"It's a Mess"  

Cover Story — April 2014

By Amy Lynn Sorrel
Associate Editor

Tex Med. 2014;110(4):16-25.

Several months into the launch of the Affordable Care Act health insurance marketplace, Texas physicians still find themselves mired in a land of confusion.

For those patients who avoided the log jam in the troubled enrollment process, their new insurance coverage began Jan. 1. One day later, Abilene otolaryngologist Austin King, MD, saw one of those newly insured patients. An oral surgeon referred the man after spotting a tumor during an examination for a toothache. 

The Texas Medical Association president-elect knew the patient needed immediate evaluation. But neither the doctor nor the patient readily knew what kind of coverage he had. All they had to go on was the member ID number the patient wrote down on a piece of paper after he signed up for insurance. Dr. King's staff called the insurer and, after half an hour on hold, gave up because they were too busy seeing other patients. 

They rescheduled the patient for the next day when they had more time to spend investigating his situation. In the meantime, knowing the man needed a computed tomography scan, Dr. King initiated the preauthorization process, but the company could not find the patient in its system either. 

When staff called back the next day, it took more than an hour to get through. Even then the insurance company could not immediately find the patient in its system. Another 15 minutes later, plan representatives confirmed the patient bought one of its bronze exchange plans but couldn't tell Dr. King the patient's deductible. 

He arranged for a hospital to take the patient on an emergent basis and convinced an oncologist to accept his referral even though the specialist at the time said he wasn't participating in any exchange plans. Like many physicians, the oncologist chose to opt out over concerns patients can't afford to pay the premiums and deductibles, which puts physicians at risk of not getting paid, especially for costly specialty care. Dr. King "had no choice" because his insurance contract automatically included him in one of its exchange plans.

He says the widespread problems with the rollout of the exchange — from government enrollment delays and errors to questionable health plan policies and networks — don't merely disrupt physicians' office operations. They affect patients' access to care.

"Once patients walk in the door and we accept them, we are responsible for their medical care, regardless of whether they can pay," Dr. King said. But when it comes to the marketplace, doctors have a hard time fulfilling that duty because "it's a mess. We can't tell by looking at a card whether they are on the exchange, and if they are, how big their deductible is. So for everybody who walks in the door, we have to call to find out, but we can't even get through. And a lot of these patients have never had insurance before, and they don't understand."

While patients expect to be cared for, marketplace rules expect physicians to bear the financial risk, he adds. 

Dr. King eventually found out the patient's deductible was so high, he likely could not afford to pay it, which means he also couldn't afford to pay for care out of pocket. 

"We probably won't get paid for this case. But this patient was better off having no insurance at all and seeking charity care," he said. 

Moreover, if patients with subsidized marketplace coverage don't pay their premiums for 90 days, physicians run the risk of health plans' clawing back any payments made during that timeframe. 

Dr. King expects more referrals like this one as newly insured patients who went for years without care start visiting doctors' offices. But if the confusion and burdensome rules persist, "physicians are the ones who will be left hanging, and that is a significant concern."

Land of Confusion

Even as the federal government attempts to smooth out the rocky launch of the marketplace that began Oct. 1, physician practices encounter new twists and turns they must navigate: The botched enrollment process on the faulty federal website and extended premium payment deadlines make it extremely difficult for practices to verify patient eligibility. Unreliable health plan directories and spotty participation fuel confusion about network access. Meanwhile, newly insured patients enter physicians' offices with vague health plan identification that equates to questionable coverage. 

Further complicating matters is yet another federal policy — a so-called "smooth transition" rule — that encourages insurers to treat physicians as in-network even if plans don't update their directories to reflect the fact that physicians either opted out or plans never included them in the first place. 

And physicians still have to grapple with a rule that puts their payments at risk if patients with subsidized marketplace coverage fail to make their premium payments for 90 days. (See "90-Day Notice."). The latest federal figures show that 79 percent of the more than 200,000 Texans enrolled in marketplace plans were eligible for financial assistance. (See "Marketplace by the Numbers.")

TMA continues to advocate for legislative and regulatory relief from rules like these that attempt to operate and fund the exchange at physicians' expense. 

"This is a federal problem that requires a federal solution, so we have made our perspective known to federal agencies," TMA Vice President for Medical Economics Lee Spangler said. 

He adds TMA is working with Texas exchange plans to help streamline eligibility verification and notification processes so physicians can timely and appropriately care for this new population of patients. 

Meanwhile, TMA officials urge physicians to remain vigilant in their business practices surrounding the marketplace. Issues with health plan networks persist as physicians continue to report a lack of communication by insurers about whether their contracts automatically include doctors in marketplace products. (See "Untested Waters," December 2013 Texas Medicine, pages 37-43, and "Marketplace Q&A.") As TMA continues to field physicians' inquiries about how to opt out of these plans, concerns mount about the adequacy of exchange plan networks and access to care. 

For their part, Centers for Medicare & Medicaid Services (CMS) officials say they are working daily to ensure the marketplace runs smoothly. 

Between Oct. 1, 2013, and Feb. 1, 2014, 3.3 million people nationally enrolled in and selected a marketplace plan, although the figures do not specify whether those enrollees paid their premiums. Texans account for about 6 percent of that group, with just 207,546 enrollees out of the Lone Star State's roughly 6 million uninsured population.

At the TMA 2014 Winter Conference in February, CMS Consortium Administrator James Randolph Farris, MD, who formerly oversaw Texas, acknowledged the "difficulties" in the initial rollout. But he said the agency ramped up outreach and education efforts and expected a "big jump" in enrollments in Texas in the coming months. 

Texas Health and Human Services Executive Commissioner Kyle Janek, MD, also expects Medicaid enrollments to spike. That is, once his agency overcomes what he called the "day-to-day headaches" caused by the federal government's poorly tested system for transferring files to the states on Medicaid-eligible patients who enroll through the exchange.

Meanwhile, Texas physicians are not alone in the marketplace confusion marked by severe technical issues, moving deadlines, and ongoing regulatory changes. More than 80 percent of physicians say they don't have enough information on ACA to serve as a reliable source to their patients or understand the impact on their practice and comply with its requirements, according to a poll of 1,265 physician across the country by QuantiaMD, a physician social media outlet. 

TMA is standing in that gap by deploying various educational campaigns to help physicians and patients understand their rights and obligations in the confusing marketplace environment. Go online to find TMA's detailed "ACA Exchange Plans: Questions and Answers for Physicians" and its "Hey, Doc" campaign for patients. 

Despite the added burdens, physicians say they are doing their best to muddle through and ensure these newly insured patients get the best care.

TMA Opposes CMS Rule

In the latest twist, the federal government in December introduced an interim rule to smooth widely reported problems with incorrect health plan network listings and concerns about patients' inability to keep their current doctors in the smaller marketplace networks. 

Federal officials acknowledge in the rule that patients shopping in the exchange could be misled by "evolving provider networks [that] may result in some directories containing outdated information." They also clarify that under existing marketplace rules, health plans "must make current provider directories available to the exchange for publication online" and ensure the directories "contain the most current listings of in-network providers so that consumers are relying upon accurate information to make enrollment decisions." 

To avoid disruptions in care, the same interim rule "strongly encourages" health plans to treat any out-of-network physician as in-network if the plan incorrectly lists that physician in its directory.

"In other words," states an opposition letter TMA filed, "a physician's out-of-network status may change without the physician's knowledge or consent, based solely on a [plan's] failure to maintain an accurate provider directory." Effectively, the policy would require physicians to abide by terms of a contract they haven't agreed to and actually may have rejected or terminated. But it provides doctors with no recourse to dispute incorrect designations and no accountability for health plans that don't do their part to maintain accurate directories, the association wrote. 

TMA shares CMS' concerns over possible disruptions in care. But "only [the marketplace plans] have the access, ability, and obligation to ensure that provider directories are accurate and up-to-date, and [they] must be held accountable for such misrepresentations," not physicians, TMA's letter states. "TMA strongly opposes the financing of [marketplace] coverage on the backs of physicians" and instead recommends that health plans:   

  • Fully pay incorrectly listed physicians and calculate the patient's financial responsibility based on the out-of-network physician's billed charge; and 
  • Allow out-of-network physicians to continue to provide care to patients when discontinuing care could cause harm, and fully pay based on the out-of-network physician's billed charge. Patients would be responsible for no more than they would have paid had the physician been in-network.  

In mid-February, TMA was reviewing newly released federal guidance that, under certain circumstances, would allow patients who had enrolled in a marketplace plan to switch to one that included their preferred physician. 

Austin Regional Clinic (ARC) Founder and Chief Executive Officer Norman Chenven, MD, says plans overall "have done a poor job of listing providers available, and it hasn't been easy for patients or providers." 

The clinic has received a number of calls from confused patients who discover their doctors are not in the plan they chose, he says. Marketplace network directories ARC participates in still list doctors who retired or moved away five years ago. And specialist availability "is very spotty for some of the plans to the point where even health plans can't tell us who's in or who's out," Dr. Chenven said.

Physician participation in the exchange isn't mandatory. While ARC opted in to two marketplace plans, it wasn't until after the launch that the clinic discovered it had automatically been included in a third insurer's marketplace plan. 

"There was no communication whatsoever," Dr. Chenven said. ARC chose to stay in that plan, "but it represents another example of the confusion of this whole transition. And, frankly, health plans' performance could be greatly improved." 

TMA officials recommend physicians check their contracts and call their health plans to confirm inclusion in exchange plans. (See "Untested Waters," December 2013 Texas Medicine, pages 37-43.)

Nacogdoches Area Physicians Association Executive Director Leesa Barnhart questions the adequacy of certain marketplace networks when only seven of its 115 member-IPA physicians participate in the Blue Cross and Blue Shield of Texas (BCBSTX) HMO exchange plan available. Out of a dozen plans participating in the Texas marketplace, the Blues is the only carrier in the Nacogdoches area, and the HMO plan is one of just two marketplace plans offered there. Access TMA's marketplace map online

"There are not enough doctors in Nacogdoches [for this plan] to have a good panel. There are seven doctors in the panel — period. And, frankly, I'm not sure if they all know they are in it," Ms. Barnhart said. Already one physician opted out upon discovering that the low payment rates offered, which barely matched Medicaid rates, would not cover the practice's costs. Others with similar contract offers "decided they weren't going to touch it with a 10-foot pole," she said.

A CMS spokesperson said the agency "is working to strengthen the network adequacy requirements that took effect for this year for the first time under the Affordable Care Act." 

The federal government issued new draft regulations in February that in 2015 require marketplace plans to include in their networks at least 30 percent of available essential community providers that serve predominantly low-income, medically underserved populations, up from 20 percent in 2014. Health plans also must offer contracts in good faith to these and other groups and provide justification if they can't meet the 30-percent threshold. 

At press time, TMA was reviewing the proposal for possible comment. 

"These are important provisions and include requirements that insurers have adequate provider networks for consumers," the CMS spokesperson said. 

For 2015, CMS will collect network data as part of the federal approval process for health plan participation or renewal in the marketplace. For 2014, CMS didn't collect such information and instead relied on state reviews of network adequacy, among other qualifications. CMS says the change will allow the agency to assess whether the plans' networks meet the statutory and regulatory certification requirements and expects improved access for enrollees.

Still, the agency maintains that it has broad oversight authority over marketplace plans and says these and other mechanisms, including requirements that plans publish their provider lists, allow CMS to take appropriate action against insurers, if necessary. CMS didn't directly respond to Texas Medicine inquiries regarding how they hold health plans accountable for keeping those lists current. Texas plans participating in the exchange also must follow state rules such as network adequacy and prompt pay. (See "Ready, Set …?" August 2013 Texas Medicine, pages 49-54, or visit www.texmed.org/EssentialBenefits.) 

BCBSTX Chief Medical Officer Dan McCoy, MD, says the carrier "worked thousands of hours to prepare for the ACA, creating adequate networks that serve all 254 Texas counties." The Blues updates its provider directories at least twice weekly and "frequently reviews its networks across the state and proactively recruits health care providers to ensure adequate coverage and options for our members by specialty and geographical area." BCBSTX is the only statewide marketplace insurer. 

Aetna says it updates its directories six times per week and sent notices to physicians in the fall indicating in-network status for the carrier's marketplace plans. 

Neither BCBSTX nor Aetna directly responded to Texas Medicine inquiries about whether physician opt-outs from exchange plans have since affected network adequacy.

Nor did the Blues say how it would handle CMS' "smooth transition" rule. 

Aetna says it will review patients' circumstances case by case, but in general would respond in one of two ways:  

  • If Aetna can substantiate that its provider information was/is inaccurate at the time the member accessed it, the insurer would cover benefits at an in-network rate. 
  • If Aetna can't substantiate that information or the member made an error, the member would be responsible for the cost of the out-of-network care.  

Cigna declined to comment for this story.

The Texas Department of Insurance didn't respond to Texas Medicine inquiries about health plan conduct since the launch of the marketplace.

A Guessing Game

CMS also says it fixed most of the technical and data glitches that delayed and complicated patients' enrollment in exchange plans through healthcare.gov. The problems prompted the federal government and health plans to push off the original deadlines set for patients to enroll in marketplace plans and pay the necessary premiums to activate their coverage. Health plans acknowledge the issues on their end, too, and say they are working with the federal government to resolve problems like missing files and discrepancies between the marketplace database and health plan eligibility information.

Physicians are bearing the brunt. 

TMA continues to field calls from practices that report wait times of up to two hours when they call health plans to verify patients' eligibility status and coverage in exchange plans, receiving little to no information once they get through. 

Such headaches could be alleviated if health plans did their part to help practices better identify patients with exchange coverage, says Austin internist Tony R. Aventa, MD, a member of TMA's Council on Socioeconomics. 

At the TMA Winter Conference, the council renewed its call for health plans to standardize their marketplace identification and eligibility verification processes. The American Medical Association, in collaboration with the Medical Group Management Association, created an exchange checklist to help practices address exchange plan problems. (See "Marketplace Checklist.")

As far as Dr. Aventa knows, he participates in just one marketplace network. Several patients already visited him with what he says looked like a valid insurance ID card for coverage with that particular carrier. It wasn't until Dr. Aventa tried to get care preauthorized that he discovered the patients were on a marketplace plan that denied his care requests. 

"The patient is left expecting to be cared for, and we're not able to get anything done. So it's very important for physicians to be able to identify these patients," he said. 

It's especially relevant now that the clock is ticking on the 90-day grace period. 

"Physicians are the ones who are going to be on the hook, and we need to be able to identify which patients to be diligent about and educate patients about what the potential consequences are," Dr. Aventa said. "At the end of the day, all we [physicians] want is to be able to provide care. It shouldn't be about us trying to decide if in the future a patient is going to be paying a bill to us or not, or making decisions on whether to see them on a particular day."

TMA's Mr. Spangler also cautions that patients' possession of a health insurance ID card does not necessarily translate to active coverage if they haven't paid their premiums. It also remains unclear whether  health plans' decisions to extend premium payment deadlines for patients seeking January coverage could delay physician payments for services delivered in January and February, the association's Director of Payment Advocacy Genevieve Davis adds.

As practices get a grasp on the different types of new exchange products sold on the exchange, physicians also report difficulties navigating the myriad benefit structures, referral procedures, and other requirements to get patients the care they need.

"It's not one new plan, but dozens, and from our experience, none of them are clear. Health plans themselves have trouble answering questions without understanding the implications" on practices and on patient care, Dr. Chenven said. 

Inaccurate directories, for example, coupled with difficult referral mechanisms, make it difficult to get care preauthorized and to timely treat patients, physicians say. And a majority of the health plans include high deductibles that patients don't understand and can't afford. 

"It's madness," he said, adding that ARC is monitoring the impact of patients who fall into the 90-day grace period.  

Health Plans Respond

Health plans acknowledge the rough start and say they are taking steps to smooth the ride and mitigate physicians' risk. 

"Health reform is a major initiative, and it's always been clear that time would be needed to make all the different pieces come together successfully," Dr. McCoy said. "We're here to best serve our members and are working hard to make sure the enrollment process is as seamless as possible. Our goal is to do everything possible to empower providers with information that will minimize risk."  

The Blues and Aetna were among plans that agreed to give patients more time to pay their January premiums to accommodate the enrollment problems in the healthcare.gov debut. Both declined to release specific enrollment numbers or premiums paid but said they are seeing a steady volume of enrollments and payments coming in and are educating patients about their coverage and payment obligations. 

Dr. McCoy says the Blues received the vast majority of premium payments for Jan. 1 coverage. He clarifies, however, that although BCBSTX extended its payment deadlines, members wouldn't be eligible for services and their claims wouldn't be processed until they paid their first month's premium. 

The influx of marketplace enrollments also means not all new members with coverage beginning Jan. 1 received their ID cards on time, he says. Blues cards will display "BAV" for patients enrolled in the Blue Advantage HMO product it offers in the marketplace, but nothing will differentiate between the PPO plans it sells on and off the exchange. Aetna insurance cards will say "QHP" to indicate patients are in an exchange plan; Humana cards will say "HMOx."

While members await their ID cards, Dr. McCoy says BCBSTX is notifying physicians and other health professionals of temporary patient eligibility verification measures. If patients have their member ID number and group number from another source, such as a welcome letter or phone confirmation, for example, the Blues can verify eligibility and benefits. To verify patient eligibility, physicians can use the following when they call: patient name, subscriber name, patient mailing address, last four digits of the patient's Social Security number, and effective date of coverage. Aetna says it sent similar welcome letters to its members. 

Physicians calling the Blues will see an improvement in call wait times, and doctors can use the carrier's electronic eligibility verification systems, both of which are "continually updated" and "will report information real-time," Dr. McCoy said.

Aetna officials say its eligibility, preauthorization, and referral processes are the same for exchange plans as for other commercial plans. "The networks for exchange plans are typically smaller than our standard networks, so it's important to confirm [that a] provider is in the exchange network before referring," representatives said in a statement. 

To help avoid nonpayment, the Blues and Aetna also encourage physicians to proactively check patients' eligibility and benefits before treatment. 

"Obtaining eligibility and benefits prior to each visit is a good practice to mitigate risk, even if several visits have already been authorized," Dr. McCoy said. 

As for the 90-day grace period, "we recognize that this may require additional actions on the part of providers," he added. The Blues and Aetna say they instituted notification measures to help physician practices cope, along with other educational resources to inform patients of their obligation to pay their premiums. 

Dr. McCoy adds physicians may notify Blues patients that if their coverage terminates at the end of the grace period, they are responsible for payment, up to the billed charges. He cautioned, however, that "our provider contracts require the provision of services to members and prohibit advance payment for such covered services except for member's required cost sharing, if any."

Because of contract requirements like these, TMA officials urge physicians to scrutinize their contract obligations surrounding the marketplace plans. TMA also warns that CMS advises against paying patients' premiums on their behalf. Read more in TMA's exchange plan Q&A for physicians

Bright Spots on the Horizon

Amid the murky marketplace, some bright spots are emerging. 

Dr. Aventa says he received timely payments for some of the exchange patients he treated. And in Nacogdoches, Ms. Barnhart says the Blues PPO network appears to have a "good panel" of doctors. 

For all the complexity, Dr. Chenven adds more patients are coming in with health insurance. 

"Would it be nice if we could do this without these transition difficulties? Sure. And I'm sure in time this will all get fixed. Meanwhile, despite the inconvenience of the transition for both providers and patients, there are a lot more people protected with health care."

CMS says it plans to engage physicians to address any issues. As part of that effort, Dr. Farris told physicians at the TMA Winter Conference the agency wants to hear from physicians about their experiences with marketplace health plans. AMA is helping to collect that information from state and specialty medical societies, as well as medical practices, to take back to CMS in hopes of resolving problems promptly. Email your feedback to ExchangePlans[at]ama-assn[dot]org.  

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email


90-Day Notice

Under the Affordable Care Act, marketplace regulations give patients with subsidized health insurance coverage three months to pay their premiums and allow health plans to deny or later recoup payments from doctors for services provided to patients who are delinquent. The patients must have paid their first month's premium at least to be eligible for that 90-day grace period.

A marketplace patient's failure to make a premium payment triggers the so-called "90-day grace period." Health plans must give the patient 90 days to catch up. Insurers must pay physicians for services provided in the first 30 days of the grace period.

Federal rules, however, allow health plans to pay, hold, deny, or later recoup claims payments for services incurred in the second or third month of that window if patients are delinquent on premium payments. TMA officials say health plans must comply with Texas' prompt pay law for claims submitted at any point in the grace period. 

Federal regulations require exchange plans to notify affected physicians "as soon as is practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider." Notification includes where the enrollee is in the grace period and the names of everyone covered by the policy. The notice must tell doctors the health plan may ultimately deny payment. 

The Centers for Medicare & Medicaid Services (CMS) says federal rules don't specify when or how insurers have to send the notification. TMA officials caution that health plans' practices will vary.

Blue Cross and Blue Shield of Texas (BCBSTX) and Aetna told Texas Medicine they instituted notification measures for physician practices and other educational resources for patients. 

The Blues says its members are eligible for covered services under their plan during the grace period. Services rendered during the first month of the grace period will be the responsibility of BCBSTX, subject to member cost sharing. During the second and third months of the grace period, BCBSTX will pay, rather than hold, claims.

"If the member does not pay the outstanding premium in full within the grace period, BCBSTX will send a request for refund to the provider for claims paid for services rendered in months two and three," officials said. 

The Blues will notify physicians when patients enter the second or third month of the grace period through its electronic and phone eligibility and benefits verification systems. All preauthorization letters will encourage providers to confirm whether the member is in a grace period. Officials say physicians also may notify members that if their health care coverage terminates at the end of the grace period, the member is responsible for payment for the full cost of services rendered, up to billed charges. 

Aetna says it will inform physicians if an exchange member is delinquent, and "any claims submitted for a service date after 30 days' delinquency will result in an EOB [explanation of benefits] to the provider which indicates the claim is being pended because the member …" is delinquent. Patients are responsible for payment if their coverage ends due to lack of premium payment. If patients pay the owed premiums before the end of the 90 days, Aetna says it will pay the claim. Aetna also published a Q&A for physicians and providers online, http://bit.ly/LYe6yz

Humana says during the first 30 days of the grace period, it will process claims “as normal.” During months two and three, it will hold claims and send a letter to physicians notifying them of a patient’s status. Humana will deny claims and terminate coverage for patients who end up delinquent, in which case physicians may collect payment from the patient. 



Marketplace Checklist

The American Medical Association advocates for legislative and regulatory relief from the many "growing pains" with the marketplace implementation that interfere in physicians' ability to run their practices and care for patients, President Ardis Hoven, MD, told members at the TMA 2014 Winter Conference. 

To cope with the problems that could arise with new exchange health plans, physicians can use the checklist created by AMA and the Medical Group Management Association. For more information, visit AMA's Affordable Care Act resource page, www.ama-assn.org/go/aca. 

Consult TMA's "ACA Exchange Plans: Questions and Answers for Physicians" for specifics on the marketplace rules and Texas-specific information on plans and state regulations. And point patients to TMA's "Hey, Doc" campaign for answers to marketplace questions.  

  • Double-check whether your practice's physicians are participating in ACA exchange products by checking your contracts or calling your current health plans. 
  • Determine your practice's ability to accept new patients. 
  • Train staff who speak with callers and patients. 
  • As with other insurance, check patient eligibility, coinsurance, deductibles, and copays for each visit. 
  • Be prepared to discuss out-of-pocket expenses and the cost of care with each patient. 
  • Know the "essential health benefits" in your state. (See "Ready, Set …?" August 2013 Texas Medicine, pages 49-54, or visit www.texmed.org/EssentialBenefits.) 


Marketplace by the Numbers (as of Feb. 1)

3.3 million     Enrollees in the marketplace nationally*
207,546     Texas marketplace enrollees
79%     Texas enrollees eligible for federal subsidies

*HHS figures don't specify whether these enrollees paid their premiums. 

By Age

18-34 27%
35-44 17%
55-64 27%

By Plan

Bronze          21%
Silver†          62%
Gold  11%
Platinum             4%
Catastrophic     1%

†Plan level that triggers access to certain subsidies and cost-sharing discounts.

Source: U.S. Department of Health and Human Services.

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Marketplace Q&A

Confused about whether your current contracts include you in marketplace plans? Unsure about which plans are participating in the exchange and how to identify patients with this coverage? 

TMA answers your marketplace questions in detail. Go online to TMA's "ACA Exchange Plans: Questions and Answers for Physicians."

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April 2014 Texas Medicine Contents
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Last Updated On

September 19, 2019

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