Medicaid Monitor
Policy Intelligence
Medicaid Monitor
Policy Intelligence
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American Hospital Association

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Federal Policy·2d ago

CMS Opens 340B Part D Claims Data Repository for Voluntary Use

CMS launched its 340B Part D claims data repository on October 1, allowing covered entities and third-party administrators to begin submitting claims data voluntarily. CMS has proposed requiring mandatory submissions starting January 1, 2027. To support entities during the transition, CMS has published a user guide, companion guide, fact sheet, and FAQ. The repository is intended to improve tracking of 340B drug claims under Medicare Part D.

Federal Policy·2d ago

CMS Finalizes GLOBE Model Testing International Drug Rebate Benchmark

CMS finalized its Global Benchmark for Efficient Drug Pricing (GLOBE) Model on Sept. 30, a mandatory test of an alternative manufacturer rebate calculation under the Medicare Part B Inflation Rebate Program. Instead of the current domestic pricing benchmark, the model uses a benchmark derived from international pricing data. After public comment, CMS excluded biosimilars, orphan-only drugs, plasma-derived products and certain cell and gene therapies, and carved out manufacturers already participating in its GENEROUS Model, leaving only four manufacturers expected to be required to participate. The model will apply to Medicare beneficiaries in a randomly selected subset of geographic areas covering about 25% of Original Medicare beneficiaries. CMS now estimates $440 million in savings over the seven-year performance period, sharply lower than its earlier $12 billion projection.

Federal Policy·3d ago

HHS Clarifies Use of SUD Records for Medicaid Work Exemptions

The HHS Office for Civil Rights issued guidance clarifying how 42 CFR Part 2 confidentiality rules for substance use disorder patient records interact with Medicaid community engagement requirements. The notice explains when state Medicaid agencies may use Part 2 records to verify whether an applicant or beneficiary qualifies as a "specified excluded individual" exempt from the work requirements established by the July 2025 reconciliation law. It includes examples illustrating permitted circumstances for this verification use. The guidance helps states implement exemption determinations without running afoul of federal SUD confidentiality protections.

Federal Policy·6d ago

SAMHSA Awards $247.9 Million in Behavioral Health Grants

The Substance Abuse and Mental Health Services Administration announced September 25 that it awarded $247.9 million in grants to expand access to addiction treatment, mental health services, and recovery support. The funds will support school-based mental health services, trauma treatment for children and families, overdose reversal efforts by first responders and communities, and employment support for people in recovery. The awards take effect immediately for grantees nationwide. For state Medicaid agencies and managed care organizations, these federal grants represent new resources that may complement or coordinate with Medicaid-funded behavioral health services, particularly for populations eligible for both programs.

Industry·9d ago

AHA Launches Week-Long Campaign on Maternal and Child Health

The American Hospital Association will run its Better Health for Mothers and Babies Awareness Week from September 28 through October 2, 2026. The campaign will share hospital and health system stories, resources, and promising practices related to maternal health, neonatal and pediatric care, workforce development, public policy, innovation, and community partnerships. Daily themes include maternal health advances, NICU Awareness Day on September 30, pediatric care innovations, and policy and workforce strategies. The AHA will host a webinar on pediatric behavioral healthcare on September 30 at 2 p.m. ET and provide social media materials, discussion guides, and resources throughout the week for hospitals and health systems to participate.

Federal Policy·9d ago

Senate Finance Committee Advances Chris Klomp Nomination for HHS Deputy Secretary

The Senate Finance Committee on September 24, 2026, advanced Chris Klomp's nomination for deputy secretary of the Department of Health and Human Services by a 15-12 vote, sending it to the full Senate. Klomp currently serves as director of Medicare and deputy administrator at CMS. The nomination now awaits a floor vote. If confirmed, Klomp would hold the second-highest position at HHS, with oversight authority spanning CMS, including Medicaid and CHIP operations, along with other departmental programs.

Federal Policy·12d ago

AHA Urges CMS to Limit Retrospective Reconciliation in Medicaid Provider Tax Rule

The American Hospital Association submitted comments September 21 on CMS's proposed rule implementing Medicaid provider tax changes from the July 2025 reconciliation law. Beginning in fiscal year 2027, states cannot raise the provider tax indirect hold harmless threshold above the rate in place at enactment; for expansion states, the hospital threshold decreases 0.5 percentage points annually starting FY 2028. AHA opposes CMS's proposed retrospective reconciliation requirement, arguing it creates unpredictability for state Medicaid programs and adds administrative burden. AHA recommends CMS use prospective estimates for ongoing compliance monitoring and limit retrospective calculations to the one-time statutory threshold determination.

Federal Policy·17d ago

WEDI Opens Survey on CMS Prior Authorization Rule Readiness Through Oct. 9

The Workgroup for Electronic Data Interchange has launched a survey to assess industry readiness for CMS's interoperability and prior authorization final rule, with responses open through Oct. 9, 2026. The anonymous survey will gather aggregated data from health plans, providers, and other stakeholders on their implementation progress. WEDI will use the results to develop recommendations for CMS, inform stakeholders, and create industry guidance and educational materials on electronic prior authorization standards compliance.

Industry·19d ago

AHA, Kaufman Hall Report Calls for Broader M&A Review Beyond Commercial Pricing

A new Kaufman Hall report prepared for the American Hospital Association argues that hospital merger reviews should assess impacts on Medicare and Medicaid beneficiaries, who account for nearly 60% of hospital patient days, not just commercial insurance pricing. The report finds that hospitals seeking mergers often serve vulnerable communities and face financial pressures, and that blocked transactions can lead to deterioration threatening services and access. The authors call for merger analysis that considers consequences if deals do not proceed and evaluates effects on government-payer populations.

Industry·20d ago

Kaufman Hall Report Examines Financial Effects of Blocked Hospital Mergers

A new Kaufman Hall report argues that antitrust review of hospital mergers focuses too narrowly on commercial insurance pricing impacts and overlooks effects on Medicare and Medicaid patients, who represent nearly 60% of acute-care hospital patient days. The report finds that among 88 canceled hospital transactions, potential acquirees experienced a median 50% reduction in operating profit margin and 38% reduction in days cash on hand in the following year. The analysis shows hospitals seeking acquisition serve communities with higher vulnerability and higher Medicare/Medicaid patient shares than their prospective acquirers, and that facility closures or service reductions following blocked mergers may disproportionately affect Medicare and Medicaid beneficiaries whose access to care is at risk even though government-set rates would not change.

Federal Policy·31d ago

AHA Opposes CMS Home Health Payment Update and Enrollment Changes in CY 2027 Proposed Rule

The American Hospital Association submitted comments August 28, 2026 opposing CMS's proposed 2.4% payment update for home health services in calendar year 2027, calling it inadequate, and urging suspension of behavioral adjustments tied to the patient-driven grouping model. The proposed rule also includes Medicare provider enrollment changes affecting all Medicare-enrolled providers and suppliers. AHA warned the enrollment provisions would create significant reporting burdens and risk compliant providers' enrollment status. Comments urged CMS to finalize only narrowly tailored enrollment policies with objective standards and procedural safeguards protecting providers and beneficiary access.

Industry·31d ago

AHA Webinar on Medicare Advantage Electronic Prior Authorization Implementation

The American Hospital Association is hosting a webinar on preparing for Medicare Advantage's electronic prior authorization mandate effective January 1, 2027. The session will feature representatives from AHA, CMS, and Epic discussing workflow integration, implementation challenges, and readiness strategies for hospital and health system leaders. The webinar focuses on operational preparation for the new Medicare Advantage requirement.

Federal Policy·37d ago

CMS Releases 340B Part D Claims Repository Guidance Ahead of October Launch

CMS issued a fact sheet and FAQs on the 340B Part D claims data repository launching October 1, 2026. Data submissions will be voluntary for 340B hospitals initially, but CMS has proposed making them mandatory beginning in 2027. The guidance provides operational details on repository structure, submission requirements, and timelines. The repository aims to improve transparency around 340B drug claims in Medicare Part D, affecting hospitals participating in the 340B program and their Part D relationships.

Federal Policy·45d ago

HHS Adds Two Peer Support Programs to Title IV-E Clearinghouse for Federal Reimbursement

The Department of Health and Human Services announced August 18 that its Administration for Children and Families added two behavioral health peer support programs to the Title IV-E Prevention Services Clearinghouse: Family-Based Recovery (in-home treatment for parents with addiction who have children ages 0-5) and Wellness Recovery Action Plan (peer-facilitated mental health and addiction recovery coaching). The additions allow all states to claim federal reimbursement for these services under Title IV-E prevention. This expands state options for using federal funds to support families with substance use disorders and mental health conditions in child welfare prevention programs.

Federal Policy·46d ago

CMS Launches QualTech Event to Identify AI and Digital Quality Technology Solutions

CMS announced QualTech, a new event seeking technology proposals from U.S.-based teams, academic institutions, nonprofits, private companies, and industry associations. Proposals must address one of four priority areas: AI to protect patients and strengthen quality, AI to increase Medicare annual wellness visits, next-generation digital quality measure calculators, or a national quality hospital dashboard. Applications are due September 4, 2026, with finalists presenting at CMS headquarters to agency leadership. CMS may pursue continued engagement with selected organizations, including potential pilots, demonstrations, or roles in the 2027 CMS Quality Conference.

Federal Policy·46d ago

HHS Awards $96.7 Million in SAMHSA Behavioral Health Grants

The Department of Health and Human Services announced $96.7 million in grants through the Substance Abuse and Mental Health Services Administration for behavioral health services. The grants fund programs for individuals with serious mental illness experiencing homelessness, suicide prevention and early intervention, substance use disorder treatment, training and technical assistance, peer support, and disaster-related emotional support. The funding supports service delivery infrastructure that Medicaid managed care organizations and behavioral health providers rely on to serve beneficiaries with complex needs.

Federal Policy·47d ago

CMS Proposes Regulations Codifying Medicare Drug Price Negotiation Program

The Centers for Medicare & Medicaid Services has issued a proposed rule to codify regulations for the Medicare Drug Price Negotiation Program established under the Inflation Reduction Act. The American Hospital Association submitted comments on August 17, 2026, urging CMS to require manufacturers to make negotiated maximum fair prices available at point-of-sale rather than through retrospective rebates. AHA expressed concern that allowing retrospective price adjustments could encourage manufacturers to shift the 340B drug discount program from upfront discounts to rebates. The proposal affects how Medicare Part D beneficiaries and covered entities access negotiated drug prices.

Industry·47d ago

AHA Network Hosts Webinar on Coordinated Behavioral Health Response Strategies

The American Hospital Association's Community Health Improvement network will host a webinar on August 26, 2026, at noon ET featuring CredibleMind leaders discussing coordinated behavioral health response frameworks. The session will cover upstream prevention strategies, community engagement approaches, cross-sector coordination mechanisms, and accountability frameworks. The webinar is aimed at hospital and health system leaders seeking to strengthen behavioral health service coordination.

Federal Policy·51d ago

CMS Sets October 13 Deadline for APM Participants to Update Billing Information or Forfeit 2026 Payments

CMS issued an advisory requiring certain alternative payment model participants to update taxpayer identification numbers by October 13, 2026, to receive APM incentive payments for the 2026 payment year based on 2024 performance. The agency could not identify valid TINs for some participants after processing payments. Clinicians who fail to submit updated billing information by the deadline will forfeit their APM incentive payments for this payment period.

Federal Policy·WA·54d ago

HHS Declares Public Health Emergency for Washington Wildfires, Enabling Section 1135 Waivers

HHS Secretary Robert F. Kennedy Jr. declared a public health emergency for Washington state on August 7, 2026, following President Trump's emergency declaration on August 4. The dual declarations enable Washington to request Section 1135 waivers, which allow temporary flexibility from certain Medicare, Medicaid, and CHIP regulatory requirements during the wildfire emergency. The Administration for Strategic Preparedness and Response has deployed regional staff to support state response efforts, and the Washington State Hospital Association is providing resources to assist providers.

Industry·59d ago

AHA Blog Links Rural Hospital Access to Healthcare Affordability and Community Stability

The American Hospital Association published a blog by Shannon Wu, director of payment policy, connecting rural hospital viability to healthcare affordability. Wu argues that proximity to hospitals reduces patient travel costs, enables timely emergency care, and provides access to essential services from primary care to behavioral health and cancer treatment. The blog frames rural hospital closures as threats to community health, stability, and economic well-being beyond individual patient impact. No specific policy action or data is reported.

Federal Policy·59d ago

AHA Urges CMS to Lift Funding Caps in $50 Billion Rural Health Transformation Program

The American Hospital Association submitted comments to CMS on August 5, 2026, requesting changes to the Rural Health Transformation Program, which will distribute $50 billion to rural providers from FY 2026 through FY 2030. AHA urged CMS to eliminate a 15% cap on provider payments and a 20% cap on infrastructure and capital improvement funding for program years two through five. The association also requested that CMS work with Congress to allow states to revise initial applications, extend spending timelines for obligated funds, publicly post state-reported funding data, remove administrative barriers to hospital fund access, and ensure RHTP funds are separately reported on Medicare cost reports.

Federal Policy·61d ago

CMS Finalizes 2.3% Medicare Hospital Payment Increase for FY 2027

CMS issued a final rule increasing Medicare inpatient payment rates by a net 2.3% for FY 2027, reflecting a 3.2% market basket increase offset by a 0.9% productivity adjustment. The rule adds $2.9 billion in total hospital payments, including $228 million in DSH and uncompensated care payments and $779 million in new technology payments. The rule expands the Comprehensive Care for Joint Replacement bundled payment model nationwide starting January 1, 2028, making it mandatory for most acute care hospitals with accountability for spending and quality during inpatient stays and 90 days post-discharge. Changes to quality reporting programs include eight new measures for the Inpatient Quality Reporting Program and electronic prior authorization requirements extending to medical benefit drugs beginning in 2028.

Federal Policy·62d ago

HHS Announces Revised 340B Rebate Model Pilot for Medicare Negotiated Drugs Starting January 2027

HHS issued a notice announcing a revised 340B Rebate Model Pilot Program that allows qualifying drug manufacturers to use rebates rather than upfront discounts for certain 340B-eligible drugs. The pilot is limited to drugs included on the CMS Medicare Drug Price Negotiation Selected Drug Lists for 2026 and 2027. Manufacturers must submit participation plans to HRSA by August 24, 2026, with approval decisions by September 24, 2026, and approved models taking effect January 1, 2027. The AHA opposes the pilot, citing concerns about administrative burdens, cash-flow disruptions, and compliance costs for hospitals serving vulnerable populations, and is considering legal options to block implementation.

Federal Policy·65d ago

CMS Sets Aug. 12 Deadline for Essential Community Provider Applications and Renewals

The Centers for Medicare & Medicaid Services requires current and prospective essential community providers to submit new applications or renew existing ones by August 12, 2026. ECPs include federally qualified health centers, rural health clinics, Ryan White HIV/AIDS Program providers, Title X family planning providers, Indian healthcare providers, and critical access hospitals. CMS encourages existing ECPs to complete annual renewal even without changes to maintain current information for Health Insurance Marketplace issuers seeking ECP network partners. The designation affects providers serving predominantly low-income and medically underserved populations.

Federal Policy·66d ago

CMS Finalizes 2.4% SNF Payment Increase for FY 2027, Expands Quality Reporting

CMS issued a final rule July 29 updating the skilled nursing facility prospective payment system for fiscal year 2027, increasing aggregate payments by 2.4% (3.3% market basket minus 0.9% productivity adjustment). The rule also revises the SNF Quality Reporting Program by removing two COVID-19 vaccination measures, shortening data reporting timelines, and requiring facilities to submit assessment data for all patients regardless of payer source. Changes take effect October 1, 2026. The all-payer reporting requirement expands data submission obligations beyond Medicare to include Medicaid and other payers.

Federal Policy·66d ago

HHS Launches National Behavioral Health Quality Pledge with Insurers and Providers

HHS Secretary announced July 29 that dozens of insurers, medical societies, providers, and behavioral health experts have pledged to strengthen behavioral health systems through improved access, quality measurement, patient-centered recovery services, and whole-person care integrating behavioral and physical health. The voluntary initiative commits participants to advancing best practices in mental health and addiction treatment. HHS positioned the effort as part of the administration's broader strategy to address addiction and mental illness and improve long-term patient outcomes.

Federal Policy·66d ago

CMS Finalizes 2.3% IPF Payment Increase for FY 2027, Delays Outlier Cap

CMS issued a final rule July 29 increasing inpatient psychiatric facility payments by 2.3% ($60 million) for fiscal year 2027, reflecting a 3.2% market basket update minus a 0.9-point productivity adjustment. The rule finalizes an outlier payment cap but defers implementation until FY 2028 and excludes facilities with fewer than 50 stays annually. CMS also removes two quality reporting measures on alcohol and tobacco screening effective CY 2026/FY 2028 and modifies implementation of the standardized IPF Patient Assessment Instrument with a lower compliance threshold and extended timeline. Changes take effect October 1, 2026.

Federal Policy·67d ago

CMS Electronic Prior Authorization Requirements Take Effect January 1, 2027 for Medicare Advantage and Medicaid Managed Care

On January 1, 2027, Medicare Advantage organizations, Medicaid managed care plans, CHIP managed care entities, and federally facilitated exchange QHP issuers must support electronic prior authorization through standardized APIs under CMS's 2024 Interoperability and Prior Authorization final rule. The rule requires impacted payers to enable providers to determine prior authorization requirements, submit requests, and receive approval decisions electronically through EHR integration, using standardized HL7 FHIR-based workflows. The rule does not eliminate prior authorization or change medical necessity criteria — it standardizes the electronic exchange of prior authorization information between providers and health plans. Hospitals should engage EHR vendors and health plans now to prepare workflows, test systems, and train staff before implementation.

Federal Policy·72d ago

CMS Halts Premium Tax Credit Reconciliation Enforcement After Court Injunction

CMS issued implementation guidance July 22 following a federal district court injunction that blocked eight provisions of its 2027 notice of benefit and payment parameters final rule. The injunction, issued July 16, prevents enforcement of provisions set to take effect July 20. CMS directed exchanges to immediately stop removing or denying advance premium tax credits for applicants who failed to file and reconcile prior years' credits, effective for plan years 2026 and 2027. The agency also reinstated the automatic 60-day extension for resolving household income data inconsistencies.

Federal Policy·74d ago

AHA Urges CMS to Scale Back Medicaid State-Directed Payment Limits in Proposed Rule

The American Hospital Association submitted comments July 21, 2026, opposing portions of a CMS proposed rule implementing reconciliation-mandated changes to Medicaid state-directed payments. The rule proposes new limits on targeted fee-for-service payments and SDP design that exceed statutory requirements. CMS projects the rule would reduce Medicaid payments by $510.1 billion over 10 years—more than triple the Congressional Budget Office estimate of $149.4 billion. AHA argues the cuts would reduce care access, worsen workforce shortages, and threaten hospital financial viability, urging CMS to rescind provisions beyond what Congress required and mitigate SDP reductions.

Federal Policy·74d ago

CMS Proposes New Provider Tax Thresholds, Phases Out 6% Hold Harmless Rule

CMS released a proposed rule updating Medicaid provider tax policies following the July 2025 reconciliation law. The rule replaces the current 6% indirect hold harmless threshold with state- and provider class-specific thresholds based on taxes enacted as of July 4, 2025, and implements phased reductions for Medicaid expansion states starting in fiscal year 2028. CMS proposes to sunset the current 75/75 compliance test and establishes a new "Services of Health Insurers" provider tax class, bringing existing state taxes on health insurers under federal oversight. Comments are due 60 days after Federal Register publication.

Federal Policy·75d ago

Maryland Court Enjoins Eight Provisions of CMS 2027 Marketplace Payment Rule

A federal district court in Maryland issued a preliminary injunction on July 16, 2026, blocking eight provisions of CMS's 2027 notice of benefit and payment parameters final rule. The enjoined provisions include expanded out-of-pocket maximums for bronze and catastrophic plans, broader catastrophic plan eligibility, relaxed network adequacy standards, and a new pathway for non-network plans to qualify as marketplace coverage. The court found plaintiffs likely to succeed on Administrative Procedure Act claims and that irreparable harm would occur without relief. The injunction took effect July 20, 2026, while the remainder of the rule proceeded as scheduled.

Federal Policy·76d ago

CMS Updates PAMA Lab Data Reporting FAQ Ahead of July 31 Deadline

The Centers for Medicare & Medicaid Services has released an updated FAQ on Protecting Access to Medicare Act private payer data reporting requirements for hospital outreach laboratories. The deadline is July 31, 2026, for laboratories to report private payer clinical diagnostic laboratory data for services furnished during the first six months of 2025. Reporting must include Healthcare Common Procedure Coding System codes, associated private payer rates, and volume data. CMS has published a guide and additional resources to help hospital outreach laboratories determine their reporting obligations.

Federal Policy·79d ago

CMS Launches Risk-Based Survey Process for High-Performing Nursing Homes Nationwide

CMS announced July 16 nationwide implementation of a risk-based survey process for high-performing nursing homes, effective September 2026 following state agency training. Approximately 12% of nursing facilities will initially qualify based on criteria including five-star ratings, zero harm citations, and accurate data submission. Qualifying facilities receive streamlined recertification surveys and a new Care Compare icon, though state agencies retain authority to use traditional surveys when safety concerns arise. All nursing homes continue receiving surveys at least every 15 months regardless of performance tier.

Federal Policy·79d ago

DHS Finalizes Public Charge Rule Tying Medicaid and CHIP Receipt to Immigration Bonds

The Department of Homeland Security on July 16 finalized a rule rescinding 2022 public charge regulations and establishing that receipt of Medicaid or CHIP will breach public charge bonds for immigrants. The final rule removes previous exemptions and the 2022 Public Charge Inadmissibility Framework definitions. It takes effect 60 days after Federal Register publication, likely in mid-September 2026. The change may reduce Medicaid and CHIP enrollment among eligible immigrant populations, affecting managed care plan membership and revenue.

Federal Policy·80d ago

AHA Urges CMS to Preserve Essential Health Benefits Coverage Standards in RFI Response

The American Hospital Association submitted comments July 15 responding to a CMS request for information on potential modifications to the Affordable Care Act's Essential Health Benefits framework. AHA supported updating EHBs to reflect changes in healthcare delivery but warned against changes that would reduce coverage adequacy. The association emphasized that affordability requires adequate benefits, not just lower premiums, and cautioned that reduced benefits, narrower standards, or increased cost-sharing would increase patient financial exposure. CMS is reviewing the EHB framework, which establishes minimum coverage requirements for comprehensive insurance.

Federal Policy·87d ago

CMS Ends Fast-Track Review Process for Medicaid 1115 Waiver Extensions

CMS announced July 7 that it is eliminating the fast-track review process for certain Medicaid section 1115 demonstration extensions, formally rescinding 2015 guidance that established the expedited pathway. The change stems from a July 2025 reconciliation bill requirement that the CMS chief actuary certify budget neutrality for all 1115 demonstrations, effective January 1, 2027. CMS stated the fast-track process would make it difficult to evaluate renewal applications under the new budget neutrality certification requirements. The bulletin did not specify when the elimination takes effect, but states should anticipate longer review timelines for waiver extensions.

Federal Policy·95d ago

AHA Opposes Bill Adding IRS Schedule H Reporting Requirements for Tax-Exempt Hospitals

The American Hospital Association submitted comments June 30 to the House Ways and Means Committee opposing H.R. 9504, the Tax-Exempt Hospital Transparency Act, ahead of a scheduled July 1 markup. The bill would add reporting requirements to hospitals' Schedule H IRS forms, affecting nearly two-thirds of all hospitals. While the AHA acknowledged improvements from an earlier draft — including removal of a parallel for-profit tax calculation and inclusion of standardized definitions — it maintains serious concerns about administrative and financial burdens, particularly requirements focused on financial assistance reporting that exclude Medicaid shortfall and other community benefit components. The bill includes carve-outs for small facilities but still requires eventual compliance.

Managed Care·CO·96d ago

Denver Health CEO Discusses Housing Program for Medicaid, Uninsured Patients

Denver Health CEO Donna Lynne describes the health system's Housing Outreach, Partnerships and Engagement (HOPE) program, which provides 34 apartments to patients experiencing homelessness or housing insecurity. The program, which won the 2026 AHA Dick Davidson NOVA Award, includes 20 recuperative care units with average 2-3 day stays and 14 longer-term apartments for up to six months. Denver Health serves a patient population that is 47% Medicaid and 15% uninsured; the program reduces length of stay and readmissions for homeless patients, who typically stay 2.5 times longer than housed patients. The health system partners with Colorado Coalition for the Homeless and Denver Housing Authority to transition patients to permanent housing.

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