2014 -- H 7527

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LC004660

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE

     

     Introduced By: Representatives Serpa, and Fellela

     Date Introduced: February 26, 2014

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

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     SECTION 1. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby

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amended by adding thereto the following section:

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     40-8-16.1. Managed care arrangements for long-term care. – (a) Definitions. For

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purposes of this section, the following terms shall have the following :

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     (1) “Beneficiary” means an individual who is eligible for medical assistance under the

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Rhode Island Medicaid state plan established in accordance with 42 U.S.C. 1396, and includes

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individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. Sec.

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1395, et seq.) or other health plan.

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     (2) “Duals demonstration project” means a demonstration project established pursuant to

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the financial alignment demonstration established under § 2602 of the Patient Protection and

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Affordable Care Act (Pub. L. 111-148), involving a three way contract between Rhode Island, the

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federal Centers for Medicare and Medicaid Services (“CMS”) and qualified health plans, and

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covering health care services provided to beneficiaries.

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     (3) “EOHHS” means the Rhode Island executive office of health and human services.

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     (4) “EOHHS level of care tool” means to a set of criteria established by EOHHS and used

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in January 2014 to determine the long-term care needs of a beneficiary as well as the appropriate

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setting for delivery of that care.

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     (5) “Long-term care services and supports” means a spectrum of services covered by the

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Rhode Island Medicaid program and/or the Medicare program, that are required by individuals

 

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with post acute care needs, functional impairments and/or chronic illness, and includes skilled or

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custodial nursing facility care, as well as various home and community based services.

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     (6) “Managed long-term care arrangement” means any arrangement under which a

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managed care organization is granted some or all of the responsibility for providing and/or paying

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for long-term care services and supports that would otherwise be provided or paid under the

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Rhode Island Medicaid program. The term includes, but is not limited to, a duals demonstration

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project, and/or phase I and phase II of the integrated care initiative established by the executive

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office of health and human services.

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     (7) "Managed care organization" means any health plan, health maintenance

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organization, managed care plan, or other person or entity that enters into a contract with the state

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under which it is granted the authority to arrange for the provision of, and/or payment for, long-

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term care supports and services to eligible beneficiaries under a managed long-term care

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arrangement.

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     (8) "Plan of care" means a care plan established by a nursing facility in accordance with

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state and federal regulations, and which identifies specific problems, goals, interventions and time

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frames for care and services provided to a beneficiary.

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     (b) Beneficiary choice. Any managed long-term care arrangement shall offer

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beneficiaries the option to decline participation and remain in traditional Medicaid and, if a duals

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demonstration project, traditional Medicare. Beneficiaries must be provided with sufficient

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information to make an informed choice regarding enrollment, including:

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     (1) Any changes in the beneficiary's payment or other financial obligations with respect

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to long-term care services and supports as a result of enrollment;

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     (2) Any changes in the nature of the long-term care services and supports available to the

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beneficiary as a result of enrollment, including specific descriptions of new services that will be

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available or existing services that will be curtailed or terminated;

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     (3) A contact person who can assist the beneficiary in making decisions about

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enrollment;

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     (4) Individualized information regarding whether the managed care organization's

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network includes the health care providers with whom beneficiaries have established provider

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relationships. Directing beneficiaries to a website identifying the plan's provider network shall not

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be sufficient to satisfy this requirement; and

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     (5) The deadline by which the beneficiary must make a choice regarding enrollment, and

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the length of time a beneficiary must remain enrolled in a managed care organization before

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being permitted to change plans or opt out of the arrangement.

 

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     (c) Ombudsman process. EOHHS shall designate an ombudsperson to advocate for

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beneficiaries enrolled in a managed long-term care arrangement. The ombudsperson shall

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advocate for beneficiaries through complaint and appeal processes and ensure that necessary

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health care services are provided. At the time of enrollment, a managed care organization must

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inform enrollees of the availability of the ombudsperson, including contact information.

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     (d) Provider/plan liaison. EOHHS shall designate an individual, not employed by or

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otherwise under contract with a participating managed care organization, who shall act as liaison

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between health care providers and managed care organizations, for the purpose of facilitating

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communications and assuring that issues and concerns are promptly addressed.

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     (e) Financial savings under managed care. To the extent that financial savings are a goal

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under any managed long-term care arrangement, it is the intent of the legislature to achieve such

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savings through administrative efficiencies, care coordination, and improvements in care

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outcomes, rather than through reduced reimbursement rates to providers or limiting access to

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medically necessary care and services. Therefore:

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     (1) Any managed long-term care arrangement shall include a requirement that

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participating managed care organizations reimburse providers for services in accordance with the

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following:

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     (i) The annual adjustment to rates by the change in a recognized national nursing home

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inflation index as described in § 40-8-19(a)(2)(vi) or successor statute shall be applied to rates of

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payment to nursing facilities for Medicaid-covered services.

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     (ii) For a duals demonstration project, the managed care organization:

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     (A) Shall not combine the rates of payment for post-acute skilled and rehabilitation care

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provided by a nursing facility and long-term and chronic care provided by a nursing facility in

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order to establish a single payment rate for dual eligible beneficiaries requiring skilled nursing

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services;

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     (B) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or

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long-term and chronic care rates that reflect the different level of services and intensity required

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to provide these services; and

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     (C) For purposes of determining the appropriate rate for the type of care identified in

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subsection (e)(l)(ii)(B), the managed care organization shall pay no less than the rates which

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would be paid for that care under Medicare and Rhode Island Medicaid for these service types.

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     (iii) For a managed long-term care arrangement that is not a duals demonstration project,

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the managed care organization shall reimburse providers in an amount no less than the rate that

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would be paid for the same care by EOHHS under the Medicaid program.

 

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     (2) Any managed long-term care arrangement shall include a requirement that

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participating managed care organizations use only the EOHHS level of care tool in determining

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coverage of long-term care supports and services for beneficiaries. EOHHS may amend the level

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of care tool provided that any changes are established upon public notice and comment; in

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consultation with beneficiaries and providers of Medicaid-covered long-term care supports and

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services; and are based upon reasonable medical evidence or consensus, in consideration of the

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specific needs of Rhode Island beneficiaries. Notwithstanding anything else herein, however, in

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the case of a duals demonstration project a managed care organization may use a different level of

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care tool for determining coverage of services that would otherwise be covered by Medicare,

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since the criteria established by EOHHS are directed towards Medicaid-covered services;

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provided that such level of care tool is established upon public notice and comment; in

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consultation with beneficiaries and providers of Medicaid-covered long-term care supports and

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services; and is based upon reasonable medical evidence or consensus, in consideration of the

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specific needs of Rhode Island beneficiaries.

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     (3) Any managed long-term care arrangement shall include a requirement that

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participating managed care organizations establish a mechanism under which providers furnish

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input into the managed care organization's long-term care policies and procedures, including case

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management; nursing care; quality management and reporting; and claims processing and

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payment, as well as a mechanism under which beneficiaries furnish input into the managed care

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organization's policies and procedures regarding the delivery of long-term care services and

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supports.

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     (e) Payment incentives. In order to encourage quality improvement and promote

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appropriate utilization incentives for providers in a managed long-term care arrangement a

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managed care organization may use incentive or bonus payment programs that are in addition to

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the rates identified in subsection (e)(1).

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     (f) Any willing provider. A managed care organization must contract with and cover

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services furnished by any nursing facility licensed under chapter 23-17, and certified by CMS that

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provides Medicaid-covered nursing facility services pursuant to a provider agreement with the

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state, provided that the nursing facility is not disqualified under the managed care organization's

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quality standards that are applicable to all nursing facilities; and the nursing facility is willing to

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accept the reimbursement rates described in subsection (e) of this section.

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     (g) Case management/plan of care. No managed care organization acting under a

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managed long-term care arrangement may require a provider to change a plan of care if the

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provider reasonably believes that such an action would conflict with the provider's responsibility

 

LC004660 - Page 4 of 6

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to develop an appropriate care plan under state and federal regulations.

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     (i) Care transitions. In the event that a beneficiary: (1) Has been determined to meet level

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of care requirements for nursing facility coverage as of the date of his or her enrollment in a

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managed care organization; or (2) Been determined to meet level of care requirements for nursing

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facility coverage by a managed care organization after enrollment; and there is a change in

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condition whereby the managed care organization determines that the beneficiary no longer meets

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such level of care requirements, the nursing facility shall promptly arrange for an appropriate and

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safe discharge (with the assistance of the managed care organization if the facility requests it),

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and the managed care organization shall continue to pay for the beneficiary's nursing facility care

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at the same rate until the beneficiary is discharged.

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     (j) Reporting requirements. EOHHS shall report to the general assembly and shall make

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available to interested persons a separate accounting of state expenditures for long-term care

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supports and services under any managed long-term care arrangement, specifically and separately

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identifying expenditures for home and community based services, assisted living services,

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hospice services within nursing facilities, hospice services outside of nursing facilities, and

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nursing facility services. Such reports shall be made twice annually, six (6) months apart,

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beginning six (6) months following the implementation of any managed long-term care

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arrangement, and shall include a detailed report of utilization of each such service. In order to

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facilitate such reporting, any managed long-term care arrangement shall include a requirement

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that a participating managed care organization make timely reports of the data necessary to

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compile such reports.

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     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE

***

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     This act would provide a choice for beneficiaries to decline participation in any managed

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long-term care arrangement, and to remain in traditional Medicaid and/or traditional Medicare,

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designate an ombudsperson to advocate on their behalf, provide an individual to act as a liaison

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between health care providers and managed care organizations, and realize financial savings

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whenever possible without any detrimental effect on the quality of care afforded beneficiaries

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with reports required by the executive office of health and human services every six (6) months.

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     This act would take effect upon passage.

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