72nd OREGON LEGISLATIVE ASSEMBLY--2003 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 3126
Senate Bill 806
Sponsored by Senator BROWN (at the request of Oregon Mental
Health Counselors Association)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Requires individual or group health insurance policy to pay for
services rendered by professional counselors or marriage and
family therapists acting within their scope of practice if policy
provides payment or reimbursement for services by other
professionals providing same or similar services. Adds facilities
operated by professional counselors or marriage and family
therapists to definition of outpatient service for purposes of
statutes governing certain treatment programs and facilities.
A BILL FOR AN ACT
Relating to licensees of Oregon Board of Licensed Professional
Counselors and Therapists; creating new provisions; and
amending ORS 430.010, 743.556, 750.055 and 750.333.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2003 Act is added to and made
a part of ORS chapter 743. + }
SECTION 2. { + (1) Whenever any individual or group health
insurance policy provides for payment or reimbursement for
services performed by a physician, psychologist, clinical social
worker or nurse practitioner, the policy also shall pay or
reimburse the insured for services provided by a professional
counselor or marriage and family therapist licensed under ORS
675.715 to 675.835 when the counselor or therapist is acting
within the counselor's or therapist's lawful scope of practice.
(2) The insured under the policy shall be entitled to have
payment or reimbursement made to the insured or on behalf of the
insured for the services performed. The payment or reimbursement
shall be in accordance with the benefits provided in the policy
and shall be computed in the same manner whether performed by a
physician, psychologist, clinical social worker, nurse
practitioner, professional counselor or marriage and family
therapist, according to the customary and usual fee of
professional counselors and marriage and family therapists in the
area served. + }
SECTION 3. ORS 430.010 is amended to read:
430.010. As used in ORS 430.010 to 430.050, 430.140 to 430.170,
430.265, 430.270 and 430.610 to 430.695:
(1) 'Department' means the Department of Human Services.
(2) 'Health facility' means a facility licensed as required by
ORS 441.015 or a facility accredited by the Joint Commission on
Accreditation of Hospitals, either of which provides full-day or
part-day acute treatment for alcoholism, drug addiction or mental
or emotional disturbance, and is licensed to admit persons
requiring 24-hour nursing care.
(3) 'Residential facility' or 'day or partial hospitalization
program' means a program or facility providing an organized
full-day or part-day program of treatment. Such a program or
facility shall be licensed, approved, established, maintained,
contracted with or operated by the department under:
(a) ORS 430.265 to 430.380 and 430.610 to 430.880 for
alcoholism;
(b) ORS 430.265 to 430.380, 430.405 to 430.565 and 430.610 to
430.880 for drug addiction; or
(c) ORS 430.610 to 430.880 for mental or emotional disturbance.
(4) 'Outpatient service' means:
(a) A program or service providing treatment by appointment and
by medical or osteopathic physicians licensed by the Board of
Medical Examiners for the State of Oregon under ORS 677.010 to
677.450; psychologists licensed by the State Board of
Psychologist Examiners under ORS 675.010 to 675.150; nurse
practitioners registered by the Oregon State Board of Nursing
under ORS 678.010 to 678.410; { - or - } clinical social
workers licensed by the State Board of Clinical Social Workers
under ORS 675.510 to 675.600; { + or professional counselors or
marriage and family therapists licensed by the Oregon Board of
Licensed Professional Counselors and Therapists under ORS 675.715
to 675.835; + } or
(b) A program or service providing treatment by appointment
that is licensed, approved, established, maintained, contracted
with or operated by the department under:
(A) ORS 430.265 to 430.380 and 430.610 to 430.880 for
alcoholism;
(B) ORS 430.265 to 430.380, 430.405 to 430.565 and 430.610 to
430.880 for drug addiction; or
(C) ORS 430.610 to 430.880 for mental or emotional disturbance.
SECTION 4. ORS 743.556 is amended to read:
743.556. A group health insurance policy providing coverage for
hospital or medical expenses shall provide coverage for expenses
arising from treatment for chemical dependency including
alcoholism and for mental or nervous conditions. The following
conditions apply to the requirement for such coverage:
(1) The coverage may be made subject to provisions of the
policy that apply to other benefits under the policy, including
but not limited to provisions relating to deductibles and
coinsurance. Deductibles and coinsurance for treatment in health
care facilities or residential programs or facilities shall be no
greater than those under the policy for expenses of
hospitalization in the treatment of illness. Deductibles and
coinsurance for outpatient treatment shall be no greater than
those under the policy for expenses of outpatient treatment of
illness.
(2) Treatment provided in health care facilities, residential
programs or facilities, day or partial hospitalization programs
or outpatient services shall be considered eligible for
reimbursement if it is provided by:
(a) Programs or providers described in ORS 430.010 or approved
by the Department of Human Services under subsection (3) of this
section.
(b) Programs accredited for the particular level of care for
which reimbursement is being requested by the Joint Commission on
Accreditation of Hospitals or the Commission on Accreditation of
Rehabilitation Facilities.
(c) Inpatient programs provided by health care facilities as
defined in ORS 442.015. Residential, outpatient, or day or
partial hospitalization programs offered by or through a health
care facility must meet the requirements of either paragraph (a)
or (b) of this subsection in order to be eligible for
reimbursement.
(d) Residential programs or facilities described in subsection
(3) of this section if the patient is staying overnight at the
facility and is involved in a structured program at least eight
hours per day, five days per week.
(e) Programs in which staff are directly supervised or in which
individual client treatment plans are approved by a person
described in ORS 430.010 (4)(a) and which meet the standards
established under subsection (3) of this section.
(3) Subject to ORS 430.065, the Department of Human Services
shall adopt rules relating to the approval, for insurance
reimbursement purposes, of noninpatient chemical dependency
programs that are not related to the department or any county
mental health program. The department shall adopt rules relating
to the approval, for insurance reimbursement purposes, of
noninpatient programs for mental or nervous conditions that are
not related to the department or any county mental health
program.
(4) A program that provides services for persons with both a
chemical dependency diagnosis and a mental or nervous condition
shall be considered to be a distinct and specialized type of
program for both chemical dependency and mental or nervous
conditions. The Department of Human Services shall develop
specific standards related to such programs for program approval
purposes and shall adopt rules relating to the approval, for
insurance reimbursement purposes, of such noninpatient programs
that are not related to the department and any county mental
health program.
(5) As used in this section:
(a) 'Chemical dependency' means the addictive relationship with
any drug or alcohol characterized by either a physical or
psychological relationship, or both, that interferes with the
individual's social, psychological or physical adjustment to
common problems on a recurring basis. For purposes of this
section, chemical dependency does not include addiction to, or
dependency on, tobacco, tobacco products or foods.
(b) 'Child or adolescent' means a person who is 17 years of age
or younger.
(c) 'Facility' means a corporate or governmental entity or
other provider of services for the treatment of chemical
dependency or for the treatment of mental or nervous conditions.
(d) 'Program' means a particular type or level of service that
is organizationally distinct within a facility.
(6) Notwithstanding the limits for particular types of services
specified in this section, a policy shall not limit the total of
payments for all treatment of any kind under this section for
chemical dependency, together with payments for all treatment of
any kind for mental or nervous conditions, to less than $13,125
for adults and $15,625 for children or adolescents. For persons
requesting payments for treatment of any kind for chemical
dependency, but not requesting payments for treatment of any kind
of mental or nervous condition, a policy shall not limit the
total of payments for all treatment to less than $8,125 for
adults and $13,125 for children and adolescents.
(7) The limits for mental or nervous conditions specified in
this section shall apply to persons with diagnoses of both
chemical dependency and mental or nervous conditions, who are
being treated for both types of diagnosis, as well as persons
with only a diagnosis of a mental or nervous condition.
(8) The higher benefit levels in this section for children or
adolescents are in recognition of the longer period of treatment
and the greater levels of staffing that may be required for
children or adolescents and are intended to permit more services
to meet the needs of children and adolescents.
(9) Payments shall not be made under this section for
educational programs to which drivers are referred by the
judicial system, nor for volunteer mutual support groups.
(10) Except as permitted by subsections (1), (6) and (12) of
this section, the policy shall not limit payments for inpatient
treatment in hospitals and other health care facilities
thereunder:
(a) For chemical dependency to an amount less than $5,625 for
adults and $5,000 for children or adolescents; and
(b) For mental or nervous conditions to an amount less than
$5,000 for adults and $7,500 for children or adolescents.
(11) Except as permitted by subsections (1), (6) and (12) of
this section, the policy shall not limit payments for treatment
in residential programs or facilities or day or partial
hospitalization programs:
(a) For chemical dependency to an amount less than $4,375 for
adults and $3,750 for children or adolescents; and
(b) For mental or nervous conditions to an amount less than
$1,250 for adults and $3,125 for children or adolescents.
(12) Notwithstanding the minimum benefits for particular types
of services specified in subsections (10) and (11) of this
section, and except as permitted by subsection (1) of this
section, the policy shall not limit total payments for inpatient,
residential and day or partial hospitalization program care or
treatment:
(a) For chemical dependency to an amount less than $10,625 for
children or adolescents; and
(b) For mental or nervous conditions to an amount less than
$10,625 for adults and $13,125 for children or adolescents.
(13) Except as permitted by subsections (1) and (6) of this
section, in the case of benefits for outpatient services, the
policy shall not limit payments:
(a) For chemical dependency to an amount less than $1,875 for
adults and $2,500 for children or adolescents; and
(b) For mental or nervous conditions to an amount less than
$2,500.
(14) If so specified in the policy, outpatient coverage may
include follow-up in-home service associated with any health care
facility, residential, day or partial hospitalization or
outpatient services. The policy may limit coverage for in-home
service to persons who have completed their initial health care
facility, residential, day or partial hospitalization or
outpatient treatment and did not terminate that initial treatment
against advice. The policy may also limit coverage for in-home
service by defining the circumstances of need under which payment
will or will not be made.
(15) Under ORS 430.021 and 430.315, the Legislative Assembly
has found that health care cost containment is necessary and
intends to encourage insurance policies designed to achieve cost
containment by assuring that reimbursement is limited to
appropriate utilization under criteria incorporated into such
policies, either directly or by reference.
(16) A group health insurance policy may provide, with respect
to treatment for chemical dependency or mental or nervous
conditions, that any one or more of the following cost
containment methods shall be in effect and the method or methods
used by an insurer in one part of the state may be different from
the method or methods used by that insurer in another part of the
state:
(a) Proportion of coinsurance required for treatment in
residential programs or facilities, day or partial
hospitalization programs or outpatient services less than the
proportion of coinsurance required for treatment in health care
facilities.
(b) Subject to the patient or client confidentiality provisions
of ORS 40.235 relating to physicians, ORS 40.240 relating to
nurse practitioners, ORS 40.230 relating to
psychologists { + , + } { - and - } ORS 40.250 and 675.580
relating to licensed clinical social workers { + and ORS 40.262
relating to licensed professional counselors and licensed
marriage and family therapists + }, review for level of treatment
of admissions and continued stays for treatment in health care
facilities, residential programs or facilities, day or partial
hospitalization programs and outpatient services by either
insurer staff or personnel under contract to the insurer, or by a
utilization review contractor, who shall have the authority to
certify for or deny level of payment:
(A) This review shall be made according to criteria made
available to providers in advance upon request.
(B) To facilitate implementation of utilization review programs
by insurers, the Director of Human Services shall draft an
advisory or model set of criteria for appropriate utilization of
inpatient, residential, day or partial hospitalization, and
outpatient facilities, programs and services by adults, children
and adolescents, and persons with both a chemical dependency
diagnosis and a mental or nervous condition. These criteria shall
be consistent with this section and shall not be binding on any
insurer or other party. However, at the time of contract
negotiation or amendment, with the agreement of the parties to
the contract, any insurer may adopt the criteria or similar
criteria with or without modification. The director shall revise
these criteria at least every two years. In developing and
revising these criteria, the director shall organize a technical
advisory panel including representatives of the Department of
Consumer and Business Services, the Department of Human Services,
the insurance industry, the business community and providers of
each level of care. The director shall place substantial weight
on the advice of this panel.
(C) Review shall be performed by or under the direction of a
medical or osteopathic physician licensed by the Board of Medical
Examiners for the State of Oregon; a psychologist licensed by the
State Board of Psychologist Examiners; a nurse practitioner
registered by the Oregon State Board of Nursing; { - or - } a
clinical social worker licensed by the State Board of Clinical
Social Workers { + ; or a professional counselor or marriage and
family therapist licensed by the Oregon Board of Licensed
Professional Counselors and Therapists + }, with physician
consultation readily available. The reviewer shall have expertise
in the evaluation of mental or nervous condition services or
chemical dependency services.
(D) Review may involve prior approval, concurrent review of the
continuation of treatment, post-treatment review or any
combination of these. However, if prior approval is required,
provision shall be made to allow for payment of urgent or
emergency admissions, subject to subsequent review. If prior
approval is not required, insurers shall permit treatment
providers, policyholders or persons acting on their behalf to
make advance inquiries regarding the appropriateness of a
particular admission to a treatment program. Insurers shall
provide a timely response to such inquiries. Approval of a
particular admission does not represent a guarantee of future
payment.
(E) An appeals process shall be provided.
(F) An insurer may choose to review all providers on a sampling
or audit basis only; or to review on a less frequent basis those
providers who consistently supply full documentation, consistent
with confidentiality statutes on each case in a timely fashion to
the insurer.
(17) For purposes of subsection (16)(b) of this section, a
utilization review contractor is a professional review
organization or similar entity which, under contract with an
insurance carrier, performs certification of reimbursability of
level of treatment for admissions and maintained stays in
treatment programs, facilities or services.
(18) For purposes of subsection (16)(b) of this section, when
implemented through an insurance contract, reimbursability of
inpatient treatment requires demonstration that medical
circumstances require 24-hour nursing care, or physician or nurse
assessment, treatment or supervision that cannot be readily made
available on an outpatient basis, or in:
(a) The current living situation;
(b) An alternative, nontreatment living situation;
(c) An alternative residential program or facility; or
(d) A day or partial hospitalization program.
(19) For purposes of subsection (16)(b) of this section, when
implemented through an insurance contract, reimbursability of
treatment at the residential, day or partial hospitalization
level of treatment shall require demonstration that outpatient
services, if appropriate and less costly than residential, day or
partial hospitalization services:
(a) Are not presently appropriate and available;
(b) Cannot be readily and timely made available; and
(c) Cannot meet documented needs for nonmedical supervision,
protection, assistance and treatment, either in the current
living situation or in a readily and timely available
alternative, nontreatment living situation, taking into account
the extent of both the available positive support and existing
negative influences in the occupational, social and living
situations; risks to self or others; and readiness to participate
consistently in treatment.
(20) For purposes of subsection (16)(b) of this section,
reimbursability of treatment at the level for outpatient
facility, service or program shall require demonstration that
treatment is justified, considering the individual's history, and
the current medical, occupational, social { + , therapeutic + }
and psychological situation, and the overall prognosis.
(21) Discrete medical or neurologic diagnostic or treatment
services including any professional component of that service,
costing in excess of $300, occurring concurrently with but not
directly related to treatment of mental or nervous conditions
shall not be charged against the inpatient benefit level.
(22) The benefits described in this section shall renew in full
either on the first day of the 25th month of coverage following
the first use of services for the treatment of chemical
dependency or mental or nervous conditions, or both, or on the
first day following two consecutive contract years.
(23) Health maintenance organizations, as defined in ORS
750.005 (3), shall be subject to the following conditions and
requirements in their provision of benefits for chemical
dependency or mental or nervous conditions to enrollees:
(a) Notwithstanding the provisions of subsection (1) of this
section, health maintenance organizations may establish
reasonable provisions for enrollee cost-sharing, so long as the
amount the enrollee is required to pay does not exceed the amount
of coinsurance and deductible customarily required by other
insurance policies which are subject to the provisions of this
chapter for that type and level of service.
(b) Nothing in this section prevents health maintenance
organizations from establishing durational limits which are
actuarially equivalent to the benefits required by this section.
(c) Health maintenance organizations may limit the receipt of
covered services by enrollees to services provided by or upon
referral by providers associated with the health maintenance
organization.
(d) The Department of Human Services shall make rules
establishing objective and quantifiable criteria for determining
when a health maintenance organization meets the conditions and
requirements of this subsection.
(24) Nothing in this section shall prevent an insurer or health
care service contractor other than a health maintenance
organization, except as provided in subsection (23) of this
section, from contracting with providers of health care services
to furnish services to policyholders or certificate holders
according to ORS 743.531 or 750.005, subject to the following
conditions:
(a) An insurer or health care service contractor may establish
limits for contracted services which are actuarially equivalent
to the benefits required by this section, so long as the same
range of treatment settings is made available.
(b) An insurer or health care service contractor, other than a
health maintenance organization, may negotiate with contracting
providers as to the cost of actuarially equivalent benefits, and
such actuarially equivalent benefits for services of contracting
providers shall be deemed to equal the minimum benefit levels
specified in this section.
(c) An insurer or health care service contractor is not
required to contract with all eligible providers, and payment for
covered services of contracting providers may be in alternative
methods or amounts rather than as specified in this section.
(d) Insurers and health care service contractors other than
health maintenance organizations shall pay benefits toward the
covered charges of noncontracting providers of services for the
treatment of chemical dependency or mental or nervous conditions
at the same level of deductible or coinsurance as would apply to
covered charges of noncontracting providers of other health
services under the same group policy or contract. The insured
shall have the right to use the services of a noncontracting
provider of services for the treatment of chemical dependency or
mental or nervous conditions. Policies described in this
subsection shall be subject to the provisions of subsection (1)
of this section, whether or not the services for chemical
dependency or mental or nervous conditions are provided by
contracting or noncontracting providers.
(e) The department shall make rules establishing objective and
quantifiable criteria for determining that a contract meets the
conditions and requirements of this subsection and that
actuarially equivalent services of contracting providers equal or
exceed services obtainable with the minimum benefits specified in
this section.
(25) The intent of the Legislative Assembly in adopting this
section is to reserve benefits for different types of care to
encourage cost effective care and to assure continuing access to
levels of care most appropriate for the insured's condition and
progress.
(26) The director, after notice and hearing, may adopt
reasonable rules not inconsistent with this section that are
considered necessary for the proper administration of these
provisions.
SECTION 5. ORS 750.055 is amended to read:
750.055. (1) The following provisions of the Insurance Code
shall apply to health care service contractors to the extent so
applicable and not inconsistent with the express provisions of
ORS 750.005 to 750.095:
(a) ORS 705.137, 705.139, 731.004 to 731.150, 731.162, 731.216
to 731.362, 731.382, 731.385, 731.386, 731.390, 731.398 to
731.430, 731.428, 731.450, 731.454, 731.488, 731.504, 731.508,
731.509, 731.510, 731.511, 731.512, 731.574 to 731.620, 731.592,
731.594, 731.640 to 731.652, 731.730, 731.731, 731.735, 731.737,
731.750, 731.752, 731.804 and 731.844 to 731.992.
(b) ORS 732.215, 732.220, 732.230, 732.245, 732.250, 732.320,
732.325 and 732.517 to 732.592, not including ORS 732.549 and
732.574 to 732.592.
(c)(A) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.620, 733.635 to 733.680 and 733.695 to
733.780 apply to not-for-profit health care service contractors.
(B) ORS chapter 733, not including ORS 733.630, applies to
for-profit health care service contractors.
(d) ORS chapter 734.
(e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065, 742.150
to 742.162, 742.400, 742.520 to 742.540, 743.010, 743.013,
743.018 to 743.030, 743.050, 743.100 to 743.109, 743.402,
743.412, 743.472, 743.492, 743.495, 743.498, 743.522, 743.523,
743.524, 743.526, 743.527, 743.528, 743.529, 743.549 to 743.555,
743.556, 743.560, 743.600 to 743.610, 743.650 to 743.656,
743.693, 743.694, 743.697, 743.699, 743.701, 743.706 to 743.712,
743.721, 743.722, 743.726, 743.727, 743.728, 743.729, 743.804,
743.807, 743.808, 743.809, 743.814 to 743.839, 743.842, 743.845,
743.847, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861,
743.862, 743.863, 743.864, 743.866 and 743.868 { + and section 2
of this 2003 Act + }.
(f) The provisions of ORS chapter 744 relating to the
regulation of agents.
(g) ORS 746.005 to 746.140, 746.160, 746.180, 746.220 to
746.370 and 746.600 to 746.690.
(h) ORS 743.714, except in the case of group practice health
maintenance organizations that are federally qualified pursuant
to Title XIII of the Public Health Service Act unless the patient
is referred by a physician associated with a group practice
health maintenance organization.
(i) ORS 735.600 to 735.650.
(j) ORS 743.680 to 743.689.
(k) ORS 744.700 to 744.740.
(L) ORS 743.730 to 743.773.
(m) ORS 731.485, except in the case of a group practice health
maintenance organization that is federally qualified pursuant to
Title XIII of the Public Health Service Act and that wholly owns
and operates an in-house drug outlet.
(2) For the purposes of this section only, health care service
contractors shall be deemed insurers.
(3) Any for-profit health care service contractor organized
under the laws of any other state which is not governed by the
insurance laws of such state, will be subject to all requirements
of ORS chapter 732.
(4) The Director of the Department of Consumer and Business
Services may, after notice and hearing, adopt reasonable rules
not inconsistent with this section and ORS 750.003, 750.005,
750.025 and 750.045 that are deemed necessary for the proper
administration of these provisions.
SECTION 6. ORS 750.333 is amended to read:
750.333. (1) The following provisions of the Insurance Code
apply to trusts carrying out a multiple employer welfare
arrangement:
(a) ORS 731.004 to 731.150, 731.162, 731.216 to 731.268,
731.296 to 731.316, 731.324, 731.328, 731.378, 731.386, 731.390,
731.398, 731.406, 731.410, 731.414, 731.418 to 731.434, 731.454,
731.484, 731.486, 731.488, 731.512, 731.574 to 731.620, 731.640
to 731.652, 731.804 to 731.992.
(b) ORS 733.010 to 733.050, 733.140 to 733.170, 733.210,
733.510 to 733.680 and 733.695 to 733.780.
(c) ORS chapter 734.
(d) ORS 742.001 to 742.009, 742.013, 742.061 and 742.400.
(e) ORS 743.028, 743.053, 743.524, 743.526, 743.527, 743.528,
743.529, 743.530, 743.560, 743.562, 743.600, 743.601, 743.602,
743.610, 743.693, 743.694, 743.699, 743.727, 743.728, 743.730 to
743.773 (except 743.760 to 743.773), 743.801, 743.804, 743.807,
743.808, 743.809, 743.814 to 743.839, 743.842, 743.845, 743.847,
743.854, 743.856, 743.857, 743.858, 743.859, 743.861, 743.862,
743.863 and 743.864.
(f) ORS 743.556, 743.701, 743.703, 743.706, 743.707, 743.709,
743.710, 743.712, 743.713, 743.714, 743.717, 743.718, 743.719,
743.721, 743.722, 743.725 and 743.726 { + and section 2 of this
2003 Act + }. Multiple employer welfare arrangements to which ORS
743.730 to 743.773 apply are subject to the sections referred to
in this paragraph only as provided in ORS 743.730 to 743.773.
(g) Provisions of ORS chapter 744 relating to the regulation of
agents and insurance consultants, and ORS 744.700 to 744.740.
(h) ORS 746.005 to 746.140, 746.160, 746.180 and 746.220 to
746.370.
(i) ORS 731.592 and 731.594.
(2) For the purposes of this section:
(a) A trust carrying out a multiple employer welfare
arrangement shall be considered an insurer.
(b) References to certificates of authority shall be considered
references to certificates of multiple employer welfare
arrangement.
(c) Contributions shall be considered premiums.
(3) The provision of health benefits under ORS 750.301 to
750.341 shall be considered to be the transaction of health
insurance.
SECTION 7. { + Section 2 of this 2003 Act and the amendments
to ORS 430.010, 743.556, 750.055 and 750.333 by sections 3 to 6
of this 2003 Act apply to health insurance policies and health
care service contracts issued or reissued on or after the
effective date of this 2003 Act. + }
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