Response to Comments

8_CMS Responses to 60-Day Comments on the Contract Year 2019 PART C - Medi....pdf

Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits (CMS-10237)

Response to Comments

OMB: 0938-0935

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Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits as defined in Part 417 & 422 of 42 C.F. R.
CMS-10237, OMB 0938-0935
CMS Responses to 60-Day Comments on the Contract Year 2019 PART C - Medicare Advantage and 1876 Cost Plan Expansion Application
# Topic
Comment Text
CMS Response
1

HSD

CMS Supply
File

CMS Action (Requirements/ Attachments/Burden
Change)
We would support the removal of HSD submissions from the 2019
CMS appreciates the concern and would like to clarify that this is None. CMS has not revised any requirements,
applications if CMS is able to provide clear and concrete information
simply a procedural change, and an organization’s first review
attachments, or burden estimates as a result of this
regarding the timeline and process flow around what activities are due and would occur after their application is approved, but prior to the start comment.
of the first year in which the plan is offered. This gives new plans
when they are due. However, until there is more predictability around the
CMS disposition of a network adequacy review and exception requests, we and existing plans that are expanding their service area additional
time to secure a compliant network prior to the start of the year.
recommend CMS continue to include network adequacy as part of the
application process. From a timing and resource perspective, conducting the CMS will give careful thought to the compliance approach when an
initial applicant is found to have network deficiencies or when an
network adequacy review as part of the application process works well. If
existing applicant applying for a service area expansion has
the review is conducted later in the year, we have concerns with the
availability of time and plan resources because CMS has released no details deficiencies. CMS is currently discussing these details internally
and will release guidance to the industry as soon as possible.
about how quickly a review would begin under a triggering event.
We have observed discrepancies in the CMS Supply File, CMS online FFS
provider search tools and Quest Analytics software, especially for counties
with rural areas as those have resulted in unexpected disapprovals of
exception requests. The CMS Supply File in HPMS needs to have
information that is complete and consistent across all states. For example, in
the MN file some zip codes are missing. We also strongly urge CMS to add
the county code and/or county name to the file as well as release the file
more frequently throughout the year (last updated 4/27/17). CMS must also
be better at informing plans when a new Supply File is available in HPMS.

Per the Medicare Advantage Network Adequacy Criteria Guidance, None. CMS has not revised any requirements,
“given the dynamic nature of the market, the database may not be a attachments, or burden estimates as a result of this
complete depiction of the provider and facility supply available in comment.
real-time. Additionally, the supply file is limited to CMS data
sources – organizations may have additional data sources that
identify providers/facilities not included in the supply file used as
the basis of CMS’s network adequacy criteria. As a result,
organizations should not rely solely on the supply file when
establishing networks, as additional providers and facilities may be
available. CMS uses the supply file when validating information
submitted on Exception Requests. Therefore, CMS and its
contractor may update the supply file periodically to reflect updated
provider and facility information and to capture information
associated with Exception Request submissions.” This updated
supply file and additional organization-provided information is
used in the acquisition of the Exception Requests. As CMS makes
the procedural change of removing network reviews from the
application process, it will look to improve policies and procedures
surrounding the supply file in order to increase efficiency and data
accuracy.

CMS Supply
File

We seek to understand how CMS is defining hospitals in the supply file as CMS recommends that the commenter submit their specific
having Critical Care Services - ICU services and where we can get the ICU questions to the CMS mailbox, located at: https://dmao.lmi.org.
bed counts. For example, Sanford Sheldon Medical Center hospital in
Spencer, IA is a hospital listed with services for Cardiac Catheterization
Services and Cardiac Surgery Program, but does not list the service for
Critical Care Services - ICU. Meanwhile a small town hospital like, Boone
County Hospital has Critical Care Services - ICU but that location only has
the typical hospital services of Acute Care Hospital, Diagnostic Radiology,
Mammography, Outpatient Infusion/Chemotherapy and Surgical Services.
We do not understand why a hospital that has Cardiac
Catheterization Services and a Cardiac Surgery Program is not listed with
ICU services on the supply file? Additionally, the CMS POS data file does
not have ICU bed count and we've seen that the identification of hospitals
with ICU on that file are not matching up with the supply file either. If plans
are required to provide bed counts for ICUs in the HSD facility tables, we
strongly urge CMS to include a definition for ICU population on the supply
file and provide a way for plans to access that information more readily,
either from the CMS POS or the supply file. We have historically spent a lot
of time on ICU and will continue to spend a lot of time if we have to get ICU
bed counts for hospitals that don't have a separate ICU.

HSD

CMS needs to issue the Exception Request form in Excel or Word format
that will allow plans to merge data and information already written,
organized and validated into the form. The current Exception Request PDF
fillable form is not user friendly and quite cumbersome to use. In the free
text sections, the font size is not readable as it shrinks when populated with
more than 100 characters. The only way we can view the information
entered in the fields is to copy/paste the text into a Word document. This is
an unnecessary and burdensome step for plans to have to take when
completing the exception form.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

HSD

The annual hours and resources needed to complete an entire network
submission for one contract (see Table 4 of the Supporting Statement - Part
A, proposed Three-Year Network Adequacy) are grossly underestimated.
Based on our recent experience, we estimate three times what CMS lists for
each activity required. Multiple staff are required, gaps need to be
researched, provider contracting may be needed, new reports run, staff
analysis completed, etc. These activities account for many more hours than
what is represented in the table.

HSD

We are requesting CMS to clarify the process and timing for removing from CMS recommends that the commenter submit their specific
the service area pending counties versus existing counties. Based on the
questions to the CMS mailbox, located at: https://dmao.lmi.org.
April 11, 2017, CMS memo, the date to remove EXISTING counties from
the service area was Monday, June 5, 2017. However, CMS staff informed
us that the date to remove EXISTING counties was actually May 22, 2017
(the same time to remove pending counties from the service area). The
guidance does not align with the information provided by CMS staff and
caused much confusion due to lack of consistency.

HSD

During the 2018 application process, directions from CMS and Quest
Analytics about time standards enforcement were inconsistent. Both CMS'
Medicare Adv and Cost Plan Network Adequacy Criteria (1.18.17) and
CMS' HSD Reference File (1.10.2017) indicate time standards apply across
all specialty/county combinations. However, CMS approved without
explanation 2 specialty areas in a CEAC county where internal analyses
showed non-passing time results. Quest Analytics executives have directed
our plan to always run 'Distance Only' reports and stated that CMS only
applies time standards to Large Metro counties. We want to allocate
resources only where needed. We want to mirror CMS' use of Quest. During
the 2019 application process, will CMS always apply all the time standards
in CMS' HSD Reference File when testing HSD tables?

CMS considered the feedback from organizations concerning the
methodology for estimating the hour burden for submitting Health
Service Delivery (HSD) tables and Exception Requests to CMS,
but after further review of its internal process, CMS is confident in
its estimation. There may be minimal burden associated with this
change for those contracts that have never expanded beyond their
original footprint or experienced an event that would trigger a full
network review since they joined the program. In the case of an
SAE, CMS would review only the new service area’s network (i.e.,
the expansion counties), and the entire network review would occur
at the contract’s three-year anniversary. With regard to burden on
the federal government, as CMS makes the procedural change to
move the network review out of the application and into this threeyear review, CMS has simply shifted the annualized cost to the
federal government from the application PRA package to this new
PRA package. Therefore, no new cost to CMS has been added.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

Thank you for your comment regarding CMS's exception request
None. CMS has not revised any requirements,
policy and network adequacy criteria. Consistent with the
attachments, or burden estimates as a result of this
Supporting Statement, CMS removed the Health Services Delivery comment.
tables and Exception Request template from this information
collection. CMS will consider this comment as it develops the
details surrounding the information collection for CMS-10636,
OMB 0938-New. CMS also recommends that the commenter
submit their specific question related to the automated review of
network adequacy in HPMS (via Quest) to the CMS mailbox,
located at : https://dmao.lmi.org.

HSD

CMS Action (Requirements/ Attachments/Burden
Change)
CMS appreciates the positive feedback and support. CMS will
None. CMS has not revised any requirements,
strive for appropriate, equitable implementation of this information attachments, or burden estimates as a result of this
collection.
comment.

We strongly support the application changes proposed in CMS-10237.
Network Adequacy is an operational area and, like other operational areas
for MAOs (ODAG, CDAG, etc.), it should be reviewed in its proper
operational context and time frame. The goal of tying a Plan's network to its
proposed SAE expansion to assure a Plan can properly provide for its
members on day one is a good one. But there are better ways to test this,
especially since the application time frame and data used to support an
application can be up to one year out of date as of day one of a Plan's go live
into its new area.
We greatly appreciates CMS’ efforts to streamline the service area
CMS appreciates the positive feedback and support. CMS will
None. CMS has not revised any requirements,
expansion process by separating network adequacy reviews from the
strive for appropriate, equitable implementation of this information attachments, or burden estimates as a result of this
application process. We understand the need for CMS to conduct oversight collection.
comment.
monitoring to ensure that MA plans continue to maintain adequate networks.
As such, we support the proposal to conduct three year network adequacy
reviews and support the proposal to remove the Health Service Delivery
(HSD) tables from the MA application. We believe that these changes will
reduce burden on plans as well as CMS staff, while establishing a
transparent, predictable process for comprehensive network reviews.
Exceptions: We respectfully request CMS reconsider the requirement that all
network adequacy exceptions be re-reviewed annually. Exceptions are often
the result of a lack of provider specialties in a given geographic area, which
presents a challenge to Medicare broadly. Thus we recommend CMS retain
previously approved exception requests in between the three year review
cycle as long as there were no negative changes to the network from the
approved contract year.
Provider-Specific Plans (PSPs): CMS did not address how review of PSP
networks will be handled. We recommend they be included as part of the
three year review cycle. If CMS continues to review PSP networks annually,
we strongly suggest that CMS limit their review to the affected service areas.

Thank you for your comment regarding CMS's exception request
None. CMS has not revised any requirements,
policy. Consistent with the Supporting Statement, CMS removed
attachments, or burden estimates as a result of this
the Exception Request template from this information collection.
comment.
CMS will consider this comment as it develops the details
surrounding the information collection for CMS-10636, OMB 0938New.
Thank you for your comment regarding the information collection None. CMS has not revised any requirements,
for CMS-10636, OMB 0938-New. CMS will consider this
attachments, or burden estimates as a result of this
comment as it develops the details related to the three year network comment.
review cycle.

Service Area

SMAC

I-SNP

CMS Action (Requirements/ Attachments/Burden
Change)
CMS agrees with this comment. Recent analysis of claims data and Requirements. CMS modified attestation 3.8.6 as
industry trends demonstrates that Medicare Advantage (MA)
follows: Applicant agrees that it will provide all
enrollees often receive Orthotics and Prosthetics services in the
medically necessary durable medical equipment,
home or a hospital. Therefore, CMS does not believe time and
prosthetics, orthotics, and supplies (DMEPOS),
distance criteria standards are unrealistic for this specialty type.
including access to providers qualified to fit these
While CMS removed the health service delivery tables from this
devices, to its Medicare enrollees in full agreement with
application (see Supporting Statement), CMS does include several Chapter 4 of the MMCM.
attestations under the Service Area section of the application. CMS
agrees with the recommendation to include an attestation for
Attachment and Burden. CMS has not revised any
orthotics and prothestics coverage in the attestation, consistent with attachments or burden estimates as a result of this
the attestations included for home health, transplant facilities, and comment.
durable medical equipment.

We recommend CMS transition the Orthotics and Prosthetics specialty to
monitoring through an attestation.
Similar to Home Health and Durable Medical Equipment, care provided by
the Orthotics and Prosthetics specialty is not bound to a facility or office
location, as services are provided at a patient's home or local hospital or
clinic. For this reason, time and distance requirements are not appropriate
for this specialty.
Other specialties for which the time and distance requirements are not
appropriate are currently monitored through attestation.
To operationalize this recommendation, we propose the addition of the
following language to 3.8.6: "Applicant agrees that it will provide all
medically necessary durable medical equipment, prosthetics, orthotics, and
supplies (DMEPOS), including access to providers qualified to fit these
devices, to its Medicare enrollees in full agreement with Chapter 4 of the
MMCM."
The proposed modification will ensure that prosthetics and orthotics are
included in the application process as an attestation, similar to the other
monitored programs and services.
The SMAC and FIDE submission dates are listed as July 5, 2018. Previously CMS agrees with this comment. SMAC and FIDE submissions are Requirements. CMS modified section 5.4 of the
the SMAC and FIDE submissions were due the first Monday in July which due on the first Monday in July, or on July 2, 2018. CMS modified application as follows: The SMAC documents will be
the instructions under 5.4 of the application based on this comment. due by July 2, 2018.
would be July 2, 2018. Could CMS please clarify if this changed?

The intent of the language in Attestation No. 1 (Section 5.5 "I-SNP:
CMS agrees with this comment. CMS modified 5.5 of the
Attestations and Uploads") is somewhat confusing and appears to conflict
application for I-SNP Individuals Residing ONLY in Institutions
with other guidance regarding requirements of I-SNPs to be under contract consistent with the commentor's suggestion.
with and operate LTC facilities. The attestation states: "Applicant will only
enroll institutionalized individuals residing in a long-term care (LTC) facility
under contract with and owned by the SNP, or if no ownership, a contract
exists between the I-SNP and LTC." We propose that this attestation be
modified as follows:
"Applicant will only enroll institutionalized individuals residing in a longterm care (LTC) facility under contract with or owned and operated by the
SNP."

Attachment and Burden. CMS has not revised any
attachments or burden estimates as a result of this
comment.
Requirements. CMS modified one attestation for I-SNP
Individuals Residing ONLY in Institutions under section
5.5 of the application as follows: Applicant will only
enroll institutionalized individuals residing in a longterm care (LTC) facility under contract with or owned
and operated by the SNP.
Attachments and Burden. CMS has not revised any
attachments or burden estimates as a result of this
comment.

I-SNP

MSA

Our understanding is that I-SNPs may, but are not required, to contract with
Assisted living facilities (ALF). Question 4.a. of the I-SNP Individuals
Residing in Both Institutions and the Community Upload Document reads:
"Applicant is contracting with assisted living facilities or other residential
facilities." We believe this question should be re-worded to be clear that ISNP applicants that intend to serve individuals that reside in both
institutions and the community have the option to contract with ALFs, and
suggest that the question be modified as follows:
"For institutional equivalent individuals residing in the community, provide
a list of applicable assisted living facilities or other residential facilities, e.g.,
continuing care communities. (Note use of ALF or other residential facilities
is optional for I-SNPs that serve institutional equivalent individuals in the
community.)"
Compliance Crosswalk: On page 24 of the 2019 Part C Application, section
3.5.C., there is a request to complete and upload the crosswalk for Part C
compliance plan document. No crosswalk template is provided in the 2019
(or CY2018) application information.
Inform Health recommends that CMS either eliminate the crosswalk
requirement or provide the desired template for submission.

CMS agrees with this comment. CMS modified 5.13.3 of the
application consistent with the commentor's suggestion.

CMS Action (Requirements/ Attachments/Burden
Change)
Requirements. CMS modified one attestation in the
upload document under section 5.13.3 of the application
as follows: 4.a. For institutional equivalent individuals
residing in the community, provide a list of applicable
assisted living facilities or other residential facilities,
e.g., continuing care communities. (Note: The use of
Assisted Living Facilities or other residential facilities is
optional for I-SNPs that serve institutional equivalent
individuals in the community.)

Attachments and Burden. CMS has not revised any
attachments or burden estimates as a result of this
comment.
Thank you for your comment. Under attestation 3.5.1, CMS
Requirements. CMS will only require that MA-only nonrequires that organizations respond yes or no to the following
network PFFS and MSA plans complete the compliance
attestation:
attestation under 3.5.1. CMS will no longer require
uploads of the compliance plan and supporting matrix
Applicant will adhere to all compliance regulations in accordance documents. CMS deleted 3.5.B and 3.5.C from the
with but not limited to 42 CFR 422.503(b)(4)(vi).
application.
Under 3.5.B and 3.5.C, CMS required that MA-only non-network Burden. CMS anticipates a reduction of two hours based
(Private Fee-for-Service and Medical Savings Account) applicants on this change for the MA-only non-network MSA and
PFFS intitial and SAE applications only.
upload a compliance plan and compliance plan crosswalk in
addition to the attestation.
Attachments. CMS modified the Summary Statement to
account for the burden reduction associated with this
Upon review, CMS will remove both 3.5.B and 3.5.C from the
removal.
application requirements. CMS believes that the response to
attestation 3.5.1 provides the necessary assurances for CMS to
determine the MA-only non-network applicants adherence to
CMS's compliance requirements for the purpose of 42 CFR Subpart
K.

MSA

CMS Action (Requirements/ Attachments/Burden
Change)
Banking Contract: On page 43 of the 2019 Part C Application, sections
Thank you for your comment. Under attestation 3.25.B, CMS
Requirements. CMS modified attestation C.25.6 as
3.25.6 and 3.25.B., the application requires uploading an executed banking requires that organizations respond yes or no to the following
follows: Applicant will establish a relationship with a
contract. Section 3.25.B. is very clear on the required CMS direct and/or
attestation:
banking partner that meets the Internal Revenue Service
delegated contracting requirements are included in the contract, but does not
(IRS) requirements (as a bank, insurance company or
provide any additional guidance on banking contract requirements. Inform Applicant will adhere to all compliance regulations in accordance other entity) as set out in Treasury Reg. Secs. 1.408Health recommends that CMS state any specific MSA banking requirements with but not limited to 42 CFR 422.503(b)(4)(vi).
2(e)(2) through (e)(5). Applicant will establish policies
outside of those currently articulated in section 3.25.B. that need to be
and procedures with its banking partner that include the
included in the MSA banking executed contract.
Under 3.5.B and 3.5.C, CMS required that MA-only non-network services provided by the banking partner, including how
Inform Health also recommends that CMS offer a standard MSA banking
(Private Fee-for-Service and Medical Savings Account) applicants members access funds, how spending is tracked and
applied to the deductible, and how claims are processed.
contract template in the 2019 Part C Application to ensure all requirements upload a compliance plan and compliance plan crosswalk in
Burden.
are clear and included by MSA applicants.
addition to the attestation.
Upon review, CMS will remove both 3.5.B and 3.5.C from the
application requirements. CMS believes that the response to
attestation 3.5.1 provides the necessary assurances for CMS to
determine the MA-only non-network applicants adherence to
CMS's compliance requirements for the purpose of 42 CFR Subpart
K.

CMS also removed the requirement for MSAs to upload
an executed banking contract. In removing this
requirement, CMS renumbered the remaining MSA-only
upload documents.
Attachments and Burden. CMS has not revised any
attachments or burden estimates as a result of this
comment. CMS did not include a burden estimate for
the banking contract upload in the initial Supporting
Statement. CMS notes that MSA banking
contract/reporting requirements are discussed in the
information collection under OMB control number 09380753, CMS-R-267.

HSD

Removal of Health Services Delivery (HSD) Tables. CMS is proposing to
remove the submission and review of the provider and facility Health
Services Delivery (HSD) tables and related exceptions requests from the
MA application process beginning with the CY 2019 application cycle.
Under the proposal, CMS would no longer evaluate and review MA provider
and facility networks with the application, and would instead create a
separate and distinct process to conduct network reviews as part of contract
operations (i.e., an operational function). CMS has published a related
information collection entitled, “Three-Year Network Adequacy Review for
Medicare Advantage Organizations” that proposes to establish this new
operational function. The proposed approach would require organizations to
upload HSD tables to the HPMS Network Management Module (NMM) for
any contract that has not had an entire network review performed by the
agency in the previous three-years of contract operation. HCSC has
expressed general support for the Three-Year Network Adequacy Review
proposal, which we believe could permit CMS to take a more balanced and
uniform approach to evaluating and determining MA organization
compliance with network adequacy requirements as all contracts will be
subject to the three-year review cycle. This approach also may better
position CMS to determine whether there is potential for beneficiary harm
related to undetected network deficiencies in a manner that is consistent
across all, rather than a subset of contracts.

HSD

Transparency in the Development Process. As CMS continues to consider
CMS appreciates the positive feedback and support. CMS will
None. CMS has not revised any requirements,
removing the HSD review and submission process from the MA application, strive for appropriate, equitable implementation of this information attachments, or burden estimates as a result of this
and further refines the new proposed operational approach (e.g., identifying collection.
comment.
needed systems and other modifications), HCSC recommends that the
agency work in close and ongoing collaboration with MA organizations in a
transparent manner. These steps will allow CMS to benefit from the range of
MA organization practical experience and knowledge, and ensure any
operational issues or considerations are identified as early as possible in the
development process and well in advance of implementation. In addition,
given the increased scale and scope of the proposed approach in comparison
to the current review process, it will be important for CMS to take a flexible
approach to initial implementation of the new process to accommodate the
significant system, administrative, and timing resources that will be required
on the part of the agency and plans.

HSD

Implementation Timing. The CMS Supporting Statement indicates that the
agency’s goal is to remove the HSD submission and review process from the
MA applications beginning with the CY 2019 applications. However, the
timing of when CMS envisions the initial 3-year network reviews would
begin under a new process is unclear. For clarity, we recommend that CMS
confirm when the agency will begin the network adequacy reviews under the
revised approach, as well as the timing of when and how impacted
organizations will be notified of requests to upload HSD tables in the initial
and subsequent years of implementation. As a practical consideration, we
encourage CMS to establish a timeline that avoids implementation early in
the year, and to ensure that the sample beneficiary file against which an
organization’s networks must be compared is available well in advance of
that timing.
Exception Requests. HSCS believes it is important that MA organizations
have the ability to submit requests when an exception to the current network
adequacy criteria is warranted, especially given the continuously evolving
patterns of care in certain service areas, and we appreciate that CMS is
proposing to maintain this process under the revised network adequacy
review approach. We recommend that CMS also consider implementing a
process to make available to all organizations in a given service area,
information regarding all approved Exception Requests for certain provider
types in the service area in an effort to increase transparency and
consistency in the review process.

Thank you for your comment regarding the information collection
for CMS-10636, OMB 0938-New. CMS is currently discussing a
proposed timeline for reviews internally and will release guidance
to the industry as soon as review timeframes and activities are
defined.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

HSD

Significant Network Changes. CMS requires MA organizations to notify the CMS recommends that the commenter submit their specific
agency of any no-cause provider termination that the organization deems to questions to the CMS mailbox, located at: https://dpap.lmi.org.
be a “significant” change to the provider network, at least 90-days prior to
the effective date of the change (See https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/mc86c04.pdf). The agency
believes that MA organizations “may be in the best position to determine
whether or not a provider termination without cause is significant” and
expects organizations to take a conservative approach in making such
determinations and notifying CMS accordingly. The agency notes that an
organization that does not notify CMS of network changes that are
ultimately determined by CMS to be significant will be subject to
appropriate compliance actions. CMS guidance broadly defines
“significant” changes as those changes to provider networks that go beyond
individual or limited provider terminations that occur during the routine
course of plan operations and affect, or have the potential to affect, a large
number of enrollees. Consistent with previous comments we have submitted
on this topic, we recommend that CMS further clarify and refine the
definition of “significant” network changes, for example, by providing
guidelines and/or criteria organizations may use to make determinations. We
believe this step would promote a common understanding across MA
organizations of the agency’s expectations, as well as support compliance
with CMS’ requirements.

HSD

Changes to Application. We note that along with the draft application, CMS
issued a document that provides a high-level summary/crosswalk of changes
the agency is proposing. We appreciate that CMS has made the document
available and recommend that the agency consider providing a similar
crosswalk when the final versions of the applications are released to help
applicants more efficiently identify and navigate the year-over-year
application changes.

Thank you for your feedback regarding the high-level
summary/crosswalk of changes proposed through this information
collection. CMS has modified this summary of changes document
to include the sections impacted during the 60-day comment
process.

CMS Action (Requirements/ Attachments/Burden
Change)
None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

None. CMS has not revised any requirements,
attachments, or burden estimates as a result of this
comment.

File Type	application/pdf
Author	Stacy DAVIS
File Modified	2017-11-02
File Created	2017-11-02