Medicaid: State Financing Schemes Again Drive Up Federal Payments
(Testimony, 09/06/2000, GAO/T-HEHS-00-193).

Pursuant to a congressional request, GAO discussed the federal
government's role in helping pay for Medicaid, focusing on how: (1) the
current financing scheme works; and (2) it compromises the agreement for
federal/state sharing of Medicaid financing.

GAO noted that: (1) the current scheme inappropriately increases federal
Medicaid payments by paying certain providers more than they would
normally receive and then having the providers return the bulk of the
extra monies to the state; (2) by making an excess payment, the state
generates additional federal matching funds, which can be used to pay
its share of future Medicaid payments--thus generating even more federal
matching funds--or spent however the state determines; (3) the providers
receiving the inflated payments and passing back the excess to the state
are entities owned by local governments--for example, county-owned
nursing homes and local hospital districts; (4) according to the Health
Care Financing Administration (HCFA), as of late July, 17 states have
state plans that could allow them to use this practice, and 11 other
states have drafted plans for doing so; (5) the exact amount of
additional federal Medicaid dollars generated through this process is
unknown, but it is in the billions of dollars and growing; (6) while
most states do not specifically acknowledge how they will use the money
that makes the round-trip back to their treasuries, intended uses
reported by elected officials in some states include funding other
health-care or education programs, as well as subsidizing a state tax
cut; (7) in GAO's view, this financing practice violates the integrity
of Medicaid's federal/state partnership; (8) by receiving part of the
money back from the provider and keeping the federal share associated
with it, the state is--in effect--able to lower its own Medicaid
contribution substantially below the share specified in federal law; (9)
GAO has not yet been able to specifically determine how much of an
effect this current practice will have in any one state; (10) however,
GAO's analysis of previous financing schemes showed that the effect can
be substantial; (11) for example, in 1994 GAO analyzed Michigan's use of
similar funding mechanisms and found they had the effect of raising the
federal share for Medicaid expenditures from 56 percent to 68 percent;
(12) when related schemes came to light in years past, steps were taken
to curtail them and restore the federal/state partnership as intended;
(13) HCFA has drafted a regulation that would curtail this scheme, but
the draft has not moved far in the rulemaking process; and (14) GAO
urges HCFA to finalize this regulation and reiterate a recommendation to
Congress that would close the door on financing practices that inflate
the federal share by making excessive payments to government-owned
facilities.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-00-193
     TITLE:  Medicaid: State Financing Schemes Again Drive Up Federal
	     Payments
      DATE:  09/06/2000
   SUBJECT:  State-administered programs
	     Federal/state relations
	     Cost sharing (finance)
	     Internal controls
	     Program abuses
	     Health insurance
IDENTIFIER:  Medicaid Program

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For Release on Delivery Expected at 10: 00 a. m. Wednesday, September 6,
2000

GAO/T-HEHS-00-193

MEDICAID State Financing Schemes Again Drive Up Federal Payments

Statement of Kathryn G. Allen, Associate Director Health Financing and
Public Health Issues Health, Education, and Human Services Division
Testimony

Before the Committee on Finance, U. S. Senate

United States General Accounting Office

GAO

Page 1 GAO/ T- HEHS- 00- 193

Mr. Chairman and Members of the Committee: We are pleased to be here today
as you discuss the federal government's role in helping pay for Medicaid.
The Congress has structured Medicaid as a federal/ state partnership that
provides federal matching funds and gives states considerable flexibility in
deciding what medical services and individuals to cover, as long as certain
basic requirements are met. Over the years, the Congress has also attempted
to make the program easier for states to administer and to provide more
flexibility in how they may distribute funds to Medicaid providers. However,
several times in the 1990s reports surfaced that some states were abusing
this flexibility through various financing schemes that increased the
federal share of program costs beyond what the partnership agreement calls
for. When these practices came to light, laws or regulations were rewritten
to stop or restrict them. Now there are reports that a number of states are
engaging in a practice that is a variant of previous practices. Limiting
this practice would involve taking similar action to what has been done in
the past.

In my testimony today, I will (1) describe how this current financing scheme
works and (2) discuss how it compromises the agreement for federal/ state
sharing of Medicaid financing. We have reviewed state plans describing this
financing arrangement and have discussed the issue with officials of the
Health Care Financing Administration (HCFA) and other agencies. We have not
yet identified the extent to which these schemes have been implemented or
the amount of money involved, but at the request of the Committee, we will
be continuing our work in this regard. Because this scheme is so similar to
some practiced previously, I will also draw on our prior work. 1

In brief, the current scheme inappropriately increases federal Medicaid
payments by paying certain providers more than they would normally receive
and then having the providers return the bulk of the extra monies to the
state. By making an excess payment, the state generates additional federal
matching funds, which can be used to pay its share of future Medicaid
payments- thus generating even more federal matching funds- or spent however
the state determines. The providers receiving the inflated payments and
passing back the excess to the state are entities owned by local
governments- for example, county- owned nursing homes and local hospital
districts. According to HCFA, as of late July, 17 states have state plans
that could allow them to use this practice, and 11 other

1 See the list of related GAO products at the end of this statement.
Medicaid: State Financing Schemes Again

Drive Up Federal Payments

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 2 GAO/ T- HEHS- 00- 193

states have drafted plans for doing so. The exact amount of additional
federal Medicaid dollars generated through this process is unknown, but it
is in the billions of dollars and growing. While most states do not
specifically acknowledge how they will use the money that makes the round-
trip back to their treasuries, intended uses reported by elected officials
in some states include funding other health- care or education programs, as
well as subsidizing a state tax cut.

In our view, this financing practice violates the integrity of Medicaid's
federal/ state partnership. By receiving part of the money back from the
provider and keeping the federal share associated with it, the state is- in
effect- able to lower its own Medicaid contribution substantially below the
share specified in federal law. We have not yet been able to specifically
determine how much of an effect this current practice will have in any one
state. However, our analysis of previous financing schemes showed that the
effect can be substantial. For example, in 1994 we analyzed Michigan's use
of similar funding mechanisms (including excessive payments to county
nursing homes) and found they had the effect of raising the federal share
for Medicaid expenditures from 56 percent to 68 percent. When related
schemes came to light in years past, steps were taken to curtail them and
restore the federal/ state partnership as intended. HCFA has drafted a
regulation that would curtail this scheme, but the draft has not moved far
in the rulemaking process. We urge the Administration to finalize this
regulation and reiterate a recommendation to the Congress, first made in
1994, that would close the door on financing practices that inflate the
federal share by making excessive payments to governmentowned facilities.

The federal and state governments' shares in the cost of Medicaid are based
on a statutory formula designed to reflect differences in each state's
program needs and capacity to finance them. At a minimum, the federal
government pays 50 percent of the cost. However, poorer states- those with a
low per capita income- receive federal contributions at a higher matching
rate. The aim is to reduce differences among the states in medical care
coverage for the poor and distribute fairly the burden of financing program
benefits among the states. Under this statutory formula, the federal payment
for the poorest states can be up to 83 percent of the program's cost.

Within a broad legal framework, each state designs and administers its own
Medicaid program, including deciding how much to pay providers for a
particular service. Each state operates its program under a plan that
Background

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 3 GAO/ T- HEHS- 00- 193

HCFA must approve for compliance with current federal law and regulations.
In addition, HCFA must approve any amendments to this plan.

To control federal expenditures, HCFA established a set of upper payment
limits on the total amount it would agree to pay states for a variety of
services. For example, one upper payment limit sets a maximum amount of
federal payments for all nursing homes in a state. 2 The upper limits are
based on the payment amount allowed under the Medicare program, which is the
federal government's program for providing medical services for the elderly
and the disabled. The upper limit is not a price to be paid for each service
provided, but rather a ceiling on Medicaid expenses above which the federal
government will not share.

The flexibility states have to set Medicaid's payment rates has provided
them the opportunity to develop various financing schemes in the past that
effectively changed what the federal government paid (see table 1). Most of
these financing schemes have subsequently been restricted by law or
regulation. While such restrictions curtailed the specific schemes that had
been brought to light, the restrictions did not extend to transactions with
certain government health care providers, such as local- and county- level
providers. To address this problem, in 1994 we recommended that the Congress
enact legislation to prohibit Medicaid payments that exceed costs to any
government- owned facility. That recommendation remains outstanding.

2 Upper payment limits currently exist for different classes of services,
including inpatient hospital services, outpatient hospital services, nursing
facility services, and intermediate care services for the mentally retarded.
Separate upper payment limits are set for state- operated facilities that
provide each of these services, with the exception of outpatient hospital
services, which have no upper payment limit.

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 4 GAO/ T- HEHS- 00- 193

Table 1: Examples of Previous Medicaid Financing Schemes for Generating
Federal Funds Without Committing a Corresponding State Contribution

Financing practice Summary How subsequently restricted

Excessive payments to state facilities

Excessive payments were made to state- owned facilities, increasing federal
payments.

HCFA promulgated regulations in 1987 that established payment limits for
state- operated inpatient and institutional facilities. Provider taxes and
contributions Revenues from provider- specific taxes

or donations were used to increase state Medicaid spending. The taxes and
contributions were matched with federal funds and paid to the providers.
These providers then returned most of the federal monies to the state.

The Medicaid Voluntary Contribution and Provider- Specific Tax Amendments of
1991 essentially banned provider donations, placed a series of restrictions
on provider taxes, and set certain other restrictions for each state.

Excessive disproportionate share hospital (DSH) payments

DSH payments are meant to compensate those hospitals that care for a
disproportionate number of low income patients. Unusually large DSH payments
were made to certain hospitals, which then returned the bulk of the state
and federal funds to the state.

The Omnibus Budget Reconciliation Act of 1993 limited which hospitals could
receive DSH payments, capped the amount of DSH payments individual hospitals
could receive, and capped states' total DSH payments. The Balanced Budget
Act of 1997 further reduced state- specific DSH allotments for fiscal years
1998- 2002. Excessive DSH payments to state mental hospitals

A large proportion of state DSH payments were directly returned to the state
treasury or were paid to state operated psychiatric hospitals to indirectly
cover the cost of services provided to patients that Medicaid cannot
directly pay for.

The Balanced Budget Act of 1997 limited the proportion of a state's DSH
payment that can be paid to state psychiatric hospitals.

To better ensure that federal Medicaid dollars are used for Medicaid
services, in the Balanced Budget Act of 1997 the Congress explicitly banned
the use of federal matching funds for any non- health- related items or for
any item or service not covered by a state's Medicaid plan.

The current practice is a variation of past practices in which federal
dollars make a round- trip from the state, to a Medicaid provider, and then
back to the state. Under the current scheme, excessive payments are made to
health facilities owned by local governments. Such providers include county-
owned nursing homes, local hospital districts, and county hospitals. Unlike
schemes involving other types of providers, which have been addressed
through legislation or changes in regulation, restrictions on excessive
payments to local government providers are fewer. The Additional Federal

Funds Are Obtained Through Excessive Payments to Local Government Providers

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 5 GAO/ T- HEHS- 00- 193

round- trip arrangement that maximizes federal dollars for the state
essentially involves two steps, as shown in figure 1.

Figure 1: Overview of Process for Maximizing Federal Medicaid Dollars

In the first step, states make a payment to certain Medicaid providers over
and above the amount that Medicaid actually intends to pay them. States
determine the amount of the excess payment by computing the difference
between the upper payment limit (that is, the maximum amount of total
Medicaid expenses eligible for federal matching payments) and the total
amount the state would normally pay to Medicaid providers using its payment
rates. Local government health care facilities such as nursing homes and
hospitals constitute good candidates for these excessive payments because
states are not limited in how much they may pay local government providers,
as long as their total payments to that provider group as a whole fall below
the upper limit for that category of provider. For example, if actual
Medicaid payments to all nursing homes in a state were $100 million under
normal Medicaid rates, and the upper payment

Step 1: A payment is made to local government Medicaid providers that
exceeds what the state intends to pay for the services provided.

State Local Government Providers

Step 2: Local government providers receive excess payments and send all or a
portion back to the state.

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 6 GAO/ T- HEHS- 00- 193

limit was $120 million, the amount available for the excessive payment to
county- owned nursing homes would be $20 million. 3 Assuming a 50- percent
federal matching rate, the federal share of the aggregate payments would
thus be driven from $50 million to $60 million.

The second step is the transfer of all or an agreed- upon share of the
excess payments from the local government providers back to the state
treasury. Without this step, the local providers would benefit, but the
states would realize no financial benefit. In fact, the state would actually
lose from the arrangement, because it would simply be paying more than
normal for the same services. However, once a payment is made to a local
government provider, the funds become local government funds, and the local
government is free to make any intergovernmental transfer of the funds.
Thus, the states can receive the transfer and reap the financial benefit of
the federal share of the excess payment.

While most states are silent on the distribution of excessive payments once
the local government providers are paid, some states are quite clear that
the money is intended to complete the round- trip and be returned to the
state (see table 2 for examples).

3 When the excess payments are made, they are a combination of federal and
state funds.

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 7 GAO/ T- HEHS- 00- 193

Table 2: Examples of State Plan Descriptions of Disposition of Excess
Payments State Excerpts from state plan amendments Status a Effective date

Alaska “While it is probable that some portion of the payments will be
retained by the publicly owned and operated hospitals, Alaska intends that
the largest share of the payments will be returned to the State through an
intergovernmental transfer.”

Pending Deemed approval estimated for November 2000

South Dakota “A government nursing facility funding pool is created to
increase payments to nursing facilities that are owned by political
subdivisions of the state (publicly owned). . . Each publicly owned nursing
facility, upon receiving a distribution of the funding pool, remits the
amount of that payment, less a transaction fee, to the Department of Social
Services thereby creating an intergovernmental transfer of funds.”

Pending Deemed approval estimated for September 2000

Tennessee “. . .( B) ased upon an executed intergovernmental transfer
agreement and subsequent transfer of funds, qualifying Medicaid level II
nursing facilities shall receive a Medicaid nursing facility level II
disproportionate share payment one time each fiscal year.”

Deemed approved July 2000 Washington “The supplemental payments made
to public hospital

districts are subject to. . .a contractual commitment by each hospital
district to return a minimum of 82% by intergovernmental transfer to the
state treasurer. . .”

Approved September 1999 a By law, if HCFA neither denies nor approves plan
amendments submitted by the states within 90 days, the amendments
automatically become accepted and approved. In some cases, HCFA does not
have grounds to deny the state proposals but will not officially approve
them. As a result, these proposals become “deemed approved”
after 90 days. In some cases, this process extends up to 180 days if
additional information is requested from the state.

Figure 2 shows how the round- trip payment process works in one state we
examined in prior work, illustrating how long the practice has prevailed.
The illustration is based on a financing arrangement between the state of
Michigan and some county nursing homes. We first reported on it in 1994. 4
As illustrated, the state determined that it could pay an additional $277
million to county nursing homes and still stay under the upper payment limit
for all nursing homes. Michigan then made a payment of $277 million, which
included $155 million in federal matching funds, to the homes. On the same
day that the county facilities received the money, they wired $271 million
of the payment back to the state. None of these funds were returned to the
federal government but instead were intended to reduce the state's share of
Medicaid payments.

4 See Medicaid: States Use Illusory Approaches to Shift Program Costs to
Federal Government (GAO/ HEHS- 94- 133, Aug. 1, 1994).)

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 8 GAO/ T- HEHS- 00- 193

Figure 2: Michigan's Excessive Payment Arrangement With County Nursing
Homes, 1993

Several variations to this basic approach exist among state plans. For
example, in one state, county- owned nursing homes obtain the equivalent of
a bank loan to finance both the state and federal shares of the excessive
payment. The county- owned nursing homes transfer the total amount borrowed
to the state, which returns all the funds plus a transaction fee to the
county- owned nursing homes as a Medicaid payment for nursing services. The
nursing homes use the payment to pay off their loans. The net result of this
variation is the same: hundreds of millions of dollars in federal funds are
generated with ultimately no state contribution.

The exact amount of additional federal Medicaid matching dollars generated
from states' use of these practices is unknown, but it is likely

$277 Million Excess Payments

Federal Share = $155 million State Share = $122 million

State County Nursing Homes

$6 Million Retained

$271 Million Returned to State the Same Day It was Received

Upper Payment Limit for All Nursing Homes = $1, 199 million

Normal Payment Using State Rates = $890 million

Excess Available = $309 million

Excess Payment = $277 million

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 9 GAO/ T- HEHS- 00- 193

substantial and increasing. HCFA estimates that of a $3.4 billion increase
in its fiscal year 2000 spending above earlier projections, $1.9 billion was
likely due to the circulation of funds through round- trip arrangements with
local government providers. According to HCFA, as of July 26, 2000, 17
states had approved state plans that would permit the use of this
reimbursement practice, and another 11 states have submitted proposed plan
amendments for approval to do so. The quick and dramatic increase in
Medicaid expenditures that accompanied the adoption of schemes involving DSH
payments in the early 1990s shows the potential of the current financing
arrangement to increase expenditures. In that earlier set of schemes, DSH
payments increased from $1 billion in 1990 to over $17 billion in 1992.

Because HCFA regulations currently allow excessive payments as long as they
do not exceed the upper payment limit, HCFA's position is that it has no
grounds to deny these plans. A review of just a few of the proposals,
approved plan amendments, and various media reports shows the potential for
generating a significant amount of additional Medicaid federal matching
dollars without assurances that the money will be spent on Medicaid services
and beneficiaries.

Iowa's plan, which took effect last year, pays county nursing homes this
year about $95 million and will pay an estimated $125 million in 2001 in
additional federal dollars. 5 These payments will result in average federal
spending of about $969 daily per Medicaid bed in county nursing homes, or a
1,700- percent increase from the current federal spending level of $54 per
bed per day. While Iowa's plan does not specify how these funds will be
spent, a state Medicaid official told us the funds will be returned to the
state to create a trust fund that will be spent on assisted living for the
elderly, which may or may not be related to covered Medicaid services or
beneficiaries.

New Jersey's plan, which lapsed into effect September 1, will generate an
additional federal payment of about $500 million over a 15- month period by
increasing payments to county nursing facilities by $999 million. The
counties initiate the excess payment by transferring the total expected
excess payment amount, both state and federal shares, to the state. The
state immediately sends the money back to the county facilities as a
Medicaid payment. This state payment triggers the federal share of the
payment, which it can then spend at its discretion.

5 This year's excess payment amount is based on a 9- month period. In 2001,
the payment amount will be based on a full 12 months, which is the basis for
our estimate.

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 10 GAO/ T- HEHS- 00- 193

Media reports from some other states have cited elected officials' plans to
use the federal funds for state education programs or to subsidize a state
tax cut.

The fiscal integrity of the Medicaid program is a shared federal/ state
responsibility. As such, states have considerable programmatic flexibility
but also the fiduciary responsibility to manage program finances efficiently
and economically and to make responsible spending decisions. Because states
share in the program costs, they have a strong incentive to contain health
care costs through prudent program decisions.

The current funding arrangements with local government health providers
undermine this incentive and circumvent the federal and state funding
balance that is set by law. These funding arrangements effectively increase
the federal matching rate by increasing federal expenditures, while total
state contributions remain unchanged or even decrease. For example, we
reported in 1994 that the state of Michigan increased its federal matching
rate from 56 percent to 68 percent by reducing state payments by $773
million through several different funding practices. These practices
included the funding arrangement explained in figure 2.

The current excessive payment rates used or proposed by states have the same
potential. For example, under New Jersey's excessive payment plan to county
nursing facilities, an additional $500 million in federal funds will be paid
over a 15- month period. While the state has not indicated how much of this
payment it will ultimately retain, keeping all additional federal funds
would have the effect of increasing the federal share from 50 percent to 62
percent. HCFA is aware of 15 other similar plan amendments involving local
government nursing homes. Together, these 16 state funding arrangements, if
they all take effect, could result in over $2 billion in annual excessive
federal payments.

In the past, efforts to curtail round- trip financing schemes have focused
on restricting the size of the excessive payments. The same approach can be
taken for the current scheme. More specifically, in 1987, in response to
some states' excessive Medicaid payments to state- operated facilities, HCFA
promulgated regulations that established separate upper payment limits for
state- owned facilities in certain provider categories. Expanding this
approach to include all government- owned Medicaid providers would
essentially shrink the upper payment limit loophole and reduce the financial
benefit of current financing arrangements with local government providers.
For example, if an upper payment limit was established for Financing Scheme

Undermines Congressionally Determined Federal Share of Medicaid Expenditures

Restricting the Size of Excessive Payments Can Limit Financing Schemes

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 11 GAO/ T- HEHS- 00- 193

payments to all government providers, the federal share of the excessive
payment amount in Iowa could be reduced from over $95 million to less than
$3 million. This decline would occur because the excess amount available for
payment would be reduced from $151 million for all nursing homes to about $4
million for nursing homes operated by local governments.

Some action on this front is under way. In response to the increasing
magnitude of the current payment schemes, HCFA has drafted regulations that,
if put into effect, would curtail excessive payments to local government
providers in the same manner as for state- owned facilities. HCFA officials
acknowledged that they had been aware that some states have been using the
current scheme for a number of years. They said they had become more
motivated to take action because of the increasing number of states
submitting plans to use the scheme and the drain of federal dollars as a
result. HCFA's draft regulations are awaiting approval from the Office of
Management and Budget (OMB). If OMB approves them, the regulations must
undergo a public comment period before they can take effect. HCFA officials
were unable to definitively estimate when proposed regulations would be
issued for public comment.

The financing scheme that states are increasingly using is basically no
different from the schemes that have been identified and subsequently
prohibited in the past. The current schemes take advantage of a technicality
that allows states to, in effect, supplant state Medicaid dollars with
federal Medicaid dollars. In so doing, states violate the basic integrity of
Medicaid as a joint federal/ state program.

HCFA's proposed regulatory change, which would impose an upper payment limit
on providers owned by local government entities, would extend the existing
limits on payments to state- owned facilities. While such a change would
probably not discourage other attempts to find ways to increase federal
payments, it would at least curtail the scheme now in widest use. Because of
the potential for excessive payments to persist in other forms, the Congress
should consider implementing a recommendation that remains outstanding from
our 1994 work to enact legislation to prohibit Medicaid payments that exceed
costs to any government- owned facility. Finally, continuing attempts to
exploit program loopholes also point to the need to be ever vigilant to
identify the next innovative arrangement before it reaches such financial
magnitude that it becomes both a staple of state financing and a potential
threat to the integrity of the funding partnership. Conclusions and

Previous Recommendation

Medicaid: State Financing Schemes Again Drive Up Federal Payments

Page 12 GAO/ T- HEHS- 00- 193

Mr. Chairman, this concludes my prepared statement. I will be happy to
answer any questions that you or Members of the Committee may have.

For future contacts regarding this testimony, please call Kathryn G. Allen
at (202) 512- 7118. Frank Pasquier, Tim Bushfield, Robert Crystal, Evan
Stoll, and Stan Stenersen also made key contributions to this testimony .
GAO Contact and

Staff Acknowledgments

Page 13 GAO/ T- HEHS- 00- 193

Medicaid in Schools: Poor Oversight and Improper Payments Compromise
Potential Benefit( GAO /T- HEHS/ OSI- 00- 87, Apr. 5, 2000).

Medicaid in Schools: Improper Payments Demand Improvement in HCFA Oversight(
GAO/ HEHS/ OSI- 00- 69, Apr. 5, 2000). Medicaid: Disproportionate Share
Payments to State Psychiatric Hospitals (GAO/ HEHS- 98- 52, Jan. 23, 1998).

State Medicaid Financing Practices( GAO/ HEHS- 96- 76R, Jan. 23, 1996).
Michigan Financing Arrangements( GAO/ HEHS- 95- 146R, May 5, 1995).
Medicaid: States Use Illusory Approaches to Shift Program Costs to Federal
Government( GAO/ HEHS- 94- 133, Aug. 1, 1994). Related GAO Products

Related GAO Products Page 14 GAO/ T- HEHS- 00- 193

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