceeding underscoring the importance of texting as a vital communications medium by which many individuals may wish to obtain crisis counseling. Further, many of these commenters noted that texting is particularly important for âmembers of vulnerable communities such as young people, low-income individuals, members of the LGBTQ community, and individuals who are deaf and hard of hearing.â We seek comment on our tentative conclusion and the assertions of these commenters regarding the importance of texting as a means to access the lifesaving resources offered by the Lifeline.

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

We seek comment on this preliminary analysis. 4. As the Commission noted in the 988 Report and Order, young people are disproportionately at risk for mental health crises. They are also more likely to be most comfortable communicating via text.

According to the National Alliance on Mental Illness, â[n]early 95% of teens have access to smart phones and say that texting is the primary way that they connect.â For this reason, the International Council for Helplines describes the increasing use of âchat and text services. . . For those who are in a mental health crisis,â pointing to a recent survey indicating that â75% of millennials prefer texting over talking.â According to Mental Health America, â[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,â including a study finding that young people âwere more likely to forgo psychological support than talk in person or over the phone.â As a result, Mental Health America argues, the âdata strongly support[â] the implementation of texting for providing resources to individuals experiencing suicidal ideation.â We seek comment on these views and whether adopting a text-to-988 mandate would provide particular benefits for young Americans.

Are young people more inclined to seek help by text than by telephone, and if Start Printed Page 31405so, would making it easier to text the Lifeline save lives?. 5. In our preliminary view, facilitating Lifeline accessibility by text message to 988 is also likely to provide significant benefits to many other at-risk communities as well, further justifying our proposed mandate. As the Commission explained in the 988 Report and Order, a broad range of American communities are disproportionately impacted by suicide, including Veterans, LGBTQ individuals, racial and ethnic minorities, and rural Americans.

Many members of these affected communities may prefer to seek help through text messages. For example, Mental Health America reports that data they collect demonstrate that individuals âwho identify as Black or African American are more likely to report that they would like to receive a phone number they can immediately call or text for helpâ than members of any other race or ethnicity. Do commenters agree with Mental Health America that making crisis counseling services available via text message âmay mean the difference between accessing psychological support and forgoing it, especially among youth of color?. Â Is Mental Health America correct that easy access to crisis services via text may be the difference between seeking and forgoing help for such groups, and if so would use of a 3-digit dialing code for the Lifeline make a significant difference in widespread understanding that such crisis services are available?.

6. Indeed, demographic evidence regarding usage of currently available non-governmental text and chat options indicate that texting is a particularly valuable means to obtain help, not only for young people, but also for many members of low income, minority, and other communities that are disproportionately impacted by mental health crises. Several commenters in this proceeding have pointed to the successes that private non-profit services like the Trevor Project have had in providing crisis counseling to at-risk communities through text messages, offering that their experiences demonstrate the need to provide text access to 988. In addition, as one commenter to the 988 notice of proposed rulemaking argued, adding text access to 988 could allow the Lifeline and Veterans Crisis Line âto more efficiently route those in need to specialized services,â further leveraging the expertise of organizations like the Trevor Project, which provides mental health support and counseling specific to the needs of LGBTQ youth.

We preliminarily agree with this assessment and believe that establishing text access to 988 will complement the important work already being done by these and other private sector organizations, and further facilitate access to the lifesaving resources offered by the Lifeline and Veterans Crisis Line. We seek comment on these views and on the benefits of text-to-988 for at-risk groups. Are there additional at-risk communities that may benefit from texting as an option to access the Lifeline?. 7.

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

Access to telecommunications for individuals with disabilities is a longstanding Commission priority and statutory obligation, and facilitating access to 988 for deaf and hard of hearing individuals is a particularly important policy objective in light of studies finding a significantly increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. We seek comment on these views and whether our proposal would ease access to lifesaving counseling for individuals with disabilities. Do commenters agree with the Communications Equality Advocates that the ability for individuals normally using text for the bulk of their communications, including people with disabilities, to access trained mental health professionals using text-to-988 will be of âparamount importanceâ?. Currently, how do people with disabilities reach the Lifeline?.

How would texting grant access or enhance their ability to communicate with the Lifeline?. We seek comment on whether texting would be more accessible than the options currently available, including the Lifeline's online chat portal. 8. We tentatively conclude that the potential lifesaving benefits of expanding access to suicide prevention and mental health crisis services for all Americansâand particularly the at-risk groups discussed aboveâjustifies a text-to-988 mandate, and we seek comment on this view.

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

Would mandating text-to-988 amplify the benefits of promoting 988 as the telephone number for the Lifeline?. What are the costs or drawbacks to our proposal?. 9. In our preliminary view, the Lifeline's soft launch of a texting capability is a significant changed circumstance that supports mandating text-to-988.

When the Commission adopted the 988 Report and Order, the Lifeline was not capable of receiving or responding to text messages. The Commission, stating that it has no authority to require the Lifeline to develop texting capability, deferred âconsideration of mandating text-to-988 at this time so that we could revisit the issue promptly should the Lifeline develop integrated texting.â Now, the Lifeline is capable of responding to texts sent to the Lifeline. The Lifeline's ability to respond to texts significantly strengthens the case for imposing a text-to-988 mandate on providers. We seek comment on this evaluation.

10. We preliminarily expect many of the same lifesaving benefits from texting to 911 to accrue from texting to 988. In its comments in support of adopting a text-to-988 requirement, CTIA notes that text-to-911 functionality âhas saved countless lives and enabled public safety to keep pace with the modern Start Printed Page 31406communications preferences of consumers.â Given the parallels between the Commission's efforts to promote text access to 911 and our proposals in this FNPRM, are there lessons learned in the context of establishing text-to-911 capability that would be instructive here?. CTIA states that there are âsignificant technical and policy differences between the national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.â For example, unlike calls to 911, which carriers route to one of thousands of local PSAPs across the country based on the caller's geographic location, all calls to 988 are routed to a central toll free number, and are then directed within the Lifeline network to a local crisis center.

How might these or other differences between the 911 and 988 networks affect our proposal to adopt a text-to-988 requirement?. B. Proposed Implementation of Text-to-988 1. Scope of Text-to-988 Requirement 11.

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

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

12. First, we propose to define the outer bound of text messages that covered text providers may be required to transmit to 988 based on the definition of âtext messageâ that Congress enacted in 2018 in the context of Truth in Caller ID requirements. The term âtext messageâ (i) means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number or N11 service code. (ii) includes a [SMS] message and a multimedia message service (commonly referred to as `MMS') message.

And (iii) does not includeâ(I) a real-time, two-way voice or video communication. Or (II) a message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in clause (ii). The Commission's Truth in Caller ID rules define MMS as âa wireless messaging service that is an extension of the SMS protocol and can deliver a variety of media, and enables users to send pictures, videos, and attachments over wireless messaging channels.â We seek comment on this proposed scope. We believe this definition has several advantagesâit incorporates multimedia messages.

It is not limited to specific technologies. And it reflects a recent determination by Congress, albeit in a different policy context. For the purpose of our text-to-988 rules, we propose adding âor 988â to the phrase â10-digit telephone number or N11 service codeâ so that text messages from the Lifeline identified by the 3-digit code 988 are included within the scope of covered text providers' obligations, and we seek comment on this proposal. We seek comment on whether using the Truth in Caller ID definition appropriately sets an outer bound that would achieve our goals of adopting a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers.

13. We note that the Truth in Caller ID statutory definition of âtext messageâ excludes âreal-time, two-way voice or video communications,â as well as âmessages sent over. . .

IP-enabled messaging services to another user of the same messaging service.â If we adopt the Truth in Caller ID definition, we seek comment on how we should interpret each of these two exclusions here. Is there any reason to adopt a different interpretation of the relevant exclusions in this context compared to the Truth in Caller ID context?. Â Would adopting the Truth in Caller ID definition of âtext message,â with the exclusions specified above, prevent us from possibly adding ânext-generationâ text messages to our requirements in the future?. 14.

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

We note that the Truth in Caller ID model is newer than the text-to-911 definition, originates with Congress rather than the Commission, and unlike the text-to-911 definition explicitly includes images, sounds, and other non-textual information. On the other hand, the Commission developed the text-to-911 definition in a more analogous policy context than the Truth in Caller ID definition. Do these or other considerations suggest that one or the other model is superior?. 15.

Should we ensure that any definition we adopt encompasses next-generation forms of text messaging, such as MMS, Rich Communications Services (RCS), and/or real-time text (RTT), and what modificationsâif anyâwould we need to make to the definitions we are considering to ensure that such forms are within our proposed scope?. RCS has been described as a âsuccessor protocolâ to SMS, or as ânext-generationâ SMS. What are the fundamental differences between SMS, MMS, and RCS?. How would the costs to implement SMS, MMS, and RCS differ?.

The Commission has previously concluded that âmessages sent over other IP-enabled messaging services that are not SMS or MMSâsuch as [RCS]âare excluded fromâ the Truth in Caller ID definition of text message âto the extent such messages are sent to other users of the same messaging service.â Would it be necessary to modify the Truth in Caller ID definition for our purposes to ensure that it includes RCS or other next-generation services?. 16. We also seek comment on whether we should ensure that our proposed outer bound definition of text message encompasses RTT. Telecommunications for the Deaf and Hard of Hearing, Inc., et al.

Have urged us to mandate the ability to reach 988 by RTT, noting that the Commission âhas acknowledged the benefits of RTT in crisis situations such as `allow[ing] for interruption and reduc[ing] the risk of crossed messages Start Printed Page 31407because the. . . Call taker is able to read the caller's message as it is being typed, rather than waiting until the caller presses the `send' key.â We seek comment on this assertion and other potential benefits and drawbacks of RTT to 988.

We note that pursuant to the 2016 RTT Order, all wireless service providers are permitted to support RTT on their IP networks for purposes of 911 compliance (and for purposes of complying with the general accessibility requirements of Parts 6, 7, and 14 of the Commission's rules) as an alternative to supporting TTY communications over IP. In light of the deployment of such RTT capabilities in wireless IP networks, are there any impediments to wireless service providers routing RTT texts to the 988 number, in the event that Lifeline chooses to support RTT?. Do newer text messaging protocols like RTT and RCS represent a significant portion of the text messaging ecosystem, or are they likely to in the near future?. Are consumers likely to expect the ability to use these kinds of platforms to send text messages to 988?.

Do these texting solutions make texting more accessible for individuals with disabilities?. Are there other reasons to include, or exclude, these types of applications from our definition?. Are there any text message formats that we should specifically exclude from the definition we adopt?. For example, in crafting the text-to-911 rules, the Commission chose to exclude from its requirements a variety of services, including ârelay service.

. . , mobile satellite service (MSS), and in-flight text messaging services,â as well as âtext messages that originate from Wi-Fi only locations or that are transmitted from devices that cannot access the CMRS network.â Should we adopt any similar exclusions here?. 17.

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

We seek comment on this proposal. Does it appropriately balance the need for expedient implementation with avoiding unduly burdening covered text providers with implementing formats that the Lifeline cannot receive?. Should we require the Bureau to issue a Public Notice more or less often than annually?. Or is there another mechanism, such as one similar to the Commission's Text-to-911 PSAP registry, whereby PSAPs issue a valid request for texting service from covered text providers, that we should consider?.

Is technical feasibility an appropriate standard for exclusion, or do commenters recommend a different standard?. Should we have a standard for exclusion by the Bureau at all?. If we do not have a standard for excluding certain technologies, is notice and comment necessary?. What is an appropriate implementation deadline for us to specify after the Bureau issues its Public Notice requiring implementation?.

For instance, would six months be sufficient?. Should we instead allow the Bureau flexibility to set an appropriate deadline?. Should we provide any further direction to the Bureau regarding the evaluation we propose to require?. 18.

We also seek comment on structuring the scope of covered text messages differently. For instance, should we simply adopt a definition of âtext messageâ and require covered text providers to support all such formats, regardless of whether the Lifeline can support that format presently?. Should we adopt a narrower definition of âtext messageâ that conforms to what the Lifeline can support at present?. While we appreciate the simplicity of either of these approaches compared to our proposal, how would commenters address our concern that the former is unnecessarily burdensome, and the latter is not adequately future-proofed?.

19. Covered Text Providers. We propose to apply our text-to-988 requirement to âcovered text providersâ as that term is defined in the text-to-911 rules, to âinclude[â] all CMRS providers as well as all providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.â We note that the term âcovered text providerâ used in this notice of proposed rulemaking differs from the term âcovered providersâ used in the rules the Commission adopted in the 988 Order, which refers to all telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers.

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

Would using âCMRS providersâ exclude services over certain spectrum bands or non-switched wireless services that transmit text messages to 988, and should we instead include âwireless carriers,â or a different term, in our definition of âcovered text providers?. Â 20. Interconnected Text Messaging Services. In adopting the text-to-911 rules, the Commission observed that there are a variety of widely available text messaging services and platforms with different technological capabilities, including SMS, MMS, and âover-the-topâ (OTT) applications delivered over internet protocol (IP)-based mobile data networks.

As the Commission explained in the Text-to-911 Second Report and Order, âSMS requires use of an underlying carrier's SMS Center (SMSC) to send and receive messages from other usersâ while â[MMS]-based messaging makes use of the SMSC but also involves the use of different functional elements to enable transport of the message over IP networks.â A third category, OTT applications, may be offered by CMRS providers or third parties and allow consumers âto send text messages using SMS, MMS or directly via IP over a data connection to dedicated messaging servers and gateways.â These OTT services, which are often downloaded through mobile app stores, are increasingly popular with consumers and may be interconnected with the publicly Start Printed Page 31408switched telephone network (PSTN) or not. For purposes of the Commission's text-to-911 rules, interconnected text messaging applications enable consumers to âsend text messages to all or substantially all text-capable U.S. Telephone numbers and receive text messages from the same,â while non-interconnected applications âonly support communication with a defined set of users of compatible applications but do not support general communication with text-capable telephone numbers.â The Commission's text-to-911 rules include interconnected text messaging services but exclude non-interconnected applications because they do not provide the ability to communicate with text-capable U.S. Telephone numbers.

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

Since the services provided by the Lifeline require two-way communication and, by definition, non-interconnected text messaging applications cannot support two-way texting with âall or substantially all text-capable U.S. Telephone numbers,â we believe it is unlikely that these services would be technically capable of supporting text-to-988 functionality. We seek comment on this view. Are there any tools available to the Commission to mitigate the potential for consumer confusion regarding the availability of text-to-988 across different text messaging platforms and technologies, particularly with respect to non-interconnected text messaging applications?.

2. Routing Texts to 988 22. We propose to require that covered text providers route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK), and we seek comment on this proposal. This proposal is consistent with the Commission's decision for routing calls to 988 in the 988 Report and Order.

In the 988 Report and Order, the Commission required âthat service providers transmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline,â finding that a centralized routing solution will allow for faster implementation of the 988 3-digit dialing code, lower costs to maintain 988 routing, and provide continued easy access to Lifeline by callers with disabilities. We preliminarily believe that there are similar benefits to routing texts to 988 to a single, centralized number and seek comment on this view. 23. There is support in the record thus far for routing to the Lifeline.

CTIA supports directing texts sent to 988 to the Lifeline as a âcentral point for receiving such communications,â consistent with the Commission's mandate for routing 988 voice calls. Vibrant Emotional Health, the administrator of the Lifeline, argues in support of text-to-988 functionality integrated into the current Lifeline structure for routing voice and chat services, with oversight squarely within the role of the Lifeline's administrator. We seek comment on these assessments. 24.

We anticipate that requiring covered text providers to route to a single destination provides SAMHSA and the VA with flexibility to develop their own routing solutions among the local crisis centers, including adding new crisis centers in the future, as compared to requiring covered text providers to implement additional updates or routing changes as more centers are added. Callers to 1-800-273-8255 (TALK) can reach the Veterans Crisis Line by pressing option 1 to connect with one of three linked call centers in New York, Georgia, or Kansas. For other calls, calls to the Lifeline from anywhere in the United States are routed to the closest certified local crisis center according to the caller's area code or, should the closest center be overwhelmed by call volume, experience a disruption of service, or if the call is placed from part of a state not covered by Lifeline's network, the system automatically routes calls to a backup center. We seek comment on this preliminary analysis.

Do the current obligations to route voice calls to 988 to the Lifeline 10-digit number offer any opportunities for streamlining implementation or reducing costs associated with routing texts to 988 to the same number?. 25. In the alternative, we seek comment on whether instead to follow a model more comparable to the text-to-911 architecture, whereby covered text providers route directly to a PSAP by requiring routing directly to a Lifeline local crisis center or to a Veterans Crisis Line crisis center. We anticipate that this approach would be significantly more costly than centralized routing and seek comment on this preliminary view.

Is it easier to route texts to a single number than to individual crisis centers?. As the Veterans Crisis Line is not currently set up for geographic distribution, would this architecture be appropriate for messages by Veterans or Service Members?. Are covered text providers able to leverage existing text-to-911 systems to reduce costs if required to route texts to 988 directly to local crisis centers?. In the 988 Report and Order, the Commission recognized that some commenters expressed there may be benefits to routing voice calls to individual crisis centers, such as familiarity with a caller's area and potentially easier coordination with local emergency services, but ultimately concluded that the advantages associated with routing to a single number outweighed the benefits of localized routing.

Does that rationale apply here?. Are there benefits to routing texts to the individual crisis centers that are unique to text messages, such as providing localized support to the public in the vicinity of the crisis center?. What are the costs or drawbacks to covered text providers to route texts to the Lifeline 10-digit number versus the local crisis centers?. Which approach will lead to speedier implementation, and how should that impact our analysis?.

Is there another alternative approach, other than centralized routing or routing by crisis center, that we should consider?. 26. Currently, Veterans and Service Members may dial the Lifeline to reach the Veterans Crisis Line via voice call, but the Lifeline texting service and the VA's short code texting service require contacting separate numbers. How should we account for this distinction in evaluating what rules to adopt to ensure that Veterans, Service Members, and their families are able to reach the Veterans Crisis Line directly and promptly?.

We seek comment on whether and how we can act to facilitate integration of the Veterans Crisis Line's separate short code-based texting service into text-to-988 routing. Are there specific actions that the Commission should take to allow users to text 988 and reach both the Lifeline and Veteran-specific assistance?. For instance, should we require covered text providers to provide an automated inquiry as to whether the texter is a Veteran or Service Member and route Start Printed Page 31409the text to either the existing Lifeline number or the existing short code for Veterans depending on the response?. Alternatively, would it be feasible to immediately prompt individuals texting to 988 to reply with the number â1â or âVetâ to be routed to the Veterans Crisis Line, similar to the experience for voice callers?.

Are other prompts preferable?. We seek comment on possible solutions to ensure that texts are routed to the proper counseling services via the Lifeline or the Veterans Crisis Line, including input on technical feasibility, ways to minimize consumer confusion, and implementation costs. Should other text or chat services be integrated into 988 text routing, and if so, how?. 27.

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

If consumers generally are aware that calls and texts to 911 include their location, would the same expectation apply to texts to 988?. Would including location information deter at-risk individuals from texting to 988?. We seek comment on any complications inherent in this plan and on ways for covered text providers to work with SAMHSA and the VA to limit misrouting of texts. 3.

Implementation Timeframe for Text-to-988 28. Uniform Nationwide Deadline. We seek comment on an appropriate implementation timeframe for requiring covered text providers to support texting to 988 on a nationwide basis. We preliminarily propose adopting a uniform nationwide deadline for implementation for all covered text providers and for all covered 988 text messages, as determined by the Bureau.

In the 988 Report and Order, the Commission determined that the ârollout of 988 will be most effective if [it] set a single implementation deadline so that stakeholders can clearly and consistently communicate to the American public when 988 will be universally available.â We preliminarily believe that the same holds true here, and we seek comment on this view. Are there other benefits to a uniform nationwide implementation deadline?. What drawbacks, if any, exist?. 29.

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

If so, what are they and why?. Are there any other considerations, such as any existing contractual obligations between our federal partners and other entities, that we should take into account in setting a deadline or deadlines?. 30. Appropriate Deadline.

We observe that CTIA and other commenters have previously argued that the Commission should not mandate text-to-988 before the Lifeline is capable of receiving and responding to texts, in part because the Lifeline's readiness to receive and respond to text messages is crucial to implementing text-to-988 successfully. We seek comment on this assertion. We also seek comment on CTIA's proposal to require covered text providers to âdeliver text-to-988 to the Lifeline by July 16, 2022, or six months after the Lifeline demonstrates its readiness to accept text messages, whichever is later.â Is the Lifeline's pilot program sufficient to demonstrate that it is ready to accept text messages?. If not, how should we determine that the Lifeline has demonstrated readiness to accept text messages, both from a technical and operational standpoint?.

How should we take into account the capabilities of the Veterans Crisis Line in establishing a deadline?. Understanding that the Lifeline and Veterans Crisis Line successfully accepting and responding to text messages to 988 will require coordination between several stakeholders, we emphasize that the Commission will continue to coordinate closely with our federal partners, SAMHSA and the VA, in their efforts to enable crisis centers to respond to text messages to 988 and establish a reasonable implementation timeframe for text-to-988. We reiterate that the Commission does not wish to determine for SAMHSA how it allocates the Lifeline's resources, nor do we have the authority to require the Lifeline and its crisis centers to be capable of receiving and responding to text messages to 988. 31.

We seek comment on whether the Commission should require all covered text providers to support text-to-988 by July 16, 2022, the same implementation deadline for telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers to support voice calls to 988. Is this technically, economically and operationally feasible?. Are there benefits to requiring a uniform implementation timeline for all voice and text communications to 988?. We observe that some covered text providers have already implemented voice calling to 988.

For those providers, will requiring covered text providers to implement text-to-988 on the same timeline as voice calling to 988 create any efficiencies, such as reducing fixed costs?. Is there an expectation that once 988 is deployed nationwide for voice communications that texting to 988 will be similarly available?. Will a uniform implementation deadline discourage covered text providers from potentially supporting text to 988 before July 16, 2022?. Are there other potential benefits or drawbacks to uniform implementation deadlines for providers supporting voice calling and texting to 988?.

32. Alternatively, we seek comment on whether we should separate the timeline for implementing text-to-988 from the implementation timeline for voice-to-988. Is a phased-in approach preferable?. Would it be beneficial to consider balance of telecommunications activation needs and organizational response needs by SAMHSA and the VA?.

Would it be less burdensome on providers working to implement 988 for voice calls in accordance with the 988 Report and Order?. Would a phased-in implementation timeline create consumer confusion regarding the availability of texting to 988?. If phased-in implementation deadlines would create consumer confusion, would requiring certain covered text providers to implement text-to-988 more quickly minimize consumer confusion?. For example, if a covered text provider has already implemented voice calling to 988 and is advertising the availability of 988 to its customers, should the provider be required to implement text-to-988 before other covered text providers?.

Are there other risks associated with a phased-in approach to an implementation timeline for voice and text communications to 988 as compared to uniform implementation timeline?. What, if any, phased-in deadlines should the Commission consider?. 33. We also seek comment on whether we should we adopt the same timeline for all covered text providers, regardless of the text messaging technology they use.

Are there other preparedness concerns that we should take into Start Printed Page 31410consideration when determining an implementation timeframe?. 4. Technical Considerations 34. We seek comment on the specific technical considerations for covered text providers and equipment and software vendorsâincluding those providers who are rural or small businessesânecessary to implement text-to-988.

We propose to allow covered text providers to use any reliable method or methods (e.g., mobile-switched, IP-based) to support text routing and transmission to 988, similar to text-to-911 implementation. We seek comment on this proposal. 35. Network Upgrades.

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

CTIA notes âthere are significant technical and policy differences between national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.â We seek comment on CTIA's view, especially with regard to any âsignificantâ technical differences. Conversely, do commenters agree with Communications Equality Advocates that the costs to covered text providers for implementation of text-to-988 should be substantially lower than those associated with implementing text-to-911?. We seek further comment on the potential integration of text-to-988 solutions with existing systems, as well as other network considerations specific to covered text providers to support text-to-988. 36.

We also seek comment on whether there are unique network considerations for different text messaging service technologies within the proposed outer bound scope of text-to-988 service that impact implementation. CTIA comments that its member companies are âoptimistic about the technical feasibility of supporting text-to-988,â provided that implementation is consistent with existing capabilities of native SMS messaging. Do commenters agree?. Are there fewer network upgrades necessary to support SMS-only texts to 988?.

What specific network upgrades would be required should we obligate covered text providers to support other text messaging formats, such as MMS, RTT, or RCS?. Given that the Commission has recognized MMS as âan extension of the SMS protocol,â would support for MMS messaging be comparably feasible to support for SMS?. How does the evolution of texting services to new or future formats affect network upgrade options and implementation, and how should our rules account for such evolution?. Would requiring support for certain text messaging formats be more feasible for covered text providers to implement than others?.

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

In the text-to-911 context, the Commission's rules state. To the extent that CMRS providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 911 text messages originating on such other covered text providers' application services. Covered text providers using the CMRS network to deliver 911 text messages must clearly inform consumers that, absent an SMS plan with the consumer's underlying CMRS provider, the covered text provider may be unable to deliver 911 text messages. CMRS providers may migrate to other technologies and need not retain SMS networks solely for other covered text providers' 911 use, but must notify the affected covered text providers not less than 90 days before the migration is to occur.

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

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

38. We also seek comment on specific technical considerations for covered text providers that are rural or regional providers, or small businesses. Are there unique impediments or challenges to implementation that these types of providers face that warrant further consideration?. 39.

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

Are there upgrades necessary by vendors that are beyond the covered text providers' control that require additional coordination?. Will new standards need to be defined to ensure interoperability?. 40. In the Text-to-911 proceeding, the Commission clarified that legacy devices that are incapable of sending texts via 3-digit codes are not subject to the text-to-911 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-911.

If the device's text messaging software can be upgraded over the air to support a text to 911, however, then the Commission required the covered text provider to make the necessary software upgrade available. Should we include a Start Printed Page 31411similar exemption for legacy devices under any text-to-988 requirements we may adopt?. Have circumstances changed in the past seven years such that we should adopt a different approach here?. 5.

Cost Recovery 41. Consistent with the Commission's decision in the 988 Report and Order, we propose to require that all covered text providers bear their own costs to implement text-to-988 capability to the Lifeline 10-digit number. As with call routing to 988, we do not anticipate any shared industry costs are necessary to implement text-to-988, in contrast to previous non-988 numbering proceedings where the Commission established a cost recovery mechanism. As proposed, costs to support text-to-988 would be borne by each provider, specific to the solutions each has adopted to route texts to 988 ultimately to the Lifeline's current toll free access number, presently 1-800-273-8255 (TALK).

We seek comment on this proposal. 42. We believe this approach promotes efficiency in implementation and avoids unnecessary administrative costs. Section 251(e)(2) of the Act states that â[t]he cost of establishing telecommunications numbering administration arrangements and number portability shall be borne by all telecommunications carriers on a competitively neutral basis.â The Commission typically applies cost recovery mechanisms in situations involving some type of numbering administration arrangement, such as when the Commission hires a third party to develop a database for industry use, to ensure that the statutory cost neutrality requirements are met.

Here, as with implementation of voice calls to 988, circumstances do not require establishment of a numbering administration arrangement as there will not be shared costs. Therefore, we believe the section 251(e)(2) requirements do not apply. Furthermore, even if section 251(e)(2) applies, we believe it is satisfied if we require each provider to bear its own costs because each provider's costs will be proportional to the size and quality of its network. We seek comment on this analysis.

6. Bounce-Back Messages 43. We seek comment on whether and in what circumstances to require covered text providers to send automatic bounce-back messages where text-to-988 service is unavailable. Throughout the ongoing roll-out of text-to-911 services across the U.S., the Commission has required covered text providers to send an automatic reply, or bounce-back, text message when a consumer attempts to send a text message to a PSAP by means of the 3-digit code â911â and the covered text provider cannot deliver the text because (1) the consumer is located in an area where text-to-911 is not available, or (2) the covered text provider either does not support text-to-911 generally or does not support it in the particular area at the time of the consumer's attempted text.

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

Would requiring bounce-back messages be appropriate if we adopt a uniform nationwide deadline for text-to-988 capability later than July 16, 2022âthe uniform nationwide deadline for covered providers to support calls to 988?. Would requiring bounce-back messages be appropriate if we adopt exemptions or extensions for some providers?. 44. We seek comment on the potential benefits and costs of a bounce-back requirement.

In the text-to-911 context, the Commission determined that âthere is a clear benefit and present need for persons who attempt to send emergency text messages to know immediately if their text cannot be delivered to the proper authorities,â noting that feedback where text-to-911 is not available may be lifesaving by directing a person to seek out an alternative means of communicating with emergency services. Is that the case here as well?. Because some individuals with disabilities may rely exclusively on texting for communicating, are there unique benefits of a bounce-back requirement for these individuals?. Since the Commission designated 988 as the 3-digit dialing code to access the Lifeline, efforts have been underway to educate the public about using this 3-digit code to reach help by telephone in times of mental health crisis, including its availability for routing voice calls to the Lifeline by July 16, 2022.

In the absence of a bounce-back, might such advertising confuse the public about the availability of texting to 988?. Would an automated bounce-back help to prevent such confusion?. Are there other advantages to requiring covered text providers to send bounce-back messages for attempts to text 988 where service is unavailable?. Are any providers included under the proposed âcovered text providersâ definition currently sending bounce-back messages to texts sent to 988?.

45. What are the costs of requiring a bounce-back message?. What work or upgrades would be necessary for text service providers to implement an automatic bounce-back reply?. Given that covered text providers must provide a bounce-back in circumstances in which text-to-911 is unavailable, would adding a comparable bounce-back message for 988 be easier than if that existing infrastructure were not in place?.

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

Are there any drawbacks to the public of requiring covered text providers to send bounce-back messages when text-to-988 is not available?. One commenter contends that if at-risk texters receive a bounce-back message regarding the unavailability of services, âthe risks of disengagement and adverse outcomes increase.â Do commenters agree with the assessment that an automatic bounce-back message will negatively impact individuals seeking help during a crisis?. Would a bounce-back message have the effect of making the sender more discouraged, such that it that could increase, not decrease, the likelihood of suicide?. Alternatively, if there is no automatic reply, and the sender is left wondering whether the Lifeline received the text message, would that uncertainty also increase sender's likelihood of suicide?.

We seek comment on whether the benefits of receiving an automatic bounce-back message outweigh the potential risk of disengagement. 47. If we were to adopt a bounce-back requirement, we seek comment on the specific requirement we should adopt. To align with the scope of the proposed outer bound text-to-988 capability requirements, we propose that if we were to adopt a bounce-back requirement, we would require all covered text providers to provide automatic bounce-back messages to text messages, as defined by our outer bound Start Printed Page 31412proposal herein, sent to 988 where text-to-988 service is unavailable.

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

Should we limit any bounce-back requirement to covered text providers, as proposed, or should the requirement sweep more broadly?. CTIA asserts that text-to-988 implementation should be consistent with existing SMS capabilities. Should any bounce-back requirement we may explore likewise remain consistent with SMS?. Is sending a bounce-back message in response to texts to 988 feasible on legacy SMS systems?.

We seek comment on the impact including other text or chat service providers, or other forms of messages, may have on the implementation costs, technical feasibility, and timeframe for our proposed bounce-back message requirements. 48. Should we adopt a bounce-back requirement, we seek comment on whether and how to expand on the circumstances in which a covered text provider must provide a bounce-back message due to unavailability of text-to-988. In the text-to-911 context, when a customer is roaming away from his or her âhome networkâ (i.e., the network of the customer's mobile carrier), the CMRS provider operating the customer's home network is nonetheless responsible for providing a bounce-back message when required.

And the provider operating the network on which the customer is roaming must not impede the bounce-back response by the home network operator. We seek comment on adopting a similar requirement here. Additionally, we anticipate that there may be circumstances in which the Lifeline is unable to receive and respond to texts, including where demand may exceed its capacity to respond. In instances amounting essentially to a âbusy signalâ for text delivery, are covered text providers capable of determining that the text cannot be delivered to 988?.

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

49. If we were to adopt a bounce-back requirement, we propose to adopt the same exceptions to our bounce-back notification requirement for text-to-988 as currently exist for the Commission's text-to-911 rules. If we adopt that same approach, a covered text provider would not be required to provide an automatic bounce-back message when. (1) Transmission of the text message is not controlled by the provider.

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

Are there other situations where a covered text provider should not be required to send bounce-back messages to consumers attempting to text to 988?. Furthermore, we seek comment on the circumstances in which the provider of a pre-installed or downloaded interconnected text application would be considered to have âcontrolâ over the transmission of text messages for the purposes of any requirements we adopt. If a user or third party modifies or manipulates the application after it is installed or downloaded so that it no longer supports bounce-back messaging, should the application provider be presumed not to have control?. 50.

If we adopt a bounce-back requirement, should we specify or provide guidance regarding the content of the bounce-back message, and if so, what should we specify or encourage?. Similar to automatic messages sent in response to undeliverable texts to 911, we propose that any bounce-back messages to consumers attempting to text 988 would not require all covered text providers to use identical wording for their automatic responses. Rather, if we were to adopt a bounce-back requirement, we propose that a covered text provider would be deemed to have met its obligation so long as the bounce-back message to 988 includes, at a minimum, two essential points of information. (1) That text-to-988 is not available.

And (2) identify other means to reach the Lifeline, such as by telephone. We seek comment on this approach and on alternatives. We seek comment on what role our federal partners and non-governmental mental health organizations could play in developing best practices regarding the content of messages. 7.

Role of the Substance Abuse and Mental Health Services Administration and the Department of Veterans Affairs 51. Although the Commission has an important role to play in expanding access to crisis counseling through its implementation of 988, SAMHSA and the VA are ultimately responsible for ensuring the continued success of these lifesaving resources. As such, we propose to direct the Bureau to continue to coordinate the implementation of 988 with SAMHSA and the VA, including any issues pertaining to the delivery of text messages to 988. 52.

We seek comment on this proposal. How we can best support the work of our federal partners in administering the Lifeline and Veterans Crisis Line?. We recognize that many commenters have stressed the importance of ensuring adequate funding and staffing for the Lifeline and the Veterans Crisis Line over the course of this proceeding. Although these issues are beyond our jurisdiction, are there unique considerations pertaining to staffing, funding, or the availability of other resources at the Lifeline or Veterans Crisis Line that we should be aware of as we consider adopting rules to require the delivery of text messages to 988?.

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

To that end, we intend to coordinate with SAMHSA and the VA, and we encourage other industry stakeholders in the wireless and texting service industry to coordinate with these agencies as well. Assuming that our adoption of rules implementing text-to-988 capability will require expenditure of additional resources by SAMHSA and the VA, are there ways that we can structure our rules to minimize the burden on our federal partners?. Are there any steps we should take to deter misuse of text-to-988, so as to limit the unnecessary expenditure of resources by our federal partners?. Are there any solutions that have been employed in other contexts, such as text-to-911, that we or others should adapt here to deter misuse of text-to-988?.

53. In addition, we encourage SAMHSA and the VA to coordinate with outside organizations that have expertise in providing crisis counseling via text message as they develop the infrastructure to receive and respond to text messages which may one day be delivered to the Lifeline and Veterans Crisis Line via 988. Many commenters in this proceeding have urged collaboration between private entities like the Trevor Project and federal agencies providing similar services. We therefore seek comment on how to facilitate such coordination across federal agencies and the private sector, as we work towards our shared goal of ensuring that all Americans have ready access to mental health counseling and support services.

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

In particular, we seek comment on whether, and if so, to what extent, our numbering authority under section 251(e) of the Act provides an additional source of authority for the rules proposed and for which we seek comment in this further notice of proposed rulemaking. Finally, we also seek comment on whether we should employ our ancillary authority. We note that, in our preliminary review, the National Suicide Hotline Designation Act of 2020 does not provide additional support forânor does it hinderâthe actions proposed in this further notice of proposed rulemaking. We seek comment on these views.

55. The rules we propose and for which we seek comment in this further notice of proposed rulemaking are analogous to those the Commission has adopted to facilitate text-to-911 communications, which relied, in part, on the Commission's Title III authority over wireless carriers, including sections 301, 303, 307, 309, and 316. We propose concluding that, with respect to CMRS providers, Title III provides us with appropriate authority to require wireless carriers to support text-to-988 service and to require delivery of a bounce-back message to consumers in cases where delivery of a text to 988 cannot be completed. As the Supreme Court has long recognized, Title III grants the Commission a âcomprehensive mandateâ regarding regulation of spectrum usage, and courts have routinely found that Title III provides the Commission with âbroad authority to manage spectrum.

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

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

56. With respect to interconnected text messaging service providers, we propose to find that the CVAA provides us with authority to adopt the proposals in this further notice of proposed rulemaking, as some commenters in this proceeding suggest. Congress enacted the CVAA to increase the accessibility of modern communications technologies to people with disabilities, including access related to emergency services, and the Commission relied, in part, on this authority when it adopted similar text-to-911 requirements. The CVAA provides the Commission with authority to âachiev[e] equal access to emergency services by individuals with disabilities, as a part of the migration to a national internet protocol-enabled emergency network.â In particular, the CVAA granted the Commission the authority to adopt regulations to implement recommendations proposed by the Emergency Access Advisory Committee established by the CVAA, which concern access to 911 and NG911 services, and to adopt âother regulationsâ as are necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network.

We tentatively conclude that the CVAA provides authority for our proposals because access to 988 is similar to 911 access for the purposes of our CVAA authority. We seek comment on this tentative conclusion. Do commenters agree that access to the Lifeline or Veterans Crisis Line through 988 constitute âaccess to emergency servicesâ under the CVAA?. Do commenters agree that text-to-988 is necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network?.

More generally, does the CVAA provide us with authority to adopt the rules proposed in this further notice of proposed rulemaking?. 57. We seek comment on any other sources of authority available to the Commission to adopt the proposals detailed in this further notice of proposed rulemaking. In particular, we seek comment on whether our section 251(e) authority over numbering provides authority to require support for text-to-988 service.

Section 251(e)(1) of the Act grants us âexclusive jurisdiction over those portions of the North American Numbering Plan that pertain to the United Statesâ and provides that numbers must be made âavailable on an equitable basis.â This provision gives the Commission âauthority to set policy with respect to all facets of numbering administration in the United States.â The Commission found in the 988 Report and Order that section 251(e) provides us with the ability to regulate interconnected and one-way VoIP providers that make use of numbering resources when they connect with the PSTN. We seek comment on whether our numbering authority provides an additional, independent basis to adopt rules with respect to CMRS providers Start Printed Page 31414and interconnected text messaging services. 58. We also seek comment on the Commission's authority to mandate location information with text-to-988 service.

Section 222 of the Communications Act, as amended, provides strong legal protections for customer proprietary network information (CPNI), including geolocation information. Section 222(d) provides exceptions to allow CPNI and call location data to be shared for âemergency services.â We seek comment on whether this could encompass the transmission of geolocation information with 988 calls. Should we choose to require covered text providers to include location information with texts to 988, does section 222 authorize the disclosure of location information with texts to 988?. Are there other privacy concerns that we should consider with regard to texts to 988?.

59. Finally, we seek comment on whether exercise of our ancillary authority would be necessary or appropriate to support any of our proposed rules. The Commission relied in part on ancillary authority to apply the bounce-back notification requirement to providers of interconnected text messaging services when it adopted text-to-911 requirements. Would a similar finding be appropriate with respect to any aspect of our text-to-988 rules?.

D. Benefits and Costs of Text-to-988 60. We expect to find that the benefits of requiring service providers to support text-to-988 service will exceed the costs of implementation. We seek comment on this proposal, and any specific data regarding both the benefits of facilitating access to the Lifeline via texts to 988 and on the costs or burdens implementation of text-to-988 may impose upon covered text providers.

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

As outlined above, we preliminarily believe that enabling text-to-988 service will improve access to lifesaving resources for individuals contemplating suicide or experiencing mental health crises, especially for members of at-risk communities such as young people, LGBTQ, people of color, and individuals with disabilities, thereby saving lives. By expanding access to counseling, text-to-988 may help break the cycle of pain, suffering, and suicide. We seek comment generally on these and other important benefits that may follow from increased access to mental health resources via texting to 988. 62.

We further seek comment on ways to quantify these benefits. Of course, the benefits to individuals who the Lifeline or Veterans Crisis Line places on a path to recovery, much less to their families and friends, cannot be reduced to dollars and cents. That being said, even if text-to-988 service could annually place just one-per-one-thousand suicide victims on a path to long-term recovery, the economic gain would be $19.2 million in any single year, for a present-value of $78.7 million over five years and $134.9 million over ten years. In estimating benefits, we focus on teens and individuals with disabilities, as individuals in these groups are more likely to use a text-to-988 capability.

Based on the most recent CDC data from 2015-2019, 11,283 youth (ages 15-19) and an estimated 13,101 individuals who are deaf, hard of hearing, deafblind or speech disabled committed suicide (using an estimated incidence among adults of 6%), or an average of more than 2,000 per year for each group. To calculate the estimated benefits for a single year, we multiply the annual average by 0.1% and the VSL (2,000 * 0.001 * $9.6 million = $19.2 million). We discount over five years and ten years at a 7% discount rate. We seek comment on this analysis.

63. Our proposed analysis does not examine certain categories of benefits. For example, we have not estimated the cost savings from medical expenses and loss-of-work avoided through reduced suicides and suicide attempts. We also have not estimated the cost savings of reduced burdens on PSAPs, police, ambulance, and fire and rescue services, which currently respond to some 911 texts that will be routed to the Lifeline, where they will be more effectively and efficiently de-escalated or otherwise resolved.

Moreover, we have not examined the benefits of text-to-988 usage by every demographic group. For example, smartphone ownership and suicide are particularly common in younger age groups. According to the Common Sense Census. Media Use by Tweens and Teens, 2019, 53% of children have their own smartphone by age 11, and 69% have one at age 12.

Currently, our estimated benefits analysis looks at youth ages 15-19. To accurately estimate these benefits, we seek comment on how broadly we should define youth who may text to 988. Relatedly, there is the possibility that adults without hearing or speech disabilities may rely exclusively on text-to-988 for added privacy or convenience, meriting inclusion in our benefit estimates. We also seek comment on ways to better assess the long-term impact of text-to-988 service.

Without longitudinal studies evaluating the long-term effectiveness of suicide call centers, we cannot pinpoint how many suicides text-to-988 will prevent in the long run. Available survey-based studies, however, reveal call centers can substantially reduce suicides during the initial call and follow-up periods. We seek comment on the types and magnitudes of these and other benefits not covered in this further notice of proposed rulemaking, as well as any overlooked categories of costs. 64.

In the Text-to-911 proceeding, the Commission estimated that the total cost for covered providers to implement text-to-911 service amounted to less than $21 million. The costs of nationwide deployment of text-to-911 fell into three categories. CMRS and PSAP system cost components. Interconnected text providers' software upgrades.

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

Similarly, we convert the estimate for interconnected text messaging providers to implement text-to-911 service into 2021 dollars by using a CPI factor of 1.105. To soberly assess Lifeline capability, we assume that 100% of Lifeline call centers may require SMS upgrades and thus multiply PSAP software estimates by 2.22. To estimate the costs to equip the more than 180 Lifeline crisis centers, we calculate an average cost based on an estimated per PSAP cost of $40,613 (=($263,277,595 + $12,891,283)/6,800), for a total of $7,310,340 (=180 * $40,613). Therefore, we preliminarily estimate that total costs for implementing text-to-988 will be approximately $27 million.

We seek Start Printed Page 31415comment on this analysis, including our preliminary assumption that text-to-911 software and equipment can be leveraged for texting to 988. Do commenters agree with CTIA that there are âsignificant technical and policy differencesâ between 988 and 911 service, and if so, how might those differences impact our evaluation?. Furthermore, we seek comment on whether cost estimates for PSAPs from the Text-to-911 proceeding reflect an appropriate estimate for costs to the Lifeline or Veterans Crisis Line. Are there other costs borne by the Lifeline or Veterans Crisis Line needed to implement text-to-988 service?.

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

66. Deterring suicide has benefits that simply cannot be reduced to numbersâsaving lives has value beyond measure. While recognizing this fact, to illustrate how the benefits of our proposal relate to the more aptly quantified costs, we attempt to estimate the quantifiable value of suicide prevention using a measure of collective willingness to pay. We propose calculating that the level of suicide prevention needed to generate benefits exceeding our preliminary estimate of $27 million in text-to-988 costs is a total of four suicides avoided over five years.

Specifically, the level of teen suicide prevention needed to generate benefits exceeding $27 million is one per 2,821, and the level of suicide prevention among individuals with disabilities to generate benefits exceeding $27 million is one per 3,275. Even assuming that text-to-988 prevented no suicides in its inaugural year as the service rolled out but prevented one suicide in each of the ensuing four years, measured in terms of the public's willingness to pay for that mortality reduction, the present value of the benefit would be $30.39 million, more than three million dollars greater than the total cost. The present value would be an uneven stream of payments of $9.6 million ($0 in Year 1 + $9.6 million per year in Year 2 through Year 5) at a 7% discount rate. We seek comment on our analysis.

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

Even if sizable Lifeline deployment costs are added, increasing estimated total cost to nearly $27 million, the estimated benefits of text-to-988 remain greater by a multiple of nearly six. Over ten years, the benefits rise to $269.8 million, exceeding costs by a multiple of nearly ten. We seek comment on these estimates. We also seek comment on the methods and underlying benefits and costs estimates, including those submitted by third parties, used to arrive at our overall proposed conclusion.

II. Initial Regulatory Flexibility Analysis 1. As required by the Regulatory Flexibility Act of 1980, as amended (RFA), the Commission has prepared this Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities by the policies and rules proposed in this Implementation of the National Suicide Hotline Improvement Act of 2018 further notice of proposed rulemaking (FNPRM). The Commission requests written public comments on this IRFA.

Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments provided on the first page of the further notice of proposed rulemaking. The Commission will send a copy of the further notice of proposed rulemaking, including this IRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA). In addition, the further notice of proposed rulemaking and IRFA (or summaries thereof) will be published in the Federal Register. A.

Need for, and Objectives of, the Proposed Rules 2. In this FNPRM, the Commission proposes and seeks comment on requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, the PSTN (covered text providers) to enable delivery of text messages to 988. The Commission proposes to require that covered text providers route 988 text messages to the National Suicide Prevention Lifeline's (Lifeline) 10-digit number, currently 1-800-273-8255 (TALK). The Commission believes these proposed rules will expand the availability of mental health and crisis counseling resources to Americans who suffer from depressive or suicidal thoughts, by allowing individuals in crisis to reach the Lifeline by texting 988.

B. Legal Basis 3. The legal basis for any action that may be taken pursuant to this FNPRM is contained in sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251, 301, 303, 307, 309, 316.

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

A âsmall-business concernâ is one which. (1) Is independently owned and operated. (2) is not dominant in its field of operation. And (3) satisfies any additional criteria established by the SBA.

5. Small Businesses, Small Organizations, Small Governmental Jurisdictions. Our actions, over time, may affect small entities that are not easily categorized at present. We therefore describe here, at the outset, three broad groups of small entities that could be directly affected herein.

First, while there are industry specific size standards for small businesses that are used in the regulatory flexibility analysis, according to data from the Small Business Administration's (SBA) Office of Advocacy, in general a small business is an independent business having fewer than 500 employees. These types of small businesses represent 99.9% of all businesses in the United Start Printed Page 31416States, which translates to 30.7 million businesses. 6. Next, the type of small entity described as a âsmall organizationâ is generally âany not-for-profit enterprise which is independently owned and operated and is not dominant in its field.â The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000 or less to delineate its annual electronic filing requirements for small exempt organizations.

Nationwide, for tax year 2018, there were approximately 571,709 small exempt organizations in the U.S. Reporting revenues of $50,000 or less according to the registration and tax data for exempt organizations available from the IRS. 7. Finally, the small entity described as a âsmall governmental jurisdictionâ is defined generally as âgovernments of cities, counties, towns, townships, villages, school districts, or special districts, with a population of less than fifty thousand.â U.S.

Census Bureau data from the 2017 Census of Governments indicate that there were 90,075 local governmental jurisdictions consisting of general purpose governments and special purpose governments in the United States. Of this number there were 36,931 general purpose governments (county, municipal and town or township) with populations of less than 50,000 and 12,040 special purpose governmentsâindependent school districts with enrollment populations of less than 50,000. Accordingly, based on the 2017 U.S. Census of Governments data, we estimate that at least 48,971 entities fall into the category of âsmall governmental jurisdictions.â 8.

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

Establishments in this industry use the wired telecommunications network facilities that they operate to provide a variety of services, such as wired telephony services, including VoIP services, wired (cable) audio and video programming distribution, and wired broadband internet services. By exception, establishments providing satellite television distribution services using facilities and infrastructure that they operate are included in this industry.â The SBA has developed a small business size standard for Wired Telecommunications Carriers, which consists of all such companies having 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year.

Of this total, 3,083 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small. 9. Local Exchange Carriers (LECs).

Neither the Commission nor the SBA has developed a size standard for small businesses specifically applicable to local exchange services. The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 show that there were 3,117 firms that operated for the entire year. Of that total, 3,083 operated with fewer than 1,000 employees. Thus under this category and the associated size standard, the Commission estimates that the majority of local exchange carriers are small entities. 10.

Incumbent LECs. Neither the Commission nor the SBA has developed a small business size standard specifically for incumbent local exchange services. The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees.

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

According to Commission data, one thousand three hundred and seven (1,307) Incumbent Local Exchange Carriers reported that they were incumbent local exchange service providers. Of this total, an estimated 1,006 have 1,500 or fewer employees. Thus, using the SBA's size standard the majority of incumbent LECs can be considered small entities. 11.

Competitive Local Exchange Carriers (Competitive LECs). Competitive Access Providers (CAPs), Shared-Tenant Service Providers, and Other Local Service Providers. Neither the Commission nor the SBA has developed a small business size standard specifically for these service providers. The appropriate NAICS Code category is Wired Telecommunications Carriers and under that size standard, such a business is small if it has 1,500 or fewer employees.

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

According to Commission data, 1,442 carriers reported that they were engaged in the provision of either competitive local exchange services or competitive access provider services. Of these 1,442 carriers, an estimated 1,256 have 1,500 or fewer employees. In addition, 17 carriers have reported that they are Shared-Tenant Service Providers, and all 17 are estimated to have 1,500 or fewer employees. Also, 72 carriers have reported that they are Other Local Service Providers.

Of this total, 70 have 1,500 or fewer employees. Consequently, based on internally researched FCC data, the Commission estimates that most providers of competitive local exchange service, competitive access providers, Shared-Tenant Service Providers, and Other Local Service Providers are small entities. 12. We have included small incumbent LECs in this present RFA analysis.

As noted above, a âsmall businessâ under the RFA is one that, inter alia, meets the pertinent small business size standard (e.g., a telephone communications business having 1,500 or fewer employees), and âis not dominant in its field of operation.â The SBA's Office of Advocacy contends that, for RFA purposes, small incumbent LECs are not dominant in their field of operation because any such dominance is not ânationalâ in scope. We have therefore included small incumbent LECs in this RFA analysis, although we emphasize that this RFA action has no effect on Commission analyses and determinations in other, non-RFA contexts. 13. Interexchange Carriers (IXCs).

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

Census Bureau data for 2012 indicate that 3,117 firms operated for the entire year. Of that number, 3,083 operated with fewer than 1,000 employees. According to internally developed Commission data, 359 companies reported that their primary telecommunications service activity was the provision of interexchange services. Of this total, an estimated 317 have 1,500 or fewer employees.

Start Printed Page 31417Consequently, the Commission estimates that the majority of interexchange service providers are small entities. 14. Local Resellers. The SBA has not developed a small business size standard specifically for Local Resellers.

The SBA category of Telecommunications Resellers is the closest NAICs code category for local resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure.

Mobile virtual network operators (MVNOs) are included in this industry. Under the SBA's size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data from 2012 show that 1,341 firms provided resale services during that year.

Of that number, all operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 213 carriers have reported that they are engaged in the provision of local resale services. Of these, an estimated 211 have 1,500 or fewer employees and two have more than 1,500 employees.

Consequently, the Commission estimates that the majority of local resellers are small entities. 15. Toll Resellers. The Commission has not developed a definition for Toll Resellers.

The closest NAICS Code Category is Telecommunications Resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure.

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

Census Bureau data show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 881 carriers have reported that they are engaged in the provision of toll resale services.

Of this total, an estimated 857 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of toll resellers are small entities. 16. Other Toll Carriers.

Neither the Commission nor the SBA has developed a definition for small businesses specifically applicable to Other Toll Carriers. This category includes toll carriers that do not fall within the categories of interexchange carriers, operator service providers, prepaid calling card providers, satellite service carriers, or toll resellers. The closest applicable size standard under SBA rules is for Wired Telecommunications Carriers. The applicable SBA size standard consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicates that 3,117 firms operated during that year. Of that number, 3,083 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of Other Toll Carriers can be considered small.

According to internally developed Commission data, 284 companies reported that their primary telecommunications service activity was the provision of other toll carriage. Of these, an estimated 279 have 1,500 or fewer employees. Consequently, the Commission estimates that most Other Toll Carriers are small entities. 17.

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

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

U.S. Census Bureau data for 2012 show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these prepaid calling card providers can be considered small entities.

According to the Commission's Form 499 Filer Database, 86 active companies reported that they were engaged in the provision of prepaid calling cards. The Commission does not have data regarding how many of these companies have 1,500 or fewer employees, however, the Commission estimates that the majority of the 86 active prepaid calling card providers that may be affected by these rules are likely small entities. 18. Wireless Telecommunications Carriers (except Satellite).

Neither the SBA nor the Commission has developed a size standard specifically applicable to Wireless Carriers and Service Providers. The closest applicable is Wireless Telecommunications Carriers (except Satellite), which the SBA small business size standard is such a business is small if it 1,500 persons or less. For this industry, U.S. Census Bureau data for 2012 show that there were 967 firms that operated for the entire year.

Of this total, 955 firms had employment of 999 or fewer employees and 12 had employment of 1000 employees or more. Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Carriers and Service Providers are small entities. 19. According to internally developed Commission data for all classes of Wireless Service Providers, there are 970 carriers that reported they were engaged in the provision of wireless services.

Of this total, an estimated 815 have 1,500 or fewer employees, and 155 have more than 1,500 employees. Thus, using available data, we estimate that the majority of Wireless Carriers and Service Providers can be considered small. 20. Cable and Other Subscription Programming.

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

The programming material is usually delivered to a third party, such as cable systems or direct-to-home satellite Start Printed Page 31418systems, for transmission to viewers.â The SBA size standard for this industry establishes as small any company in this category with annual receipts less than $41.5 million. Based on U.S. Census Bureau data for 2012, 367 firms operated for the entire year. Of that number, 319 firms operated with annual receipts of less than $25 million a year and 48 firms operated with annual receipts of $25 million or more.

Based on this data, the Commission estimates that a majority of firms in this industry are small. 21. Cable Companies and Systems (Rate Regulation). The Commission has also developed its own small business size standards, for the purpose of cable rate regulation.

Under the Commission's rules, a âsmall cable companyâ is one serving 400,000 or fewer subscribers nationwide. Industry data indicate that there are 4,600 active cable systems in the United States. Of this total, all but five cable operators nationwide are small under the 400,000-subscriber size standard. In addition, under the Commission's rate regulation rules, a âsmall systemâ is a cable system serving 15,000 or fewer subscribers.

Commission records show 4,600 cable systems nationwide. Of this total, 3,900 cable systems have fewer than 15,000 subscribers, and 700 systems have 15,000 or more subscribers, based on the same records. Thus, under this standard as well, we estimate that most cable systems are small entities. 22.

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

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

The âAll Other Telecommunicationsâ category is comprised of establishments primarily engaged in providing specialized telecommunications services, such as satellite tracking, communications telemetry, and radar station operation. This industry also includes establishments primarily engaged in providing satellite terminal stations and associated facilities connected with one or more terrestrial systems and capable of transmitting telecommunications to, and receiving telecommunications from, satellite systems. Establishments providing internet services or voice over internet protocol (VoIP) services via client-supplied telecommunications connections are also included in this industry. The SBA has developed a small business size standard for âAll Other Telecommunicationsâ, which consists of all such firms with annual receipts of $35 million or less.

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

24. Radio and Television Broadcasting and Wireless Communications Equipment Manufacturing. This industry comprises establishments primarily engaged in manufacturing radio and television broadcast and wireless communications equipment. Examples of products made by these establishments are.

Transmitting and receiving antennas, cable television equipment, GPS equipment, pagers, cellular phones, mobile communications equipment, and radio and television studio and broadcasting equipment. The SBA has established a small business size standard for this industry of 1,250 or fewer employees. U.S. Census Bureau data for 2012 show that 841 establishments operated in this industry in that year.

Of that number, 828 establishments operated with fewer than 1,000 employees, 7 establishments operated with between 1,000 and 2,499 employees and 6 establishments operated with 2,500 or more employees. Based on this data, we conclude that a majority of manufacturers in this industry are small. 25. Semiconductor and Related Device Manufacturing.

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

Census Bureau data for 2012 show that there were 862 establishments that operated that year. Of this total, 843 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small. 26.

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

The SBA has established a size standard for this industry of annual receipts of $41.5 million or less per year. U.S. Census data for 2012 indicates that 5,079 firms operated for the entire year. Of that number 4,691 firms had annual receipts of less than $25 million and 166 firms had annual receipts of $25,000,000 to $49,999,999.

Based on this data, we conclude that a majority of firms in this industry are small. 27. Internet Service Providers (Broadband). Broadband internet service providers include wired (e.g., cable, DSL) and VoIP service providers using their own operated wired telecommunications infrastructure fall in the category of Wired Telecommunication Carriers.

Wired Telecommunications Carriers are comprised of establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired telecommunications networks. Transmission facilities may be based on a single technology or a combination of technologies. The SBA size standard for this category classifies a business as small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 show that there were 3,117 firms that operated Start Printed Page 31419that year. Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, under this size standard the majority of firms in this industry can be considered small. 28.

Internet Service Providers (Non-Broadband). Internet access service providers such as Dial-up internet service providers, VoIP service providers using client-supplied telecommunications connections and internet service providers using client-supplied telecommunications connections (e.g., dial-up ISPs) fall in the category of All Other Telecommunications. The SBA has developed a small business size standard for All Other Telecommunications which consists of all such firms with gross annual receipts of $35 million or less. For this category, U.S.

Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of these firms, a total of 1,400 had gross annual receipts of less than $25 million. Consequently, under this size standard a majority of firms in this industry can be considered small. 29.

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

Census Bureau data for 2012 show that there were 512 firms that operated for the entire year. Of those firms, a total of 498 had annual receipts less than $25 million and 7 firms had annual receipts of $25 million to $49, 999,999. Consequently, we estimate that the majority of these firms are small entities that may be affected by our action. D.

Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 30. The FNPRM proposes and seeks comment on rules to require covered text providers to support text messaging to 988. It tentatively concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations, and thereby save lives. The proposed rules would require CMRS providers and interconnected text messaging service providers to route texts sent to 988 to the 10-digit Lifeline number, presently 1-800-273-8255 (TALK).

The FNPRM proposes (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. And (2) directing the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number. The FNPRM seeks comment on this proposal. The Commission preliminarily believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules for different covered text providers.

The Commission proposes that the costs and/or administrative burdens associated with the rules will not unduly burden small entities. E. Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 31. The RFA requires an agency to describe any significant alternatives that it has considered in reaching its proposed approach, which may include the following four alternatives (among others).

(1) The establishment of differing compliance or reporting requirements or timetables that take into account the resources available to small entities. (2) the clarification, consolidation, or simplification of compliance and reporting requirements under the rules for such small entities. (3) the use of performance rather than design standards. And (4) an exemption from coverage of the rule, or any part thereof, for such small entities.

32. In the FNPRM, the Commission seeks comment from all entities, including small entities, regarding the impact of these proposed rules on small entities. The Commission seeks comment on the impact, cost or otherwise, that requiring text messaging to 988 capability will impose on regional and rural carriers and small businesses. The Commission also seeks comment on whether to adopt any exemptions for small businesses and if so, under what circumstances.

The Commission asks and will consider alternatives to the proposals and on alternative ways of implementing the proposals. F. Federal Rules That May Duplicate, Overlap, or Conflict With the Proposed Rules 33. None.

III. Procedural Matters 34. Ex Parte Rules. This proceeding shall be treated as a âpermit-but-discloseâ proceeding in accordance with the Commission's ex parte rules.

Persons making ex parte presentations must file a copy of any written presentation or a memorandum summarizing any oral presentation within two business days after the presentation (unless a different deadline applicable to the Sunshine period applies). Persons making oral ex parte presentations are reminded that memoranda summarizing the presentation must (1) list all persons attending or otherwise participating in the meeting at which the ex parte presentation was made, and (2) summarize all data presented and arguments made during the presentation. If the presentation consisted in whole or in part of the presentation of data or arguments already reflected in the presenter's written comments, memoranda or other filings in the proceeding, the presenter may provide citations to such data or arguments in his or her prior comments, memoranda, or other filings (specifying the relevant page and/or paragraph numbers where such data or arguments can be found) in lieu of summarizing them in the memorandum. Documents shown or given to Commission staff during ex parte meetings are deemed to be written ex parte presentations and must be filed consistent with Rule 1.1206(b).

In proceedings governed by Rule 1.49(f) or for which the Commission has made available a method of electronic filing, written ex parte presentations and memoranda summarizing oral ex parte presentations, and all attachments thereto, must be filed through the electronic comment filing system available for that proceeding, and must be filed in their native format (e.g., .doc, .xml, .ppt, searchable .pdf). Participants in this proceeding should familiarize themselves with the Commission's ex parte rules. 35. Initial Regulatory Flexibility Analysis.

Pursuant to the Regulatory Flexibility Act (RFA), the Commission has prepared an Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities of the policies and actions considered in this FNPRM. Written public comments are requested on this IRFA. Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments on the FNPRM. The Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, will send a copy of the FNPRM, including the IRFA, to the Chief Counsel for Advocacy of the Small Business Administration.Start Printed Page 31420 36.

Comment Filing Procedures. Pursuant to Â§Â§â1.415 and 1.419 of the Commission's rules, 47 CFR 1.415, 1.419, interested parties may file comments and reply comments on or before the dates indicated on the first page of this document. Comments may be filed using the Commission's Electronic Comment Filing System (ECFS). See Electronic Filing of Documents in Rulemaking Proceedings, 63 FR 24121 (1998).

Electronic Filers. Comments may be filed electronically using the internet by accessing ECFS. Https://www.fcc.gov/âecfs/â. Paper Filers.

Parties who choose to file by paper must file an original and one copy of each filing. Filings can be sent by commercial overnight courier, or by first-class or overnight U.S. Postal Service mail. All filings must be addressed to the Commission's Secretary, Office of the Secretary, Federal Communications Commission.

Commercial overnight mail (other than U.S. Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701. U.S. Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554.

Effective March 19, 2020, and until further notice, the Commission no longer accepts any hand or messenger delivered filings. This is a temporary measure taken to help protect the health and safety of individuals, and to mitigate the transmission of buy antibiotics. See FCC Announces Closure of FCC Headquarters Open Window and Change in Hand-Delivery Policy, Public Notice, 35 FCC Rcd 2788 (OS 2020), https://www.fcc.gov/âdocument/âfcc-closes-headquarters-open-window-and-changes-hand-delivery-policy. 37.

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

Paperwork Reduction Act of 1995 Analysis. This document may contain proposed new or modified information collection requirements. The Commission, as part of its continuing effort to reduce paperwork burdens, invites the general public and the Office of Management and Budget (OMB) to comment on the information collection requirements contained in this document, as required by the Paperwork Reduction Act of 1995, Public Law 104-13. In addition, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, we seek specific comment on how we might further reduce the information collection burden for small business concerns with fewer than 25 employees.

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

Ordering Clauses 40. It is ordered, pursuant to sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251, 301, 303, 307, 309, 316, that the FNPRM in WC Docket No. 18-336 is adopted.

41. It is further ordered that the Petition for Reconsideration filed by Communications Equality Advocates is granted in part to the extent described herein. 42. It is further ordered that the Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, shall send a copy of this FNPRM, including the Initial Regulatory Flexibility Analysis, to the Chief Counsel for Advocacy of the Small Business Administration.

Start List of Subjects Communications common carriersTelecommunicationsTelephone End List of Subjects Start Signature Federal Communications Commission. Marlene Dortch, Secretary. End Signature Proposed Rules For the reasons discussed in the preamble, the Federal Communications Commission proposes to amend 47 CFR part 52 as follows. Start Part End Part Start Amendment Part1.

The authority citation for part 52 is revised to read as follows. End Amendment Part Start Authority 47 U.S.C. 151, 152, 153, 154, 155, 201-205, 207-209, 218, 225-227, 251-252, 271, 301, 303, 307, 309, 316, 332, unless otherwise noted. End Authority Start Amendment Part2.

Add Â§â52.201 to subpart E to read as follows. End Amendment Part Texting to the National Suicide Prevention and Mental Health Crisis Hotline. (a) Support for 988 text message service. Beginning [[DATE]], all covered text providers must have the capability to route a covered 988 text message to the current toll free access number for the National Suicide Prevention Lifeline, presently 1-800-273-8255 (TALK).

ÂBut others whose work has looked at thatâ¦theyâve been able to gather Cheap cipro online canada some quantitative evidence on cipro prices walmart that. For instance, thereâs been a rise of deaths of despair, particularly in rural areas in the US, and not just in suicides but also in overdoses and alcohol-related deaths.â The researchers connected these deaths of despair to the loss of quality of life and less economic opportunities, which have had âsubstantial impacts on peopleâs lives directly and on peopleâs resources but it also has damaged or undermined communities and families.â Beyond the quality of life issues, according to the National Advisory Committee on Rural Health and Human Services, rural areas also tend to be at higher risk due to limits in the âaccessibility, availability, and acceptability of mental health care services.â Rural counties tend to have smaller ratios of mental health providers per capita. For instance, in Sullivan County, Pennsylvania, there are only 16 mental health providers per every 100,000 people, according to the Pennsylvania Department of Health.

Compare that to Montgomery County, Pennsylvania, cipro prices walmart with 333 mental health providers per 100,000. And 23 of the 24 Health Professional Shortage Areas in Pennsylvania, identified by the U.S. Health Resources and Services Administration as areas that have a shortage of healthcare professionals, are rural areas of the state.

Like this story? cipro prices walmart. Sign up for our newsletter. Drug overdoses, deaths due to alcohol-related illnesses and suicides are all termed âdeaths of despair,â Mallinson said.

As weâre cipro prices walmart seeing increases in drug use, weâre also seeing increases in suicide, he said. According to economists Anne Case and Angus Deaton, he said, those deaths of despair in rural America are the result of changing economic and social forces that have left these areas behind. Bu the suicide numbers could be even higher, he said.

ÂWe commonly assume that suicide rates are actually higher than what the reported rate is and itâs because of those overdose deaths,â he cipro prices walmart said. ÂThey will only be marked as suicide if there was a note left or some other clear indicator that the overdose was intentionalâ¦ If thereâs no extra evidence to support that though, it doesnât get marked as a suicide on a death certificate.â The rise in factors contributing to suicide are highly concerning, the report said. Rates of depression tripled during the cipro, while firearm sales grew, social isolation became acute and emergency room visits for suicidal ideation , or thoughts of commiting suicide, increased.

According to cipro prices walmart the report, some researchers predict that we could see between 10,000 and 100,000 more suicides and deaths of despair over the next decade due to the cipro. During the summer of 2020, the CDC reported that suicide rates were increasing. However, as the year ended, the rates seemed to drop, Mallinson said.

ÂThat doesnât cipro prices walmart mean they went down everywhere,â he said. ÂThatâs the national rate. So, there may be places where they went up.

Overdoses went cipro prices walmart up during buy antibiotics. Suicide-related ER visits for young female adults went up last year. So the buy antibiotics picture is definitely complex and itâs still emergingâ¦And weâre still seeing the emerging information about young adults.

Weâre still learning how deep that impact was from closing schools and kids being home for a year.â Reports emerged cipro prices walmart during the cipro, the report said, that remote learning was taking a toll on students. Clark County, Nevada schools re-opened after 18 students took their lives between March and December 2020 â twice the rate of the previous year. Most suicide prevention starts in schools when mental health issues typically first emerge.

The report cipro prices walmart found that rural school districts found it harder to continue providing services during the cipro, than their urban counterparts did. To address the rural/urban suicide gap, Mallinson said, rural communities need more funding and more resources to provide prevention programs. ÂIn a privatized healthcare system, like what we have in a lot of rural counties, thereâs been a lot of healthcare consolidation,â he said.

ÂAnd consolidation cipro prices walmart has brought closures. Those closures tend to be in rural areas. So, (residents in rural communities) are in a situation where if they need care, itâs even further away.â Additionally, he said, once those programs are in place, they need to be evaluated on how well they work.

Many of cipro prices walmart the counties Mallinson worked with had no evaluation program in place, and those that did fell short of a proper program evaluation, having instead run research on satisfaction with the program. ââThatâs very different from real program evaluation,â he said. ÂOf course, program evaluation is hard and program evaluation can be expensive, so itâs another resource issue.â You Might Also LikeStart Preamble Start Printed Page 31404 Federal Communications Commission.

Proposed rule cipro prices walmart. In this document, the Federal Communications Commission proposes to require covered text providers to support text messaging to 988, the 3-digit dialing code to reach the National Suicide Prevention Lifeline. We seek comment on this proposal and related issues, such as the text message formats that covered text providers must transmit to 988 and the timeframe for implementation.

Comments are due on or before July 12, 2021, and reply comments are due cipro prices walmart on or before August 10, 2021. You may submit comments, identified by WC Docket No. 18-336, by any of the following methods.

Federal Communications Commission's Website cipro prices walmart. Http://apps.fcc.gov/âecfs/â. Follow the instructions for submitting comments.

Mail. Parties who choose to file by paper must file an original and one copy of each filing. Filings can be sent by commercial overnight courier, or by first-class or overnight U.S.

Postal Service mail. All filings must be addressed to the Commission's Secretary, Office of the Secretary, Federal Communications Commission. Commercial overnight mail (other than U.S.

Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701. U.S. Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554.

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

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

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

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

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

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

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

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

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

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

. For those who are in a mental health crisis,â pointing to a recent survey indicating that â75% of millennials prefer texting over talking.â According to Mental Health America, â[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,â including a study finding that young people âwere more likely to forgo psychological support than talk in person or over the phone.â As a result, Mental Health America argues, the âdata strongly support[â] the implementation of texting for providing resources to individuals experiencing suicidal ideation.â We seek comment on these views and whether adopting a text-to-988 mandate would provide particular benefits for young Americans. Are young people more inclined to seek help by text than by telephone, and if Start Printed Page 31405so, would making it easier to text the Lifeline save lives?.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is there any reason to adopt a different interpretation of the relevant exclusions in this context compared to the Truth in Caller ID context?. Â Would adopting the Truth in Caller ID definition of âtext message,â with the exclusions specified above, prevent us from possibly adding ânext-generationâ text messages to our requirements in the future?. 14.

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

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

RCS has been described as a âsuccessor protocolâ to SMS, or as ânext-generationâ SMS. What are the fundamental differences between SMS, MMS, and RCS?. How would the costs to implement SMS, MMS, and RCS differ?.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Alternatively, would it be feasible to immediately prompt individuals texting to 988 to reply with the number â1â or âVetâ to be routed to the Veterans Crisis Line, similar to the experience for voice callers?. Are other prompts preferable?. We seek comment on possible solutions to ensure that texts are routed to the proper counseling services via the Lifeline or the Veterans Crisis Line, including input on technical feasibility, ways to minimize consumer confusion, and implementation costs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bounce-Back Messages 43. We seek comment on whether and in what circumstances to require covered text providers to send automatic bounce-back messages where text-to-988 service is unavailable. Throughout the ongoing roll-out of text-to-911 services across the U.S., the Commission has required covered text providers to send an automatic reply, or bounce-back, text message when a consumer attempts to send a text message to a PSAP by means of the 3-digit code â911â and the covered text provider cannot deliver the text because (1) the consumer is located in an area where text-to-911 is not available, or (2) the covered text provider either does not support text-to-911 generally or does not support it in the particular area at the time of the consumer's attempted text.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A âsmall-business concernâ is one which. (1) Is independently owned and operated. (2) is not dominant in its field of operation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cipro for dental

Wealthy nations must do much more, much faster.The United Nations General Assembly in September 2021 will bring countries together at a critical time for marshalling collective action to tackle the global cipro for dental environmental crisis. They will cipro for dental meet again at the biodiversity summit in Kunming, China, and the climate conference (Conference of the Parties (COP)26) in Glasgow, UK. Ahead of these pivotal meetings, weâthe editors of health journals worldwideâcall for urgent action to keep average global temperature increases below 1.5Â°C, halt the destruction of nature and protect health.Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades.1 The science is unequivocal. A global increase of 1.5Â°C above the preindustrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse.2 3 Despite the worldâs necessary preoccupation with buy antibiotics, we cannot wait for cipro for dental the cipro to pass to rapidly reduce emissions.Reflecting the severity of the moment, this editorial appears in health journals across the world.

We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory.The risks to health of increases above 1.5Â°C are now well established.2 Indeed, no temperature rise is âsafeâ. In the past 20 years, heat-related mortality among people aged over 65 has cipro for dental increased by more than 50%.4 Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical s, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality.5 6 Harms disproportionately affect the most vulnerable, including children, older populations, ethnic minorities, poorer communities and those with underlying health problems.2 4Global heating is also contributing to the decline in global yield potential for major crops, falling by 1.8%â5.6% since 1981. This, together with the effects of extreme weather and soil depletion, is hampering efforts to reduce undernutrition.4 Thriving ecosystems are essential to human health, and the widespread destruction cipro for dental of nature, including habitats and species, is eroding water and food security and increasing the chance of cipros.3 7 8The consequences of the environmental crisis fall disproportionately on those countries and communities that have contributed least to the problem and are least able to mitigate the harms. Yet no country, no matter how wealthy, can shield itself from these impacts.

Allowing the consequences to cipro for dental fall disproportionately on the most vulnerable will breed more conflict, food insecurity, forced displacement and zoonotic disease, with severe implications for all countries and communities. As with the buy antibiotics cipro, we are globally as strong as our weakest member.Rises above 1.5Â°C increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state. This would critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change.9 10Global cipro for dental targets are not enoughEncouragingly, many governments, financial institutions and businesses are setting targets to reach net-zero emissions, including targets for 2030. The cost of renewable energy is dropping rapidly.

Many countries cipro for dental are aiming to protect at least 30% of the worldâs land and oceans by 2030.11These promises are not enough. Targets are easy to set cipro for dental and hard to achieve. They are yet to be matched with credible short-term and longer-term plans to accelerate cleaner technologies and transform societies. Emissions reduction plans do not adequately incorporate health considerations.12 Concern is growing that temperature rises above 1.5Â°C are beginning to be seen as inevitable, or even acceptable, to powerful members of the global community.13 Relatedly, current strategies for reducing emissions to net zero by the middle of cipro for dental the century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere.14 15This insufficient action means that temperature increases are likely to be well in excess of 2Â°C,16 a catastrophic outcome for health and environmental stability.

Critically, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed.17 This is an overall environmental crisis.18Health professionals are united with environmental scientists, businesses and many others in rejecting that this outcome is inevitable. More can and must be cipro for dental done nowâin Glasgow and Kunmingâand in the immediate years that follow. We join health professionals worldwide who have already supported calls for rapid action.1 19Equity must be at the centre of the global response. Contributing a fair share to the global effort means that cipro for dental reduction commitments must account for the cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond.

Wealthier countries will have to cut emissions more quickly, making reductions by 2030 beyond cipro for dental those currently proposed20 21 and reaching net-zero emissions before 2050. Similar targets and emergency action are needed for biodiversity loss and the wider destruction of the natural world.To achieve these targets, governments must make fundamental changes to how our societies and economies are organised and how we live. The current strategy of encouraging markets to swap dirty for cleaner technologies is not enough cipro for dental . Governments must intervene to support the redesign of transport systems, cities, production and distribution of food, markets for financial investments, health systems, and much more.

Global coordination is needed to ensure that the rush for cleaner cipro for dental technologies does not come at the cost of more environmental destruction and human exploitation.Many governments met the threat of the buy antibiotics cipro with unprecedented funding. The environmental cipro for dental crisis demands a similar emergency response. Huge investment will be needed, beyond what is being considered or delivered anywhere in the world. But such investments will produce cipro for dental huge positive health and economic outcomes.

These include high-quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions.22These measures will also improve the social and economic determinants of health, the poor state of which may have made populations more vulnerable to the buy antibiotics cipro.23 But the changes cannot be achieved through a return to damaging austerity policies or the continuation of the large inequalities of wealth and power within and between countries.Cooperation hinges on wealthy nations doing moreIn particular, countries that cipro for dental have disproportionately created the environmental crisis must do more to support low-income and middle-income countries to build cleaner, healthier and more resilient societies. High-income countries must meet and go beyond their outstanding commitment to provide $100 billion a year, making up for any shortfall in 2020 and increasing contributions to and beyond 2025. Funding must be equally split between mitigation cipro for dental and adaptation, including improving the resilience of health systems.Financing should be through grants rather than loans, building local capabilities and truly empowering communities, and should come alongside forgiving large debts, which constrain the agency of so many low-income countries.

Additional funding must be marshalled to compensate for inevitable loss and damage caused by the consequences of the environmental crisis.As health professionals, we must do all we can to aid the cipro for dental transition to a sustainable, fairer, resilient and healthier world. Alongside acting to reduce the harm from the environmental crisis, we should proactively contribute to global prevention of further damage and action on the root causes of the crisis. We must cipro for dental hold global leaders to account and continue to educate others about the health risks of the crisis. We must join in the work to achieve environmentally sustainable health systems before 2040, recognising that this will mean changing clinical practice.

Health institutions cipro for dental have already divested more than $42 billion of assets from fossil fuels. Others should join them.4The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5Â°C and to restore nature. Urgent, society-wide cipro for dental changes must be made and will lead to a fairer and healthier world. We, as cipro for dental editors of health journals, call for governments and other leaders to act, marking 2021 as the year that the world finally changes course.Ethics statementsPatient consent for publicationNot required.Furukawa et al1 posed the question.

How can we estimate quality-adjusted life years (QALYs) based on Patient Health Questionnaire-9 (PHQ-9) scores?. They cipro for dental recommend equipercentile linking analysis between the depression severity PHQ-9 and preference-based EQ-5D three-level version (EQ-5D-3L. UK value set), the latter used to estimate utility data for QALYs.Furukawa et al1 refer to the process of âcross-walkingâ, whereby the practice of fitting a statistical model to health utility data has been referred to as âmappingâ and 'cross-walkingâ.2 Furukawa et al1 reference two mapping-related papers (their references 7 and 9). However, their analysis seems to have missed rigorous mapping methodology and previous studies which have used these mapping processes, alongside other conceptual considerations when wanting to âcross-walkâ/âmapâ from a non-preference-based cipro for dental (often condition-specific) measure such as the PHQ-9 to the preference-based EQ-5D-3L.

Wealthy nations must do much more, much faster.The United Nations General Assembly in September 2021 cipro prices walmart will bring countries together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the biodiversity summit in Kunming, China, and cipro prices walmart the climate conference (Conference of the Parties (COP)26) in Glasgow, UK. Ahead of these pivotal meetings, weâthe editors of health journals worldwideâcall for urgent action to keep average global temperature increases below 1.5Â°C, halt the destruction of nature and protect health.Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades.1 The science is unequivocal.

A global increase of 1.5Â°C above the preindustrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse.2 3 Despite the worldâs necessary preoccupation with buy antibiotics, we cannot wait for the cipro to pass to rapidly reduce emissions.Reflecting the severity of the moment, this editorial appears in health journals across cipro prices walmart the world. We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory.The risks to health of increases above 1.5Â°C are now well established.2 Indeed, no temperature rise is âsafeâ. In the past 20 years, heat-related mortality among people aged over 65 has increased by more than 50%.4 Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical s, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality.5 6 Harms disproportionately affect the most vulnerable, including children, older populations, ethnic minorities, poorer communities and those with underlying health problems.2 4Global heating is also contributing cipro prices walmart to the decline in global yield potential for major crops, falling by 1.8%â5.6% since 1981.

This, together with the effects of extreme weather and soil depletion, is hampering efforts to reduce undernutrition.4 Thriving ecosystems are essential to human health, and the widespread destruction of nature, including habitats and species, is eroding water and food cipro prices walmart security and increasing the chance of cipros.3 7 8The consequences of the environmental crisis fall disproportionately on those countries and communities that have contributed least to the problem and are least able to mitigate the harms. Yet no country, no matter how wealthy, can shield itself from these impacts. Allowing the consequences to fall disproportionately on the most vulnerable will breed more conflict, food insecurity, forced displacement and zoonotic disease, with severe implications cipro prices walmart for all countries and communities.

As with the buy antibiotics cipro, we are globally as strong as our weakest member.Rises above 1.5Â°C increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state. This would critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change.9 10Global targets are not enoughEncouragingly, cipro prices walmart many governments, financial institutions and businesses are setting targets to reach net-zero emissions, including targets for 2030. The cost of renewable energy is dropping rapidly.

Many countries are aiming to protect at least 30% of the worldâs land and oceans by 2030.11These promises are not cipro prices walmart enough. Targets are cipro prices walmart easy to set and hard to achieve. They are yet to be matched with credible short-term and longer-term plans to accelerate cleaner technologies and transform societies.

Emissions reduction plans do not adequately incorporate health considerations.12 Concern is growing that temperature rises above 1.5Â°C are cipro prices walmart beginning to be seen as inevitable, or even acceptable, to powerful members of the global community.13 Relatedly, current strategies for reducing emissions to net zero by the middle of the century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere.14 15This insufficient action means that temperature increases are likely to be well in excess of 2Â°C,16 a catastrophic outcome for health and environmental stability. Critically, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed.17 This is an overall environmental crisis.18Health professionals are united with environmental scientists, businesses and many others in rejecting that this outcome is inevitable. More can and must be done nowâin cipro prices walmart Glasgow and Kunmingâand in the immediate years that follow.

We join health professionals worldwide who have already supported calls for rapid action.1 19Equity must be at the centre of the global response. Contributing a fair share to the global effort means that reduction commitments must account for the cumulative, historical cipro prices walmart contribution each country has made to emissions, as well as its current emissions and capacity to respond. Wealthier countries will have to cut emissions more quickly, cipro prices walmart making reductions by 2030 beyond those currently proposed20 21 and reaching net-zero emissions before 2050.

Similar targets and emergency action are needed for biodiversity loss and the wider destruction of the natural world.To achieve these targets, governments must make fundamental changes to how our societies and economies are organised and how we live. The current strategy of encouraging markets to cipro prices walmart swap dirty for cleaner technologies is not enough. Governments must intervene to support the redesign of transport systems, cities, production and distribution of food, markets for financial investments, health systems, and much more.

Global coordination is needed to ensure that the rush cipro prices walmart for cleaner technologies does not come at the cost of more environmental destruction and human exploitation.Many governments met the threat of the buy antibiotics cipro with unprecedented funding. The environmental crisis demands a cipro prices walmart similar emergency response. Huge investment will be needed, beyond what is being considered or delivered anywhere in the world.

But such investments will produce huge positive health and cipro prices walmart economic outcomes. These include high-quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions.22These measures will also improve the social and economic determinants of health, the poor state of which may have made populations more vulnerable to the buy antibiotics cipro.23 But the changes cannot be achieved through a return to damaging austerity policies or the continuation of the large inequalities of wealth and power within and between countries.Cooperation hinges on cipro prices walmart wealthy nations doing moreIn particular, countries that have disproportionately created the environmental crisis must do more to support low-income and middle-income countries to build cleaner, healthier and more resilient societies.

High-income countries must meet and go beyond their outstanding commitment to provide $100 billion a year, making up for any shortfall in 2020 and increasing contributions to and beyond 2025. Funding must be equally split between mitigation and adaptation, including improving the resilience of health systems.Financing should be through grants rather than loans, building local capabilities and truly empowering communities, and should come alongside forgiving large debts, which constrain the agency of so many cipro prices walmart low-income countries. Additional funding must be marshalled to compensate for inevitable loss and damage caused by the consequences of the environmental crisis.As health professionals, we must do all we can to aid the transition to a sustainable, fairer, resilient and healthier cipro prices walmart world.

Alongside acting to reduce the harm from the environmental crisis, we should proactively contribute to global prevention of further damage and action on the root causes of the crisis. We must hold global cipro prices walmart leaders to account and continue to educate others about the health risks of the crisis. We must join in the work to achieve environmentally sustainable health systems before 2040, recognising that this will mean changing clinical practice.

Health institutions have already divested more cipro prices walmart than $42 billion of assets from fossil fuels. Others should join them.4The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5Â°C and to restore nature. Urgent, society-wide changes must cipro prices walmart be made and will lead to a fairer and healthier world.

We, as editors of health journals, call for governments and other leaders to act, marking 2021 as the year that the world finally changes course.Ethics cipro prices walmart statementsPatient consent for publicationNot required.Furukawa et al1 posed the question. How can we estimate quality-adjusted life years (QALYs) based on Patient Health Questionnaire-9 (PHQ-9) scores?. They recommend equipercentile linking analysis between the depression severity PHQ-9 and preference-based EQ-5D three-level cipro prices walmart version (EQ-5D-3L.

UK value set), the latter used to estimate utility data for QALYs.Furukawa et al1 refer to the process of âcross-walkingâ, whereby the practice of fitting a statistical model to health utility data has been referred to as âmappingâ and 'cross-walkingâ.2 Furukawa et al1 reference two mapping-related papers (their references 7 and 9). However, their analysis seems to have missed cipro prices walmart rigorous mapping methodology and previous studies which have used these mapping processes, alongside other conceptual considerations when wanting to âcross-walkâ/âmapâ from a non-preference-based (often condition-specific) measure such as the PHQ-9 to the preference-based EQ-5D-3L. Â¦.

Ciprofloxacin cipro side effects

MDEL Bulletin, June 24 ciprofloxacin cipro side effects 2021, from the Medical Devices Compliance Program On this page Fees for Medical Device Establishment Licences (MDELs) We issue Medical Device Establishment Licences (MDELs) to http://ssbsoftware.com/cipro-generic-cost/. class I manufacturers importers or distributors of all device classes for human use in Canada The MDEL fee is a flat fee, regardless of when we receive your initial application. The same ciprofloxacin cipro side effects fee applies to applications for.

a new MDEL the reinstatement of a suspended MDEL the annual licence review (ALR) of an MDEL If you submit any of these applications, you must pay the MDEL fee when you receive an invoice. See Part 3, Division 2 of the Fees in Respect of Drugs and Medical Devices Order. Normally, we collect the ciprofloxacin cipro side effects MDEL fee before we review an application.

However, to help meet the demand for medical devices during the buy antibiotics cipro, we have been reviewing and processing MDEL applications before collecting the fees. As a result, some MDEL holders still haven't paid the fees for their 2020 initial MDEL application, despite multiple reminders. Authority to withhold services in case of non-payment As stated in the Food and Drug Act, ciprofloxacin cipro side effects Health Canada has the authority to withhold services, approvals, rights and/or privileges, if the fee for an MDEL application is not paid.

Non-payment of fees 30.64. The Minister may withdraw or withhold a service, the use of a facility, a regulatory process or approval or a product, right or privilege under this Act from any person who fails to pay the fee fixed for it under subsection 30.61(1). For more information, please refer to ciprofloxacin cipro side effects.

Cancellation of existing MDELs We will cancel MDELs for existing MDEL holders with outstanding fees for. initial applications or annual licence review applications If your establishment licence is cancelled, you are no longer authorized to conduct licensable activities (such as manufacturing, distributing or importing medical devices). You must stop licensable activities as soon as you receive your cancellation ciprofloxacin cipro side effects notice.

Resuming activities after MDEL cancellation To resume licensable activities, you must re-apply for a new establishment licence and pay the MDEL fee. See section ciprofloxacin cipro side effects 45 of the Medical Device Regulations. To find out how to re-apply for a MDEL, please refer to our Guidance on medical device establishment licensing (GUI-0016).

In line with the Compliance and Enforcement Policy (POL-0001), Health Canada monitors activities for compliance. If your MDEL has ciprofloxacin cipro side effects been cancelled, you may be subject to compliance and enforcement actions if you conduct non-compliant activities. If you have questions about a MDEL or the application process, please contact the Medical Device Establishment Licensing Unit at hc.mdel.questions.leim.sc@canada.ca.

If you have questions about invoicing and fees for an MDEL application, please contact the Cost Recovery Invoicing Unit at hc.criu-ufrc.sc@canada.ca. Related linksResponse to the Expert ciprofloxacin cipro side effects Panel Report on âPriority strategies to optimize testing and quarantine at Canadaâs bordersâ The Industry Advisory Roundtable on buy antibiotics Testing, Screening, Tracing and Data Management is pleased to release its third report. This report reiterates the importance of balancing public health measures to reduce the importation of buy antibiotics with the need to ensure the free flow of people and goods across the Canadian border and support economic recovery.

On this page Executive summary Soon after buy antibiotics was declared a global cipro in March 2020, international borders around the world closed in an effort to limit the spread of the cipro. To ensure ciprofloxacin cipro side effects the health and safety of individuals, the movement of people and goods was restricted. Yet, it was important to maintain access to essential goods and services and sustain trade-based economic sectors.

Canada responded in step with other countries. The government implemented ciprofloxacin cipro side effects public health measures such as mandatory testing and quarantine when crossing international borders. Restrictions are necessary to curb the spread of the cipro.

Yet, in a complex environment such as international borders, itâs crucial to implement and clearly communicate public health measures effectively and clearly. Border measures such as ciprofloxacin cipro side effects testing regimes and other public health measures must be based on the most recent science-based public health evidence. Such measures must also leverage advances in testing options, consider vaccination rates and balance the needs of industries operating across borders.

Furthermore, plans must be ciprofloxacin cipro side effects easy to implement consistently across several entry modes. They should also be communicated broadly and include a roadmap for easing or increasing border restrictions based on objective criteria and benchmarks. As we enter the second year of the cipro, the Roundtable is offering insights and recommendations to adjust current border measures.

We have based our recommendations on evidence collected from ciprofloxacin cipro side effects international scans and observations from industries that move goods and people across borders. The Roundtable recognizes the effort required to implement plans for easing border restrictions, given rapidly evolving public health circumstances and emerging variants of concern. Prompt action is needed to design and implement a border measures plan that reduces the risk of the cipro spreading while proactively moving towards economic recovery.

Current border environment In March 2020, the ability of people ciprofloxacin cipro side effects to move across the Canadian border was restricted. Since then, several measures were taken to reduce the importation of buy antibiotics and limit the spread of the cipro. As circumstances changed over the following weeks and months, border measures became more restrictive.

In early 2021, more stringent public health measures were introduced for non-essential travellers at air and ciprofloxacin cipro side effects land borders. This was done to reduce the importation rate of buy antibiotics and its variants of concern. Measures included the following.

mandatory pre-departure buy antibiotics molecular test contact/quarantine plan using the ArriveCAN application on-arrival and post-arrival testing for travellers arriving by air, mandatory 3-day quarantine in government-authorized hotels followed by quarantine or isolation at an approved location such as the travellerâs home The Government of Canada and the aviation industry also worked together on a plan to suspend Canadian air carrier flights ciprofloxacin cipro side effects to and from Mexico and Caribbean countries from January 31 to April 30, 2021. Then on February 3, 2021, all incoming international commercial passenger flights to Canada were restricted to the 4 largest airports. Montreal, Toronto, Calgary and Vancouver.

In order to ciprofloxacin cipro side effects prevent importation of variants of concern, the Government of Canada took additional measures that included suspension of flights from certain countries. Canada suspended all commercial and passenger flights from the United Kingdom between December 20, 2020 and January 6, 2021. Additionally, on April 22, 2021, all commercial and private passenger ciprofloxacin cipro side effects flights from India and Pakistan were suspended in response to a high number of cases detected among individuals travelling on flights originating from the two countries.

These measures are in place until at least June 21, 2021. Internal data from the Public Health Agency of Canada indicates the following positivity rates for the seven days up to and including May 27, 2021, for air and land travel combined. the 7-day average positivity rate ciprofloxacin cipro side effects for testing on arrival was 0.2% the 7-day average positivity rate for second tests was 0.3% As well, all positive tests undergo genomic sequencing to identify variants of concern.

Cross-border travel volumes decreased significantly from December 2019 to December 2020. Statistics Canada data show that the. number of travellers to Canada was ciprofloxacin cipro side effects down 93% total number of international travellers to and from Canada declined from 96.8 million in 2019 to 25.9 million in 2020 Air travel has experienced the most dramatic shifts, as travellers arriving by air are mostly non-exempt from border measures.

In comparison, travellers exempt from border measures make up the vast majority of land border traffic. Essential travel continued largely unimpeded, as governments recognized the importance of preserving vital supply chains to ensure that food, fuel and life-saving medicines continue to reach people. A shifting landscape As of ciprofloxacin cipro side effects May 28, 2021, variants of concern account for an estimated 70% of reported cases in recent weeks.

Any border measures must account for this new reality. At the same time, individuals and organizations within and outside of Canada are increasingly looking for. a concrete ciprofloxacin cipro side effects roadmap to the economic reopening of the country clear guidelines for restarting cross-border travel Plans and guidelines should clearly spell out the public health criteria for adjusting border measures.

They should also outline when and how restrictions should be eased in the short and longer term. Guidelines must take into consideration the risk of importing ciprofloxacin cipro side effects new variants of concern in the move towards a safe restart of the trade and tourism industries that operate internationally. As scientists learn more about how the cipro spreads, as travellers are tested regularly and as vaccination efforts increase, it will be easier to manage the risk of importing buy antibiotics and its variants.

Nevertheless, while the international border is open, thereâs always the risk of importation. For a safe reopening, we need ciprofloxacin cipro side effects a risk framework that takes into account public health measures and socio-economic factors. To bring the risk to an acceptable level, detection and surveillance options should be part of any robust border testing strategy.

Evidence concerning restrictive border measures, including lengthy quarantines, shows that the effectiveness of these measures declines over time. Non-compliance increases ciprofloxacin cipro side effects when measures are too tough and/or not communicated well. This can counter efforts to reduce the spread of the cipro and break the chains of transmission.

As more and more people in Canada and abroad are vaccinated, it will be necessary to update Canadaâs strategy to allow the movement of vaccinated travellers, based on emerging scientific evidence and while respecting public health measures. Complex border measures may present significant implementation challenges, which can lead to disparities ciprofloxacin cipro side effects in how the various rules, regulations and guidelines are applied at ports of entry. This may have a negative impact on people crossing the Canadian border and those industries engaged in cross-border and transnational business.

Small and medium companies may be especially impacted. Although essential workers have largely been exempt ciprofloxacin cipro side effects from border measures, the Roundtable is aware of the challenges they face when rules are applied inconsistently. For example, several Canadian companies have reported incidences where some engineers, technicians and other specialists have faced challenges crossing the Canada-US border and meeting their contractual obligations to provide skilled services.

Some business executives and professional services providers with cross-border responsibilities are constrained in their ability to manage their operations effectively. As well, disruptions to the cross-border travel of these workers could expose businesses to legal recourse from clients for failure to meet ciprofloxacin cipro side effects commitments. Many countries, including Canada, are aggressively rolling out vaccination regimes and partially permitting the movement of people (with restrictions).

Canada is now the top country in the G7, G20 and OECD ciprofloxacin cipro side effects for vaccination rates of first doses. As the campaign shifts to second doses, Canada must continue to reach vulnerable populations to ensure treatment equity and broad-based coverage to facilitate re-opening the economy and growth. Canadaâs biggest trading partner also shares its largest border.

Efforts should be made to align public health and ciprofloxacin cipro side effects economic recovery goals between Canada and the United States. Prioritizing the Canada-US border would be consistent with the commitments made by both countries in the Roadmap for a Renewed U.S.-Canada Partnership. This roadmap recommends a coordinated and science-based approach to ease border restrictions in the future.

Countries around the world are also exploring cooperative arrangements with other countries and looking ciprofloxacin cipro side effects at piloting innovative technology and information-sharing platforms designed to facilitate safe travel, such as treatment certification. Implementing significant changes requires wide support and cooperation, as highlighted in the Industry Strategy Councilâs Restart, recover, and reimagine prosperity for all Canadians report. The report proposes a three-phase action plan â restart, recover, and reimagine â focused on investment and growth, and embodies values and principles of action and shared responsibility to mobilize all sectors to propel Canada forward.

The phases are anchored in five recommendations to safely restore confidence and commerce, stabilize the hardest-hit sectors, reignite growth by doubling down on a future-oriented investment plan, develop an ambitious industrial strategy, and establish renewed ciprofloxacin cipro side effects public-private sector partnerships and investments anchored in a sound and rigorous fiscal framework. At the same time, we must recognize we live in times of uncertainty and contend with a rapidly shifting landscape. Plans should be flexible in order to balance public health concerns with the desire to ease restrictions.

We must work with public health experts to establish and clearly communicate criteria and benchmarks to help travellers and businesses understand how ciprofloxacin cipro side effects and when border restrictions will be eased or increased in the coming months. Provinces and territories have outlined their reopening plans, with an important strength being the use of benchmarks to move between several steps of restrictions. Communicating a clear path with well-defined criteria will provide a much-needed level of predictability for reopening to industry and travellers alike.

Recommendations The Industry Roundtable recommends an approach to border measures that include both short- and ciprofloxacin cipro side effects longer-term recommendations. Short-term recommendations Provide clear definitions of cross-border essential travellers and apply these in a consistent manner at all ports of entry. Recognize that companies are well positioned to identify essential travellers within their organization, enabling them to leverage existing domestic testing regimes for ciprofloxacin cipro side effects employees to demonstrate that public health requirements are met.

Accepting employer-issued proof of testing would shift the onus away from the border and alleviate traveller flow pressures. Explicitly state the conditions for testing travellers and the criteria for shortening or removing quarantine measures. Connect the pace of vaccination rollout with public health measures and the gradual lifting of travel restrictions, and include clear procedures for vaccinated, ciprofloxacin cipro side effects partially vaccinated and unvaccinated travellers.

This may need to adjust as new variants of concern emerge. Enable industry to take an active role in meeting vaccination targets in Canada by supporting priority vaccination of cross-border essential workers. Aggressive vaccination targets ciprofloxacin cipro side effects for these workers would help companies contribute to the safe reopening of the economy in a timely manner.

Apply measures consistently at air and land borders, whenever possible. Provide clear, straightforward messaging for every person and company involved in the cross-border movement of people and goods. Clear communication leads to effective, consistent implementation of any border ciprofloxacin cipro side effects measure and subsequent updates.

Longer-term recommendations Take into account evolving scientific evidence and adopt emerging findings. For example, evidence suggests that rapid antigen testing can be effective as a screening tool and adds another layer of defence when used as part of surveillance testing. Ensure that processes, information systems ciprofloxacin cipro side effects and infrastructure needed to implement modified border measures are in place and can manage increased travel volumes effectively.

Re-position Canada as a competitive participant in the tourism and global trade sectors through enabling border measures that facilitate the movement of people and goods across international borders. In collaboration with the private sector, the government should develop an enhanced framework to better prepare for and respond to future cipros..

MDEL Bulletin, June 24 2021, from the Medical Devices Compliance Program On this page Fees for Medical Device Establishment cipro prices walmart Licences (MDELs) We issue Medical Device Establishment Licences (MDELs) to. class I manufacturers importers or distributors of all device classes for human use in Canada The MDEL fee is a flat fee, regardless of when we receive your initial application. The same fee applies to cipro prices walmart applications for. a new MDEL the reinstatement of a suspended MDEL the annual licence review (ALR) of an MDEL If you submit any of these applications, you must pay the MDEL fee when you receive an invoice.

See Part 3, Division 2 of the Fees in Respect of Drugs and Medical Devices Order. Normally, we collect the MDEL fee cipro prices walmart before we review an application. However, to help meet the demand for medical devices during the buy antibiotics cipro, we have been reviewing and processing MDEL applications before collecting the fees. As a result, some MDEL holders still haven't paid the fees for their 2020 initial MDEL application, despite multiple reminders.

Authority to withhold services in case of non-payment As stated in the Food and Drug Act, Health Canada has the authority to withhold services, approvals, rights and/or privileges, if the fee for an MDEL application is cipro prices walmart not paid. Non-payment of fees 30.64. The Minister may withdraw or withhold a service, the use of a facility, a regulatory process or approval or a product, right or privilege under this Act from any person who fails to pay the fee fixed for it under subsection 30.61(1). For more information, cipro prices walmart please refer to.

Cancellation of existing MDELs We will cancel MDELs for existing MDEL holders with outstanding fees for. initial applications or annual licence review applications If your establishment licence is cancelled, you are no longer authorized to conduct licensable activities (such as manufacturing, distributing or importing medical devices). You must stop licensable activities as soon cipro prices walmart as you receive your cancellation notice. Resuming activities after MDEL cancellation To resume licensable activities, you must re-apply for a new establishment licence and pay the MDEL fee.

See section cipro prices walmart 45 of the Medical Device Regulations. To find out how to re-apply for a MDEL, please refer to our Guidance on medical device establishment licensing (GUI-0016). In line with the Compliance and Enforcement Policy (POL-0001), Health Canada monitors activities for compliance. If your cipro prices walmart MDEL has been cancelled, you may be subject to compliance and enforcement actions if you conduct non-compliant activities.

If you have questions about a MDEL or the application process, please contact the Medical Device Establishment Licensing Unit at hc.mdel.questions.leim.sc@canada.ca. If you have questions about invoicing and fees for an MDEL application, please contact the Cost Recovery Invoicing Unit at hc.criu-ufrc.sc@canada.ca. Related linksResponse to the Expert Panel Report cipro prices walmart on âPriority strategies to optimize testing and quarantine at Canadaâs bordersâ The Industry Advisory Roundtable on buy antibiotics Testing, Screening, Tracing and Data Management is pleased to release its third report. This report reiterates the importance of balancing public health measures to reduce the importation of buy antibiotics with the need to ensure the free flow of people and goods across the Canadian border and support economic recovery.

On this page Executive summary Soon after buy antibiotics was declared a global cipro in March 2020, international borders around the world closed in an effort to limit the spread of the cipro. To ensure the health and safety of individuals, the movement of people and cipro prices walmart goods was restricted. Yet, it was important to maintain access to essential goods and services and sustain trade-based economic sectors. Canada responded in step with other countries.

The government implemented public health measures such as mandatory testing and quarantine when cipro prices walmart crossing international borders. Restrictions are necessary to curb the spread of the cipro. Yet, in a complex environment such as international borders, itâs crucial to implement and clearly communicate public health measures effectively and clearly. Border measures such as testing regimes and other public health measures must be based on the cipro prices walmart most recent science-based public health evidence.

Such measures must also leverage advances in testing options, consider vaccination rates and balance the needs of industries operating across borders. Furthermore, plans cipro prices walmart must be easy to implement consistently across several entry modes. They should also be communicated broadly and include a roadmap for easing or increasing border restrictions based on objective criteria and benchmarks. As we enter the second year of the cipro, the Roundtable is offering insights and recommendations to adjust current border measures.

We have based cipro prices walmart our recommendations on evidence collected from international scans and observations from industries that move goods and people across borders. The Roundtable recognizes the effort required to implement plans for easing border restrictions, given rapidly evolving public health circumstances and emerging variants of concern. Prompt action is needed to design and implement a border measures plan that reduces the risk of the cipro spreading while proactively moving towards economic recovery. Current border environment In March 2020, cipro prices walmart the ability of people to move across the Canadian border was restricted.

Since then, several measures were taken to reduce the importation of buy antibiotics and limit the spread of the cipro. As circumstances changed over the following weeks and months, border measures became more restrictive. In early 2021, more stringent public health measures were introduced for non-essential travellers at cipro prices walmart air and land borders. This was done to reduce the importation rate of buy antibiotics and its variants of concern.

Measures included the following. mandatory pre-departure buy antibiotics cipro prices walmart molecular test contact/quarantine plan using the ArriveCAN application on-arrival and post-arrival testing for travellers arriving by air, mandatory 3-day quarantine in government-authorized hotels followed by quarantine or isolation at an approved location such as the travellerâs home The Government of Canada and the aviation industry also worked together on a plan to suspend Canadian air carrier flights to and from Mexico and Caribbean countries from January 31 to April 30, 2021. Then on February 3, 2021, all incoming international commercial passenger flights to Canada were restricted to the 4 largest airports. Montreal, Toronto, Calgary and Vancouver.

In cipro prices walmart order to prevent importation of variants of concern, the Government of Canada took additional measures that included suspension of flights from certain countries. Canada suspended all commercial and passenger flights from the United Kingdom between December 20, 2020 and January 6, 2021. Additionally, on cipro prices walmart April 22, 2021, all commercial and private passenger flights from India and Pakistan were suspended in response to a high number of cases detected among individuals travelling on flights originating from the two countries. These measures are in place until at least June 21, 2021.

Internal data from the Public Health Agency of Canada indicates the following positivity rates for the seven days up to and including May 27, 2021, for air and land travel combined. the 7-day average positivity rate for testing cipro prices walmart on arrival was 0.2% the 7-day average positivity rate for second tests was 0.3% As well, all positive tests undergo genomic sequencing to identify variants of concern. Cross-border travel volumes decreased significantly from December 2019 to December 2020. Statistics Canada data show that the.

number of travellers to Canada was down 93% total number of international travellers to and from Canada declined from 96.8 million in 2019 to cipro prices walmart 25.9 million in 2020 Air travel has experienced the most dramatic shifts, as travellers arriving by air are mostly non-exempt from border measures. In comparison, travellers exempt from border measures make up the vast majority of land border traffic. Essential travel continued largely unimpeded, as governments recognized the importance of preserving vital supply chains to ensure that food, fuel and life-saving medicines continue to reach people. A shifting landscape As of May 28, 2021, variants of concern account for an cipro prices walmart estimated 70% of reported cases in recent weeks.

Any border measures must account for this new reality. At the same time, individuals and organizations within and outside of Canada are increasingly looking for. a concrete roadmap to the economic reopening of the country cipro prices walmart clear guidelines for restarting cross-border travel Plans and guidelines should clearly spell out the public health criteria for adjusting border measures. They should also outline when and how restrictions should be eased in the short and longer term.

Guidelines must take into consideration the risk of importing new variants of concern in the cipro prices walmart move towards a safe restart of the trade and tourism industries that operate internationally. As scientists learn more about how the cipro spreads, as travellers are tested regularly and as vaccination efforts increase, it will be easier to manage the risk of importing buy antibiotics and its variants. Nevertheless, while the international border is open, thereâs always the risk of importation. For a safe reopening, we need a risk framework that cipro prices walmart takes into account public health measures and socio-economic factors.

To bring the risk to an acceptable level, detection and surveillance options should be part of any robust border testing strategy. Evidence concerning restrictive border measures, including lengthy quarantines, shows that the effectiveness of these measures declines over time. Non-compliance increases when measures are too cipro prices walmart tough and/or not communicated well. This can counter efforts to reduce the spread of the cipro and break the chains of transmission.

As more and more people in Canada and abroad are vaccinated, it will be necessary to update Canadaâs strategy to allow the movement of vaccinated travellers, based on emerging scientific evidence and while respecting public health measures. Complex border measures may cipro prices walmart present significant implementation challenges, which can lead to disparities in how the various rules, regulations and guidelines are applied at ports of entry. This may have a negative impact on people crossing the Canadian border and those industries engaged in cross-border and transnational business. Small and medium companies may be especially impacted.

Although essential workers have largely been exempt from border measures, the Roundtable is aware cipro prices walmart of the challenges they face when rules are applied inconsistently. For example, several Canadian companies have reported incidences where some engineers, technicians and other specialists have faced challenges crossing the Canada-US border and meeting their contractual obligations to provide skilled services. Some business executives and professional services providers with cross-border responsibilities are constrained in their ability to manage their operations effectively. As well, disruptions to the cross-border travel cipro prices walmart of these workers could expose businesses to legal recourse from clients for failure to meet commitments.

Many countries, including Canada, are aggressively rolling out vaccination regimes and partially permitting the movement of people (with restrictions). Canada is now the cipro prices walmart top country in the G7, G20 and OECD for vaccination rates of first doses. As the campaign shifts to second doses, Canada must continue to reach vulnerable populations to ensure treatment equity and broad-based coverage to facilitate re-opening the economy and growth. Canadaâs biggest trading partner also shares its largest border.

Efforts should be made to align public health and economic recovery goals between cipro prices walmart Canada and the United States. Prioritizing the Canada-US border would be consistent with the commitments made by both countries in the Roadmap for a Renewed U.S.-Canada Partnership. This roadmap recommends a coordinated and science-based approach to ease border restrictions in the future. Countries around cipro prices walmart the world are also exploring cooperative arrangements with other countries and looking at piloting innovative technology and information-sharing platforms designed to facilitate safe travel, such as treatment certification.

Implementing significant changes requires wide support and cooperation, as highlighted in the Industry Strategy Councilâs Restart, recover, and reimagine prosperity for all Canadians report. The report proposes a three-phase action plan â restart, recover, and reimagine â focused on investment and growth, and embodies values and principles of action and shared responsibility to mobilize all sectors to propel Canada forward. The phases are anchored in five recommendations to safely restore confidence and commerce, stabilize the hardest-hit sectors, reignite growth by doubling down on a future-oriented investment plan, develop an ambitious industrial strategy, and establish renewed public-private sector partnerships and investments anchored in cipro prices walmart a sound and rigorous fiscal framework. At the same time, we must recognize we live in times of uncertainty and contend with a rapidly shifting landscape.

Plans should be flexible in order to balance public health concerns with the desire to ease restrictions. We must work with public health experts to establish and clearly communicate criteria and benchmarks to help travellers and businesses understand how and when border restrictions will be cipro prices walmart eased or increased in the coming months. Provinces and territories have outlined their reopening plans, with an important strength being the use of benchmarks to move between several steps of restrictions. Communicating a clear path with well-defined criteria will provide a much-needed level of predictability for reopening to industry and travellers alike.

Recommendations The Industry Roundtable recommends an approach to border measures that include both short- cipro prices walmart and longer-term recommendations. Short-term recommendations Provide clear definitions of cross-border essential travellers and apply these in a consistent manner at all ports of entry. Recognize cipro prices walmart that companies are well positioned to identify essential travellers within their organization, enabling them to leverage existing domestic testing regimes for employees to demonstrate that public health requirements are met. Accepting employer-issued proof of testing would shift the onus away from the border and alleviate traveller flow pressures.

Explicitly state the conditions for testing travellers and the criteria for shortening or removing quarantine measures. Connect the pace of vaccination rollout with public health measures and the gradual lifting of travel restrictions, and include clear procedures for vaccinated, partially vaccinated cipro prices walmart and unvaccinated travellers. This may need to adjust as new variants of concern emerge. Enable industry to take an active role in meeting vaccination targets in Canada by supporting priority vaccination of cross-border essential workers.

Aggressive vaccination targets for these workers would help companies contribute to the safe reopening of the cipro prices walmart economy in a timely manner. Apply measures consistently at air and land borders, whenever possible. Provide clear, straightforward messaging for every person and company involved in the cross-border movement of people and goods. Clear communication leads to effective, consistent implementation of any border measure and cipro prices walmart subsequent updates.

Longer-term recommendations Take into account evolving scientific evidence and adopt emerging findings. For example, evidence suggests that rapid antigen testing can be effective as a screening tool and adds another layer of defence when used as part of surveillance testing. Ensure that processes, information systems cipro prices walmart and infrastructure needed to implement modified border measures are in place and can manage increased travel volumes effectively. Re-position Canada as a competitive participant in the tourism and global trade sectors through enabling border measures that facilitate the movement of people and goods across international borders.

In collaboration with the private sector, the government should develop an enhanced framework to better prepare for and respond to future cipros..