Upcoming Event: NIMHD Director’s Seminar Series Featuring Dr. L. Ebony Boulware

NIMHD Director’s Seminar Series Features L. Ebony Boulware, M.D., M.P.H on February 4 at 2:00 p.m.

Attend the NIMHD Director’s Seminar Series Lecture featuring L. Ebony Boulware, M.D., M.P.H., on Thursday, February 4 at 2:00 p.m. She will discuss “Where the Cloud Meets the Ground: Democratizing Health Data to Improve Community Health Equity.” 

Dr. Boulware is the Chief of the Division of General Internal Medicine and the Director of the Duke Clinical and Translational Science Institute. She has devoted her scholarly career to studying mechanisms to improve the quality and equity of health care and health outcomes for patients and populations with chronic diseases, such as chronic kidney disease and hypertension. Her work investigates the influence of attitudinal, social, and environmental contexts on health and health outcomes. Dr. Boulware has published more than 150 manuscripts and has mentored numerous students, fellows, and faculty members in clinical research. She frequently engages with community members, patients, and their families, and other stakeholders, to develop and implement relevant and sustainable interventions for health improvement.

This lecture will be held virtually, is open to the public, and can be viewed through the NIH videocast system at https://videocast.nih.gov.

Questions prior to and during the seminar can be submitted to NIMHDDSS@mail.nih.gov.


RHIhub, The RURAL Monitor: Claude Worthington Benedum Foundation: Taking a Leadership Role and Building Trust

By Allee Mead/The RURAL Monitor

What other services would you like to highlight?

We did set up a grant capture team with a statewide intermediary. We funded an organization so that they could be mining all of the information that was coming out through the CARES Act and other opportunities, particularly federal, and then the dollars that came into the state. We funded people to mine the data, do short info pieces, and send them out to our statewide network systems like rural hospitals and the West Virginia Rural Health Association. We’ve funded them to do updates to their websites so there’d be current, accurate information about the virus or how to get tested, where to get PPE, and how to find funding. And we then funded the grant writers for people who needed them. We also serve as match for grants if people needed to match state or federal grants.


HHS Community Health News: Aug. 10-14, 2020

HHS Healthcare Provider and Community News

Proposal to Expand Telehealth Benefits Permanently for Medicare Beneficiaries and Advances in Access to Care in Rural Areas

The Centers for Medicare & Medicaid Services (CMS) is proposing changes to expand telehealth permanently, consistent with the Executive Order on Improving Rural and Telehealth Access. To learn more about the public input CMS is seeking and additional information about the proposed rule read the press release here.

HHS Awards Over $101 Million to Combat the Opioid Crisis

HHS awarded over $101 million to combat substance use disorders (SUD) and opioid use disorders (OUD).  $89 million was awarded to rural organizations across 38 states as part of the Rural Communities Opioid Response Program-Implementation (RCORP).  Another nearly $12.5 million went to organizations through the Opioid-Impacted Family Support Program (OIFSP) for workforce development.

Training and Technical Assistance Related to COVID-19

SAMHSA is committed to providing regular training and technical assistance (TTA) on matters related to the mental and substance use disorder field as they deal with COVID-19.

Webinar: Mentoring During COVID-19: Findings from a Recent Study of Mentoring Relationships in the Pandemic

Tues., Aug. 11, 2020, 1:00 p.m. EDT, Register here.

Learn the results of an important new study, “Mentoring During COVID-19”,  and how mentors are employing ways to stay in contact with mentees during this time of social distancing and technological interventions.

Webinar on Using Social Determinants of Health Data to Fight COVID-19

Wed., Aug. 12, 2020, 12:00 p.m. EDT, Register here.

This webinar is for those interested in accelerating data-driven solutions to improve the prevention, treatment, and management of resources to fight COVID-19 and support the recovery effort.

Using Data to Measure Social Capital and Build Social Connections for Vulnerable Youth

Next Week- Thurs., Aug. 20, 2020, 2:30 p.m. EDT, Register here.

This interactive training will discuss the latest research on social capital, or the value we get from our relationships with others, as well as lessons from the field.

Updated COVID-19 Guidance for Specific Populations

Visit https://www.coronavirus.gov/ for most recent COVID-19 related news, information, and guidance.   In Spanish.

CDC Updated Toolkit for Young Adults – 15 to 21

Resources and tools designed for youth and young adults to keep them healthy as they venture out.

Guidance on Unsheltered Homelessness and COVID-19 for Homeless Service Providers and Local Officials

Updated interim guidance on unsheltered homelessness and COVID-19 for homeless service providers and locals shelters.

COVID-19 in Newly Resettled Refugee Populations

Updated information for refugees to the U.S., especially those who are recently resettled, may be in living or working conditions that put them at risk of getting COVID-19.

Data on COVID-19 during Pregnancy

Updated information on tracking data on COVID-19 during pregnancy to protect pregnant women and their babies.

FAQ about Antibody Testing for COVID-19: Information for Patients and Consumers

The FDA posted frequently asked questions for patients and consumers about antibody (serology) testing during the COVID-19 public health emergency- including “Antibodies and Antibody Tests: The Basics.”  CDC updated their guidelines for antibody testing in clinical and public health settings.

The Experts Talk about Vaccine and Related Programs

FDA Commissioner: “No Matter What, Only A Safe, Effective Vaccine Will Get Our Approval

This Op-ed by Dr. Stephen Hahn, FDA Commissioner, writes about the large-scale clinical trials already have begun for several promising vaccine candidates and what information the FDA will require to decide whether approval of the vaccine for general use is justified.

HHS Podcast on Operation Warp Speed

On this episode of “Learning Curve,” HHS Assistant Secretary of Public Affairs Michael Caputo sits down with Dr. Moncef Slaoui, to discuss ongoing vaccine development efforts, convalescent plasma, and the role of the military in Operation Warp Speed.

Facebook Conversation about Promising COVID-19 Treatment and Vaccines

NIH launched clinical trials for the use of monoclonal antibodies in treating COVID-19, the first prioritized therapeutics under the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) program. To learn about these investigative treatments, watch NIH Director Dr. Francis Collins and National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci.

Charting a Rapid Course Toward Better COVID-19 Tests and Treatments

NIH Director, Dr. Francis Collins, says that it is becoming apparent that our country is entering a new and troubling phase of the COVID-19 pandemic as the virus continues to spread across our communities and talks about their urgent efforts to create accessible and affordable diagnostic testing.

Exploring Drug Repurposing for COVID-19 Treatment

In this blogpost, Dr. Collins talks about the exploration of existing drugs and/or experimental drugs that are already in the development pipeline and have potential to be repurposed for treating COVID-19.

Rural Community Health

Social Determinants of Health in Rural Communities Toolkit

A newly released toolkit that compiles evidence-based and promising models and resources to support organizations implementing programs that address the social determinants of health in rural communities.

** Upcoming Webinar Introducing the Social Determinants of Health in Rural Communities Toolkit.
Wed. Aug. 19, 2020. 1:00 p.m. EDT.
  Register here. Speakers discuss the Social Determinants of Health in Rural Communities Toolkit and describe strategies to establishing rural programs to address various social determinants of health

CDC’s COVID-19 and Rural Communities

About 46 million Americans live in rural areas and are facing distinctive challenges during the COVID-19 pandemic. The CDC updated its information on rural communities and their response to the crisis.

Resources Supporting Rural Healthcare Surge Readiness

A dashboard developed by the COVID-19 Healthcare Resilience Working Group, a partnership with HHS, the U.S. Department of Homeland Security and other federal agencies to provide support and guidance for healthcare delivery and workforce capacity and protection.

Rural Community Toolbox.Org Launches

In case you missed it, the White House Office of National Drug Control Policy (ONDCP) launched the Rural Community Toolbox website, a clearinghouse for funding and resources to support rural leaders in addressing substance use disorder (SUD) and the opioid crisis.  The Community Assessment Tool is especially helpful.

Grants and Funding Opportunities

Please see current funding announcements by visiting Grants.gov

West Virginia’s Prescription Transparency Law Can Address Rising Drug Cost

West Virginia’s Prescription Transparency Law Can Address Rising Drug Costs 

The cost of prescription drugs is one of the leading health care issues in the United States, accounting for $335 billion of total health care spending in 2018 and over 23 percent of total health insurance premium costs. And the cost of prescription drugs is rising. The cost of prescription drugs is one of the leading health care issues in the United States.

West Virginia has not been immune to the increasing costs of prescription drugs. Between 1991 and 2014, per capita spending on prescription drugs in West Virginia grew by an average of 6.8 percent per year, from $304 per capita to $1,377, faster than all other health care spending.

Our report released this week examines the process behind prescription drug pricing, particularly the role of state budgets and Medicaid and how states have used drug price transparency reforms to improve the process.

Understanding how prescription drug prices are set will allow both patients and the state to make more informed decisions about whether prices are excessive, as well as introduce some rationality and evidence into the health care system.

Read more in Sean’s full report.

Exploring Police Spending in West Virginia

The slogan “defund the police,” acknowledges an emerging sentiment that state and local governments have spent and are currently spending too much on law enforcement and not enough on social services, mental health, housing, and education. Research suggests that spending on these and other upstream factors can lessen inequality within communities and reduce crime. To enhance this conversation, we reviewed some of the data on public safety spending in West Virginia.

Read the full post from Quenton and Bryan.

More Health Care, Not Less, Needed Amid Pandemic

Around the country, states are seeing dramatic increases in Medicaid enrollment as furloughed workers and their dependents lose their job-based health insurance and turn to Medicaid for coverage during the coronavirus pandemic.

Since March, West Virginia has seen an increase in Medicaid enrollment of approximately 24,000 people, but that is only the tip of the iceberg. Of the approximately 130,000 West Virginians who’ve lost their health coverage during this crisis, many are likely eligible for Medicaid and could sign up any time for the program. One analysis estimated that anywhere from 69,000 to 143,000 West Virginians could newly enroll in Medicaid over the next several months.

And the economic and job effects of COVID-19 are not over. The nonpartisan Congressional Budget Office estimates that national unemployment will still be as high as 9.5% at the end of 2021 – nearly as high as at the height of the last recession, which began in 2008.

A recent national analysis estimated that, by January 2021, nearly 17 million new Americans will be eligible for Medicaid. Policymakers must be prepared for a drawn-out recovery for West Virginia and the rest of the country, with years until jobless numbers go back to where they were prior to the COVID-19 crisis. We can expect that, over this time, thousands more West Virginians will need Medicaid health coverage to stay healthy.

Read Kelly’s full op-ed here which ran this week in the Charleston-Gazette Mail.

ACA Repeal More Dangerous Than Ever for West Virginians During Pandemic and Economic Crisis 

Despite the COVID-19 pandemic and resulting major recession, the Trump Administration and 18 state attorneys general, including West Virginia Attorney General Patrick Morrisey, filed briefs this week asking the Supreme Court to strike down the entire Affordable Care Act (ACA). If the lawsuit succeeds, at least 162,000 West Virginians – and likely many more – would lose health coverage.

“The administration and AGs’ lawsuit has the potential to throw our health care system into complete chaos in the middle of a pandemic and economic recession,” said Jessica Ice, Executive Director of West Virginians for Affordable Health Care. “Thousands of West Virginians, many with pre-existing health conditions, would lose coverage and many more would pay more for coverage or care.”

Research shows the ACA has improved access to care, financial security, and health outcomes – with strong evidence that both Medicaid expansion and coverage through the ACA marketplaces save lives. Reversing these coverage gains would be expected to worsen all of these outcomes, and the adverse effects would be even greater with more people depending on the ACA for coverage during the recession.

“The ACA has been critical to West Virginia’s ability to deal with both the pandemic and the resulting economic recession,” said Kelly Allen, interim deputy director of the West Virginia Center on Budget and Policy. “Striking down the law would impede efforts to end the public health crisis and deal with the fallout. West Virginia’s Attorney General Patrick Morrisey should immediately remove our state from this dangerous lawsuit.”

Read the full press release here, which was produced in partnership with West Virginians for Affordable Health Care.

CARES Act Unemployment Provisions Should Be Extended While Need Remains

Thanks to the CARES Act that was passed in March, last week more than 82,000 unemployed West Virginian workers claimed unemployment benefits that were more generous than those they normally would have received, while thousands more were able to receive benefits who otherwise would have received no benefits at all.

However, if Congress does not act, the CARES Act’s boost in benefit levels will expire on July 31 and its eligibility expansions and additional weeks of benefits will expire on December 31, despite the reality that the support unemployed workers and the economy need will remain substantial.

The CARES Act provisions have helped and will continue to help tens of thousands of unemployed workers in West Virginia make it through this uncertain time before returning to work or finding a new job. Those workers, however, will be in a far worse financial position if they lose the weekly pandemic benefit supplement and revert to the meager regular state benefit.

Policymakers must ensure that unemployed workers are not left with little or no assistance while unemployment remains high, job prospects remain limited, and unemployment spells drag out longer than when the economy is stronger and unemployment is lower.

Read Sean’s full blog post here.

2,500 Organizations Sign Letter Urging Federal Government to Fight Food Insecurity by Investing in Increased SNAP Benefits

This week, nearly 2,500 undersigned national, regional, state, and local organizations urged immediate action to address the twin challenges of COVID-19 – protecting individuals and communities against hardship and jump-starting a strong economic recovery. SNAP benefit boosts can help limit the depth and duration of the human and economic tolls this crisis threatens to exact.

COVID-19 has exacerbated already too high levels of food insecurity in America. According to the Urban Institute, in the early weeks of the pandemic, one in five U.S. adults experienced food insecurity.

Sufficient and timely federal government action is needed to prevent even more human suffering and lost productivity in the short and longer terms.

It is urgent that Congress and the White House act now to provide 1) a 15 percent boost in the SNAP maximum benefit that would help all SNAP households; 2) an increase in the SNAP monthly minimum benefit from $16 to $30; and 3) a suspension of SNAP time limits and rules changes that would cut SNAP eligibility and benefits.

Read the full letter from Food Research and Action Center.

Congrats, Rosemary Ketchum!

Huge congratulations to our board member, Rosemary Ketchum, who recently won a seat on Wheeling’s City Council. Her victory marks a historic moment, as Rosemary will become the first openly transgender elected official in the state.

Rosemary has long been dedicated to combatting social and economic challenges present in West Virginia. We feel lucky to have her as a member of our team and look forward to seeing all that she accomplishes as a City Council member.

Read more on Rosemary’s victory here.

COVID-19 Resources

For more information on the impact of the pandemic on West Virginia’s economy, safety net, unemployment resources, and more, please visit our special website page.

Health Care for All Virtual Town Hall

Are you tired of struggling or watching friends and family struggle to get life-saving health care? Do you think health care is a human right?  Do you agree that West Virginians deserve better?  We do! We need your help.

Tune in for a Virtual Town Hall on Monday, June 29, 2020, at 6:00PM, to share your ideas and join the Health Care for All WV movement. We will be living streaming directly on social media.

Learn about the Health Care for All campaign and our three big victories so far this year.


Sponsors Sought for Upcoming Sessions on Race Matters in West Virginia


Trump Administration Issues Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries

CMS NEWS: Trump Administration Issues Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries

Today, under the leadership of President Trump, the Centers for Medicare & Medicaid Services (CMS) is calling for a renewed national commitment to value-based care based on Medicare claims data that provides an early snapshot of the impact of the coronavirus disease 2019 (COVID-19) pandemic on the Medicare population.  The data shows that older Americans and those with chronic health conditions are at the highest risk for COVID-19 and confirms long-understood disparities in health outcomes for racial and ethnic minority groups and among low-income populations.

“The disparities in the data reflect longstanding challenges facing minority communities and low income older adults, many of whom face structural challenges to their health that go far beyond what is traditionally considered ‘medical’,” said CMS Administrator Seema Verma. “Now more than ever, it is clear that our fee-for-service system is insufficient for the most vulnerable Americans because it limits payment to what goes on inside a doctor’s office. The transition to a value-based system has never been so urgent. When implemented effectively, it encourages clinicians to care for the whole person and address the social risk factors that are so critical for our beneficiaries’ quality of life.”

The data released today includes the total number of reported COVID-19 cases and hospitalizations among Medicare beneficiaries between January 1 and May 16, 2020. The snapshot breaks down COVID-19 cases and hospitalizations for Medicare beneficiaries by state, race/ethnicity, age, gender, dual eligibility for Medicare and Medicaid, and urban/rural locations. The new data show that more than 325,000 Medicare beneficiaries had a diagnosis of COVID-19 between January 1 and May 16, 2020. This translates to 518 COVID-19 cases per 100,000 Medicare beneficiaries. The data also indicate that nearly 110,000 Medicare beneficiaries were hospitalized for COVID-19-related treatment, which equals 175 COVID-19 hospitalizations per 100,000 Medicare beneficiaries.

Blacks were hospitalized with COVID-19 at a rate nearly four times higher than whites. The disparities presented in the snapshot go beyond race/ethnicity and suggest the impact of social determinants of health, particularly socio-economic status.

Other key data points:

  • End-stage renal disease (ESRD) patients (individuals with chronic kidney disease undergoing dialysis) had the highest rate of hospitalization among all Medicare beneficiaries, with 1,341 hospitalizations per 100,000 beneficiaries. Patients with ESRD are also more likely to have chronic comorbidities associated with increased COVID-19 complications and hospitalization, such as diabetes and heart failure.
  • The second highest rate was among beneficiaries enrolled in both Medicare and Medicaid (also known as “dual eligible”), with 473 hospitalizations per 100,000 beneficiaries.
  • Among racial/ethnic groups, Blacks had the highest hospitalization rate, with 465 per 100,000. Hispanics had 258 hospitalizations per 100,000. Asians had 187 per 100,000 and whites had 123 per 100,000.
  • Beneficiaries living in rural areas have fewer cases and were hospitalized at a lower rate than those living in urban/suburban areas (57 versus 205 hospitalizations per 100,000).

The snapshot also shows that besides higher hospitalization rates, beneficiaries enrolled in both Medicaid and Medicare have a higher infection rate of COVID-19, with 1,406 cases per 100,000 beneficiaries. By comparison, the coronavirus infection rate for beneficiaries enrolled only in Medicare is 325 cases per 100,000. The rate of COVID-19 cases for dual eligible individuals is higher across all age, sex, and race/ethnicity groups. Previous research has shown that these individuals experience high rates of chronic illness, with many having long-term care needs and social risk factors that can lead to poor health outcomes.

Given the complexity of these disparities, any solution requires a multi-sectoral approach that includes federal, state, and local governments, community based organizations, and private industry. One piece of this is the increased implementation of a value-based system that rewards providers for keeping patients healthy and gives consumers the information about disease prevention and outcomes needed to help make healthcare choices on the basis of quality. Additionally, CMS is encouraging states to double down on efforts to protect low income seniors and look at the data and determine what resources are available, both locally and federally, to improve this disparity of health outcomes. CMS has identified a range of operational opportunities for states to improve care for dually eligible individuals and a variety of models that states can participate in that focus on improving the quality and cost of care for individuals who are concurrently enrolled in Medicaid and Medicare.

The Center for Medicaid and Children’s Health Insurance Program (CHIP) Services is developing guidance for states on new opportunities to adopt innovative, value-based payment design and implement strategies to address social determinants of health for their beneficiaries, including those who are dually-eligible for Medicare and Medicaid. In addition to these ongoing efforts and programs, the CMS Office of Minority Health will be holding a series of listening sessions with key stakeholders responsible for providing care to racial and ethnic minorities. These listening sessions are intended to help refine the ongoing outreach and work by CMS to improve future efforts on this issue.

CMS typically releases Medicare claims information on an annual basis when there are more complete claims and encounter data. However, as part of the agency’s efforts to provide data transparency during the pandemic and ensure the public has this vital information as soon as it is available, CMS is releasing this preliminary data now. The data will be updated on a monthly basis as more claims and encounter records are received. CMS anticipates releasing similar information on Medicaid beneficiaries in the future.

For more information on the Medicare COVID-19 data, visit: https://www.cms.gov/research-statistics-data-systems/preliminary-medicare-covid-19-data-snapshot

For an FAQ on this data release, visit: https://www.cms.gov/files/document/medicare-covid-19-data-snapshot-faqs.pdf

For a blog by CMS Administrator Seema Verma, visit: https://www.cms.gov/blog/medicare-covid-19-data-release-blog

HHS Finalizes Rule on Section 1557 Protecting Civil Rights in Healthcare, Restoring the Rule of Law

U.S. Department of Health and Human Services

Twitter @SpoxHHS


Friday, June 12, 2020



HHS Finalizes Rule on Section 1557 Protecting Civil Rights in Healthcare,
Restoring the Rule of Law, and Relieving Americans of Billions in Excessive Costs



Today, the U.S. Department of Health and Human Services (HHS) finalized a rule under Section 1557 of the Affordable Care Act (ACA) that maintains vigorous enforcement of federal civil rights laws on the basis of race, color, national origin, disability, age, and sex, and restores the rule of law by revising certain provisions that go beyond the plain meaning of the law as enacted by Congress.  The final rule will also relieve the American people of approximately $2.9 billion in undue and ineffective regulatory burdens over five years.

Conforming to the Text of Our Laws

In Section 1557, Congress prohibited covered health programs or activities from discriminating on any of the grounds protected by longstanding federal civil rights statutes.  One of those federal statues is Title IX of the Education Amendments of 1972 (Title IX) prohibiting discrimination on the basis of sex in certain federally funded programs. In 2016, the previous administration issued a regulation implementing Section 1557 (the 2016 Rule) that redefined sex discrimination to include termination of pregnancy and gender identity, which it defined as “one’s internal sense of gender, which may be male, female, neither, or a combination of male and female.”

On December 31, 2016, a federal court preliminarily enjoined, on a nationwide basis the prior administration’s attempt to redefine sex discrimination in the 2016 Rule, concluding that the provisions were likely contrary to applicable civil rights law, the Religious Freedom Restoration Act, and the Administrative Procedure Act. A second federal court agreed. On October 15, 2019, the first federal court issued a final judgment, and vacated and remanded these provisions as unlawful; this final ruling is binding on HHS.  HHS has not been able to enforce these provisions since December 2016, and the provisions have been vacated since October 2019.

Under the final rule, HHS eliminates certain provisions of the 2016 Rule that exceeded the scope of the authority delegated by Congress in Section 1557. HHS will enforce Section 1557 by returning to the government’s interpretation of sex discrimination according to the plain meaning of the word “sex” as male or female and as determined by biology.  The 2016 Rule declined to recognize sexual orientation as a protected category under the ACA, and HHS will leave that judgment undisturbed.

Continued Robust Enforcement of Civil Rights Law

Under the final rule, HHS will continue to vigorously enforce federal civil rights laws prohibiting discrimination on the basis of race, color, national origin, disability, age, and sex in healthcare, as Section 1557 provides.  The final rule retains protections from the 2016 Rule that ensure physical access for individuals with disabilities to healthcare facilities and appropriate communication technology to assist persons who are visually or hearing-impaired. The final rule also retains certain protections from 2016 Rule for non-English speakers, including the right to meaningful language access to healthcare, qualification standards for translators and interpreters, and limitations on the use of minors and family members as translators in healthcare settings.  Regulated entities will also continue to be required to provide written assurances to HHS that they will comply with Section 1557’s civil rights protections and the final rule.

“HHS respects the dignity of every human being, and as we have shown in our response to the pandemic, we vigorously protect and enforce the civil rights of all to the fullest extent permitted by our laws as passed by Congress.  We are unwavering in our commitment to enforcing civil rights in healthcare,” Roger Severino, Director of the Office for Civil Rights at HHS.

Removing Costly and Unnecessary Regulatory Burdens

The final rule will also relieve the American people of approximately $2.9 billion in unnecessary regulatory burdens over five years from eliminating the mandate for regulated entities to send patients and customers excessive “notice and taglines” inserts in 15 or more foreign languages in almost every health care mailing, costs that get passed down to patients and consumers.  These expensive notices have not generally proven effective at accomplishing their purpose of providing meaningful language access to healthcare.

“Now more than ever, Americans do not want billions of dollars in ineffective regulatory burdens raising the costs of their healthcare.  We are doing our part to reel in unnecessary costs that add economic burdens to patients, providers, and insurers alike,” concluded Severino.


Click to read the Final Rule on Section 1557 – PDF.

Click to read the Factsheet on Section 1557 – PDF.*

To learn more about non-discrimination on the basis of sex, race, color, national origin, age, and disability; conscience and religious freedom; and health information privacy laws, and to file a complaint with OCR, please visit www.hhs.gov/ocr.

Follow OCR on Twitter at @HHSOCR  .

* People using assistive technology may not be able to fully access information in these files. For assistance, contact the HHS Office for Civil Rights at (800) 368-1019, TDD toll-free: (800) 537-7697, or by emailing OCRMail@hhs.gov.