CSHB 227(HSS): "An Act relating to medical assistance reform measures; relating to administrative appeals of civil penalties for medical assistance providers; relating to the duties of the Department of Health and Social Services; relating to audits and civil penalties for medical assistance providers; relating to medical assistance cost containment measures by the Department of Health and Social Services; relating to medical assistance coverage of clinic and rehabilitative services; relating to federal reimbursement for Alaska Native health services; and providing for an effective date."
00 CS FOR HOUSE BILL NO. 227(HSS) 01 "An Act relating to medical assistance reform measures; relating to administrative 02 appeals of civil penalties for medical assistance providers; relating to the duties of the 03 Department of Health and Social Services; relating to audits and civil penalties for 04 medical assistance providers; relating to medical assistance cost containment measures 05 by the Department of Health and Social Services; relating to medical assistance coverage 06 of clinic and rehabilitative services; relating to federal reimbursement for Alaska Native 07 health services; and providing for an effective date." 08 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 09 * Section 1. The uncodified law of the State of Alaska is amended by adding a new section 10 to read: 11 MEDICAL ASSISTANCE REFORM: LEGISLATIVE FINDINGS AND INTENT. 12 The legislature finds that the current Medicaid program is not sustainable. Although annual 13 growth has fallen from 6.45 percent to 4.8 percent, further reductions are needed. In order to
01 maintain a viable Medicaid program, it is the intent of the legislature that 02 (1) the governor, through the Department of Health and Social Services, take 03 all necessary action to capture federal revenue and offset state general funds and evaluate the 04 most cost-effective method for revising expansion coverage, including more efficient benefit 05 plans, cost sharing, utilization control, and other innovative health care financing strategies; 06 (2) the Department of Health and Social Services be instructed to 07 (A) evaluate and implement meaningful Medicaid reform measures, 08 including working with tribal and community partners to develop innovative practices 09 leading to a sustainable Medicaid program available for future generations; 10 (B) evaluate all options available to it, including 11 (i) obtaining waivers to the Medicaid program to address 12 choice, statewide compatibility, or other core Medicaid requirements; and 13 (ii) regulatory action to improve provider and recipient 14 compliance with program rules; 15 (C) collaborate with community mental health clinics and drug or 16 alcohol treatment centers that have received state grants and that have historically 17 provided behavioral health services in the state to expand the availability of behavioral 18 health services while maintaining quality and cost controls; 19 (3) the Department of Health and Social Services establish prevention of 20 disease as a primary model of health care in the state, as requested by the legislature in 21 Legislative Resolve 16 of the Twenty-Seventh Alaska State Legislature. 22 * Sec. 2. AS 44.62.330(a) is amended by adding a new paragraph to read: 23 (47) Department of Health and Social Services relating to civil 24 penalties assessed against medical assistance providers under AS 47.05.250. 25 * Sec. 3. AS 47.05.010 is amended to read: 26 Sec. 47.05.010. Duties of department. The Department of Health and Social 27 Services shall 28 (1) administer adult public assistance, the Alaska temporary assistance 29 program, and all other assistance programs, and receive and spend money made 30 available to it; 31 (2) adopt regulations necessary for the conduct of its business and for
01 carrying out federal and state laws granting adult public assistance, temporary cash 02 assistance, diversion payments, or self-sufficiency services for needy families under 03 the Alaska temporary assistance program, and other assistance; 04 (3) establish minimum standards for personnel employed by the 05 department and adopt necessary regulations to maintain those standards; 06 (4) require those bonds and undertakings from persons employed by it 07 that, in its judgment, are necessary, and pay the premiums on them; 08 (5) cooperate with the federal government in matters of mutual 09 concern pertaining to adult public assistance, the Alaska temporary assistance 10 program, and other forms of public assistance; 11 (6) make the reports, in the form and containing the information, that 12 the federal government from time to time requires; 13 (7) cooperate with the federal government, its agencies, or 14 instrumentalities in establishing, extending, and strengthening services for the 15 protection and care of homeless, dependent, and neglected children in danger of 16 becoming delinquent, and receive and expend funds available to the department by the 17 federal government, the state, or its political subdivisions for that purpose; 18 (8) cooperate with the federal government in adopting state plans to 19 make the state eligible for federal matching in appropriate categories of assistance, and 20 in all matters of mutual concern, including adoption of the methods of administration 21 that are found by the federal government to be necessary for the efficient operation of 22 welfare programs; 23 (9) adopt regulations, not inconsistent with law, defining need, 24 prescribing the conditions of eligibility for assistance, and establishing standards for 25 determining the amount of assistance that an eligible person is entitled to receive; the 26 amount of the assistance is sufficient when, added to all other income and resources 27 available to an individual, it provides the individual with a reasonable subsistence 28 compatible with health and well-being; an individual who meets the requirements for 29 eligibility for assistance shall be granted the assistance promptly upon application for 30 it; 31 (10) grant to a person claiming or receiving assistance and who is
01 aggrieved because of the department's action or failure to act, reasonable notice and an 02 opportunity for a fair hearing by the office of administrative hearings (AS 44.64.010), 03 and the department shall adopt regulations relative to this; 04 (11) enter into reciprocal agreements with other states relative to 05 public assistance, welfare services, and institutional care that are considered advisable; 06 (12) establish the requirements of residence for public assistance, 07 welfare services, and institutional care that are considered advisable, subject to the 08 limitations of other laws of the state, or law or regulation imposed as conditions for 09 federal financial participation; 10 (13) establish the divisions and local offices that are considered 11 necessary or expedient to carry out a duty or authority assigned to it and appoint and 12 employ the assistants and personnel that are necessary to carry on the work of the 13 divisions and offices, and fix the compensation of the assistants or employees, except 14 that a person engaged in business as a retail vendor of general merchandise, or a 15 member of the immediate family of a person who is so engaged, may not serve as an 16 acting, temporary, or permanent local agent of the department, unless the 17 commissioner of health and social services certifies in writing to the governor, with 18 relation to a particular community, that no other qualified person is available in the 19 community to serve as local welfare agent; for the purposes of this paragraph, a 20 "member of the immediate family" includes a spouse, child, parent, brother, sister, 21 parent-in-law, brother-in-law, or sister-in-law; 22 (14) provide education and health-related services and referrals 23 designed to reduce the number of out-of-wedlock pregnancies and the number of 24 induced pregnancy terminations in the state; 25 (15) investigate reports of abuse, neglect, or misappropriation of 26 property by certified nurse aides in facilities licensed by the department under 27 AS 47.32; 28 (16) establish state policy relating to and administer federal programs 29 subject to state control as provided under 42 U.S.C. 3001 - 3058ee (Older Americans 30 Act of 1965), as amended, and related federal regulations; 31 (17) administer the older Alaskans service grants under AS 47.65.010 -
01 47.65.050 and the adult day care and family respite care grants under AS 47.65.100; 02 (18) establish guidelines for medical assistance providers to 03 develop health care delivery models that encourage adequate nutrition and 04 disease prevention. 05 * Sec. 4. AS 47.05.200(a) is amended to read: 06 (a) The department shall annually contract for independent audits of a 07 statewide sample of all medical assistance providers in order to identify overpayments 08 and violations of criminal statutes. The audits conducted under this section may not be 09 conducted by the department or employees of the department. The number of audits 10 under this section each year, as a total for the medical assistance programs under 11 AS 47.07 and AS 47.08, shall be 0.75 percent of all enrolled providers under the 12 programs, adjusted annually on July 1, as determined by the department, except that 13 the number of audits under this section may not be less than 75. The audits under this 14 section must include both on-site audits and desk audits and must be of a variety of 15 provider types. The department may not award a contract under this subsection to an 16 organization that does not retain persons with a significant level of expertise and 17 recent professional practice in the general areas of standard accounting principles and 18 financial auditing and in the specific areas of medical records review, investigative 19 research, and Alaska health care criminal law. The contractor, in consultation with the 20 commissioner, shall select the providers to be audited and decide the ratio of desk 21 audits and on-site audits to the total number selected. In identifying providers who 22 are subject to an audit under this chapter, the department shall attempt to 23 minimize concurrent state or federal audits. 24 * Sec. 5. AS 47.05.200(b) is amended to read: 25 (b) Within 90 days after receiving each audit report from an audit conducted 26 under this section, the department shall begin administrative procedures to recoup 27 overpayments identified in the audits and shall allocate the reasonable and necessary 28 financial and human resources to ensure prompt recovery of overpayments unless the 29 attorney general has advised the commissioner in writing that a criminal investigation 30 of an audited provider has been or is about to be undertaken, in which case, the 31 commissioner shall hold the administrative procedure in abeyance until a final
01 charging decision by the attorney general has been made. The commissioner shall 02 provide copies of all audit reports to the attorney general so that the reports can be 03 screened for the purpose of bringing criminal charges. The department may assess 04 interest and penalties on any identified overpayment. Interest under this 05 subsection shall be calculated using the statutory rates for postjudgment interest 06 accruing from the date of the issuance of the final audit. The department may not 07 assess interest under this subsection if a provider 08 (1) identifies and reports an overpayment to the department 09 independent of an audit conducted under this section; and 10 (2) repays the amount of the overpayment to the department 11 within five months after the date the provider reported the overpayment to the 12 department. 13 * Sec. 6. AS 47.05.200 is amended by adding a new subsection to read: 14 (f) After reviewing audit reports received under this section, the department 15 may collaborate with medical assistance providers or provider entities to provide or 16 create educational information for medical assistance providers regarding the most 17 frequent errors or overpayment types. 18 * Sec. 7. AS 47.05 is amended by adding a new section to read: 19 Sec. 47.05.250. Civil penalties. (a) The department may adopt regulations to 20 assess a civil penalty against a medical assistance provider who violates a provision of 21 this chapter, AS 47.07, or a regulation adopted under this chapter or AS 47.07. 22 (b) A civil penalty imposed under this section may not be less than $100 or 23 more than $25,000 for each occurrence. 24 (c) The provisions of this section are in addition to any other remedies 25 available under this chapter, AS 47.07, or regulations adopted under this chapter or 26 AS 47.07. 27 (d) A medical assistance provider who is assessed a civil penalty under this 28 section may appeal the decision in the manner provided for appeals under AS 44.62 29 (Administrative Procedure Act). The office of administrative hearings (AS 44.64.010) 30 shall conduct the hearing for an appeal. 31 * Sec. 8. AS 47.07.020(g) is amended to read:
01 (g) For a person whose Medicaid eligibility is not calculated using the 02 modified adjusted gross income standard set out in 42 U.S.C. 1396a(e)(14), the 03 [A] person's eligibility for medical assistance under this chapter may not be denied or 04 delayed on the basis of a transfer of assets for less than fair market value if the person 05 establishes to the satisfaction of the department that the denial or delay would work an 06 undue hardship on the person as determined on the basis of criteria in applicable 07 federal regulations. The department may only consider information provided by a 08 person claiming undue hardship that the department verifies through a source 09 other than the person's own statement. 10 * Sec. 9. AS 47.07.020(m) is amended to read: 11 (m) For a person whose Medicaid eligibility is not calculated using the 12 modified adjusted gross income standard set out in 42 U.S.C. 1396a(e)(14), and, 13 except [EXCEPT] as provided in (g) of this section, the department shall impose a 14 penalty period of ineligibility for the transfer of an asset for less than fair market value 15 by an applicant or an applicant's spouse consistent with 42 U.S.C. 1396p(c)(1). 16 * Sec. 10. AS 47.07.030(d) is amended to read: 17 (d) The department shall [MAY] establish [AS OPTIONAL SERVICES] a 18 primary care case management system or a managed care organization contract in 19 which certain eligible individuals, including super-utilizers as identified by the 20 department, are required to enroll and seek approval from a case manager or the 21 managed care organization before receiving certain services. The department shall 22 establish enrollment criteria and determine eligibility for services consistent with 23 federal and state law. 24 * Sec. 11. AS 47.07.030 is amended by adding a new subsection to read: 25 (h) In an annual report to the legislature, the department shall include 26 information separately describing state costs for optional and mandatory services 27 provided under this section. 28 * Sec. 12. AS 47.07.036 is amended by adding new subsections to read: 29 (d) Notwithstanding (a) - (c) of this section, the department shall 30 (1) apply for a section 1115 waiver under 42 U.S.C. 1315(a) to use 31 innovative service delivery system models to improve care, increase efficiency, reduce
01 costs, and expand services for recipients of behavioral health services, as defined by 02 the department by regulation; 03 (2) apply for a section 1915(i) option under 42 U.S.C. 1396n designed 04 to result in cost savings to the state and to improve services and care through home 05 and community-based services to obtain a 50 percent federal match; 06 (3) apply for a section 1915(k) option under 42 U.S.C. 1396n designed 07 to result in cost savings to the state and to provide home and community-based 08 services and support to increase the federal match for these programs from 50 percent 09 to 56 percent; 10 (4) evaluate and seek permission from the United States Department of 11 Health and Human Services Centers for Medicare and Medicaid Services to participate 12 in various demonstration projects, including payment reform, care management 13 programs, workforce development and innovation, and innovative services delivery 14 models; and 15 (5) enhance telemedicine capability and reimbursement to incentivize 16 its use for Medicaid recipients. 17 (e) Notwithstanding (a) - (c) of this section and in addition to the projects and 18 services described under (d) of this section, the department shall apply for a section 19 1115 waiver under 42 U.S.C. 1315(a) to establish one or more demonstration projects 20 focused on innovative payment models for one or more groups of medical assistance 21 recipients in one or more specific geographic areas. The demonstration project or 22 projects may include 23 (1) managed care organizations as described under 42 U.S.C. 1396u-2; 24 (2) community care organizations; 25 (3) patient-centered medical homes as described under 42 U.S.C. 256a- 26 1; or 27 (4) other innovative payment models that ensure access to health care 28 without reducing the quality of care. 29 (f) The department shall implement at least one demonstration project under 30 (e) of this section that is a coordinated care demonstration project using a global 31 payment fee structure. The demonstration project must include a managed care system
01 that operates within a fixed budget to reduce medical cost inflation, improves the 02 quality of health care for recipients, and results in a healthier population. The managed 03 care system must be designed to reduce the growth in medical assistance expenditures 04 with a goal of reducing the per capita growth rate for medical assistance expenditures 05 by at least two percentage points. The managed care system must implement 06 alternative payment methodologies and create a network of patient-centered primary 07 care homes, and will be measured based on quality and performance outcomes. The 08 department shall prepare a report regarding the progress of this demonstration project 09 and shall, on or before February 1, 2019, deliver the report to the senate secretary and 10 the chief clerk of the house of representatives and notify the legislature that the report 11 is available. 12 (g) In this section, "telemedicine" means the practice of health care delivery, 13 evaluation, diagnosis, consultation, or treatment, using the transfer of medical data 14 through audio, visual, or data communications performed over two or more locations 15 between providers who are physically separated from the recipient or from each other 16 or between a provider and a recipient who are physically separated from each other. 17 * Sec. 13. AS 47.07.900(4) is amended to read: 18 (4) "clinic services" means services provided by state-approved 19 outpatient community mental health clinics [THAT RECEIVE GRANTS UNDER 20 AS 47.30.520 - 47.30.620], state-operated community mental health clinics, outpatient 21 surgical care centers, and physician clinics; 22 * Sec. 14. AS 47.07.900(17) is amended to read: 23 (17) "rehabilitative services" means services for substance abusers and 24 emotionally disturbed or chronically mentally ill adults provided by 25 (A) a drug or alcohol treatment center [THAT IS FUNDED 26 WITH A GRANT UNDER AS 47.30.475]; or 27 (B) an outpatient community mental health clinic [THAT HAS 28 A CONTRACT TO PROVIDE COMMUNITY MENTAL HEALTH 29 SERVICES UNDER AS 47.30.520 - 47.30.620]; 30 * Sec. 15. The uncodified law of the State of Alaska is amended by adding a new section to 31 read:
01 PILOT PROJECT: REDUCING PRE-TERM BIRTHS. On or before July 1, 2017, the 02 Department of Health and Social Services shall contract with a third party to establish a care 03 coordination pilot project for approximately 500 voluntary participants who are eligible for 04 medical assistance under AS 47.07.020(b)(14) for the purpose of reducing pre-term birth rates 05 in the state from the current rate of 8.5 percent. The care coordination pilot project must focus 06 on nutritional sufficiency and offer pregnancy counselling, nutritional counselling, and, as 07 necessary, vitamin D supplementation to maintain levels of 40 ng/ml vitamin D during 08 pregnancy for participants in the pilot project. The care coordination pilot project may be 09 modeled after the Protect Our Children NOW! project implemented as a cooperative project 10 of the South Carolina Department of Health and Human Services and private health 11 organizations. The goal of the care coordination pilot project is to achieve a reduction in pre- 12 term births in the state, consistent with the results of the following published studies: Wagner, 13 C. L., et al., "A Randomized Trial of Vitamin D Supplementation in Two Community Health 14 Center Networks in South Carolina," American Journal of Obstetrics and Gynecology 208 15 (February 2013); Bodnar, L. M., et al., "Maternal 25-Hydroxyvitamin D and Preterm Birth in 16 Twin Gestations," Obstetrics and Gynecology 122 (July 2013). Two years after the date the 17 Department of Health and Social Services first enrolls recipients in the care coordination pilot 18 project, the Department of Health and Social Services shall deliver a report to the senate 19 secretary and the chief clerk of the house of representatives and notify the legislature that the 20 report is available. The report must describe the results of the care coordination pilot project, 21 any difference in the pre-term birth rate for participants in the pilot project as compared to the 22 pre-term birth rate for the state, and the estimated savings to the state resulting from the pilot 23 project. 24 * Sec. 16. The uncodified law of the State of Alaska is amended by adding a new section to 25 read: 26 MEDICAID MANAGED CARE FOR SUPER-UTILIZERS. On or before January 1, 27 2017, the Department of Health and Social Services shall 28 (1) establish a primary care case management system or a managed care 29 organization contract under AS 47.07.030(d), as amended by sec. 10 of this Act, for super- 30 utilizers, as identified by the department; and 31 (2) deliver a report on the system or contract to the senate secretary and the
01 chief clerk of the house of representatives and notify the legislature that the report is 02 available. 03 * Sec. 17. The uncodified law of the State of Alaska is amended by adding a new section to 04 read: 05 MEDICAID REDESIGN; REPORTS TO LEGISLATURE. (a) On or before May 30, 06 2016, the Department of Health and Social Services shall deliver to the senate secretary and 07 chief clerk of the house of representatives the Report on Recommended Action and 08 Evaluation Plans for Expansion and Reform prepared for the department under the Medicaid 09 Redesign and Expansion Technical Assistance study, advertised under request for proposal 10 number 2015-0600-3077, issued April 21, 2015, and the department shall notify the 11 legislature that the report is available. 12 (b) The Department of Health and Social Services shall prepare a report summarizing 13 cost-sharing measures implemented before October 1, 2015, by the Department of Health and 14 Social Services under AS 47.07.042 and describing the effect of those measures on the state 15 budget. On or before the 20th day following the effective date of this section, the Department 16 of Health and Social Services shall deliver a copy of the report to the senate secretary and 17 chief clerk of the house of representatives and notify the legislature that the report is 18 available. 19 (c) The Department of Health and Social Services shall complete two reports 20 informing the legislature of the results of the applications for waivers and options under 21 AS 47.07.036(d)(1) - (3), enacted by sec. 12 of this Act and shall deliver the reports to the 22 senate secretary and chief clerk of the house of representatives and notify the legislature that 23 the reports are available. The Department of Health and Social Services shall deliver the first 24 report on or before November, 1, 2018, and the second report on or before November 1, 2019. 25 The reports must include 26 (1) information explaining whether the department's applications for a section 27 1115 waiver under 42 U.S.C. 1315(a), a section 1915(i) option under 42 U.S.C. 1396n, and a 28 section 1915(k) option under 42 U.S.C. 1396n were approved by the United States 29 Department of Health and Human Services; 30 (2) a description of cost savings to the state resulting from the programs 31 implemented under the waivers, including
01 (A) the extent to which the programs implemented under the section 02 1115 waiver under 42 U.S.C. 1315(a) achieved the savings estimated by the 03 department; 04 (B) the extent to which the programs implemented under the section 05 1915(i) and (k) options under 42 U.S.C. 1396n achieved the savings estimated by the 06 department. 07 * Sec. 18. The uncodified law of the State of Alaska is amended by adding a new section to 08 read: 09 IMPLEMENT FEDERAL POLICY ON TRIBAL MEDICAID REIMBURSEMENT. 10 (a) The Department of Health and Social Services shall collaborate with Alaska tribal health 11 organizations and the United States Department of Health and Human Services to implement 12 changes fully in federal policy that authorize 100 percent federal funding for services 13 provided to American Indian and Alaska Native individuals eligible for Medicaid. 14 Collaboration may include incentives for providers to participate in contracts for referrals, as 15 permitted under federal law. 16 (b) In this section, "Alaska tribal health organization" means an organization 17 recognized by the United States Indian Health Service to provide health-related services. 18 * Sec. 19. The uncodified law of the State of Alaska is amended by adding a new section to 19 read: 20 MEDICAID STATE PLAN INSTRUCTIONS; NOTICE TO REVISOR OF 21 STATUTES. The Department of Health and Social Services shall immediately amend and 22 submit for federal approval a state plan for medical assistance coverage consistent with this 23 Act. The Department of Health and Social Services shall apply to the United States 24 Department of Health and Human Services for any waivers necessary to implement this Act. 25 The commissioner of health and social services shall notify the revisor of statutes in writing if 26 the United States Department of Health and Human Services approves the provisions of 27 AS 47.07.030(d), as amended by sec. 10 of this Act, the provisions of AS 47.07.036(e) and 28 (f), added by sec. 12 of this Act, and the provisions of secs. 15 and 16 of this Act. 29 * Sec. 20. The uncodified law of the State of Alaska is amended by adding a new section to 30 read: 31 TRANSITION: REGULATIONS. The Department of Health and Social Services may
01 adopt regulations necessary to implement the changes made by this Act. The regulations take 02 effect under AS 44.62 (Administrative Procedure Act), but not before the effective date of the 03 relevant provision of this Act implemented by the regulation. 04 * Sec. 21. The uncodified law of the State of Alaska is amended by adding a new section to 05 read: 06 REVISOR'S INSTRUCTION. The revisor of statutes is requested to change the catch 07 line of AS 47.07.036 from "Cost containment measures authorized" to "Medical assistance 08 cost-containment and reform measures authorized." 09 * Sec. 22. The uncodified law of the State of Alaska is amended by adding a new section to 10 read: 11 CONDITIONAL EFFECT. (a) AS 47.07.030(d), as amended by sec. 10 of this Act, 12 and sec. 16 of this Act take effect only if the commissioner of health and social services 13 notifies the revisor of statutes in writing under sec. 19 of this Act, on or before January 1, 14 2017, that all of the provisions added by AS 47.07.030(d), as amended by sec. 10 of this Act, 15 and all of the provisions of sec. 16 of this Act have been approved by the United States 16 Department of Health and Human Services. 17 (b) AS 47.07.036(e), added by sec. 12 of this Act, takes effect only if the 18 commissioner of health and social services notifies the revisor of statutes in writing under sec. 19 19 of this Act, on or before February 1, 2019, that all of the provisions of AS 47.07.036(e), 20 added by sec. 12 of this Act, have been approved by the United States Department of Health 21 and Human Services. 22 (c) AS 47.07.036(f), added by sec. 12 of this Act, takes effect only if the 23 commissioner of health and social services notifies the revisor of statutes in writing under sec. 24 19 of this Act, on or before February 1, 2019, that all of the provisions added by 25 AS 47.07.036(f), added by sec. 12 of this Act, have been approved by the United States 26 Department of Health and Human Services. 27 (d) Section 15 of this Act takes effect only if the commissioner of health and social 28 services notifies the revisor of statutes in writing under sec. 19 of this Act, on or before July 1, 29 2017, that all of the provisions added by sec. 15 of this Act have been approved by the United 30 States Department of Health and Human Services. 31 * Sec. 23. If AS 47.07.030(d), as amended by sec. 10 of this Act, and sec. 16 of this Act
01 take effect, they take effect on the day after the date the commissioner of health and social 02 services makes a certification to the revisor of statutes under secs. 19 and 22(a) of this Act. 03 * Sec. 24. If AS 47.07.036(e), added by sec. 12 of this Act, takes effect, it takes effect on 04 the day after the date the commissioner of health and social services notifies the revisor of 05 statutes in writing under secs. 19 and 22(b) of this Act. 06 * Sec. 25. If AS 47.07.036(f), added by sec. 12 of this Act, takes effect, it takes effect on the 07 day after the date the commissioner of health and social services notifies the revisor of 08 statutes in writing under secs. 19 and 22(c) of this Act. 09 * Sec. 26. If sec. 15 of this Act takes effect, it takes effect on the day after the date the 10 commissioner of health and social services notifies the revisor of statutes in writing under 11 secs. 19 and 22(d) of this Act. 12 * Sec. 27. Sections 17(a), 19, 20, and 22 of this Act take effect immediately under 13 AS 01.10.070(c).