S T A T E O F N E W Y O R K
________________________________________________________________________
5224--B
2011-2012 Regular Sessions
I N S E N A T E
May 3, 2011
___________
Introduced by Sens. RANZENHOFER, DeFRANCISCO, LAVALLE, LIBOUS, STEWART-
COUSINS, ZELDIN -- read twice and ordered printed, and when printed to
be committed to the Committee on Health -- recommitted to the Commit-
tee on Health in accordance with Senate Rule 6, sec. 8 -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee
AN ACT to amend the public health law, in relation to ability of contin-
uing care retirement communities to offer seniors additional service
options
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Subdivisions 2-a, 2-b, 3, 8, 9, 10 and 10-a of section 4601
2 of the public health law, subdivision 2-a as added and subdivisions 3, 8
3 and 9 as amended by chapter 659 of the laws of 1997, subdivision 2-b as
4 amended by chapter 523 of the laws of 2011, subdivision 10 as added by
5 chapter 689 of the laws of 1989, and subdivision 10-a as added by chap-
6 ter 401 of the laws of 2003, are amended and three new subdivisions 7-a,
7 7-b and 7-c are added to read as follows:
8 2-a. "Continuing care retirement contract" shall mean a single
9 contract to provide a person the services provided by a continuing care
10 retirement community INCLUDING LIFE CARE OR LIFE CARE AT HOME.
11 2-b. "Continuing care retirement community" or "community" shall mean
12 a facility or facilities established to provide a comprehensive, cohe-
13 sive living arrangement for the elderly, oriented to the enhancement of
14 the quality of life and which, pursuant to the terms of the continuing
15 care RETIREMENT contract OFFERED BY THE COMMUNITY, at a minimum:
16 a. provides, OR SUPPORTS THROUGH LIFE CARE AT HOME, independent living
17 units, and [provides a] meal plan OPTIONS. The independent living unit
18 can be made available either through a non-equity arrangement or through
19 an equity arrangement including, but not limited to a cooperative or
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD11311-04-2
S. 5224--B 2
1 condominium. For purposes of this article, the purchase price of an
2 independent living unit in an equity arrangement, regardless of the form
3 of the purchase agreement, shall not be considered an entry fee for
4 purposes of calculating reserve liabilities, but shall be considered an
5 entry fee for escrow purposes;
6 b. provides a range of health care and social services, subject to
7 such terms as may be included within the contract, which shall include
8 adult care facility services of an on-site or affiliated adult care
9 facility, and at a minimum, sixty days of prepaid services of an on-site
10 or affiliated nursing facility for residents not receiving services
11 under a fee-for-service contract;
12 c. provides access to health services as defined in the contract,
13 prescription drugs, and rehabilitation services;
14 d. nothing in this article shall eliminate the obligation of a contin-
15 uing care retirement community to provide at least sixty days of prepaid
16 nursing facility services to all residents, with the exception of resi-
17 dents receiving services under the terms of a fee-for-service continuing
18 care contract as defined in this section. The prepaid days must include
19 the first sixty days of nursing facility services, whether or not
20 consecutive, not covered by Title XVIII of the federal social security
21 act; and
22 e. communities established under this article and offering fee-for-
23 service continuing care contracts must offer, along with such fee-for-
24 service continuing care contracts, life care and/or continuing care
25 contracts as defined in subdivision eight-a of this section.
26 3. "Contracts" or "agreements" shall mean LIFE CARE AT HOME OR contin-
27 uing care retirement contracts as defined in this article.
28 7-A. "LIFE CARE AT HOME" SHALL MEAN AN ESTABLISHED SEPARATE 501 (C) 3
29 CORPORATION AFFILIATED WITH THE EXISTING CCRC CAMPUS PROVIDER THROUGH
30 WHICH CONTRACT HOLDERS PAY AN ENTRANCE FEE AND A MONTHLY FEE, BOTH OF
31 WHICH WOULD CORRESPOND TO THE LEVEL OF SERVICE CHOSEN BY THE CONTRACT
32 HOLDER. A LIFE CARE AT HOME CONTRACT INCLUDES SERVICES COORDINATED BY A
33 CASE MANAGER BASED UPON INDIVIDUALS' NEEDS. SERVICES OFFERED INCLUDE,
34 BUT ARE NOT LIMITED TO, PERSONAL HEALTH COORDINATION, EMERGENCY RESPONSE
35 SYSTEM, HEALTH AND WELLNESS PROGRAMS, HOME NURSE VISITS, COMPANION
36 SERVICES, HOME INSPECTIONS, TRANSPORTATION, MEALS, ON-CAMPUS ACTIVITIES
37 AND CULTURAL EVENTS. LIFE CARE AT HOME SERVICES SHALL INCLUDE, BASED
38 UPON INDIVIDUAL CONTRACTS, SERVICES OF AN ON-SITE OR AFFILIATED NURSING
39 FACILITY AND AN ON-SITE OR AFFILIATED ADULT CARE FACILITY.
40 7-B. "LIFE CARE AT HOME CONTRACT" SHALL MEAN A SINGLE CONTRACT TO
41 PROVIDE A PERSON, FOR THE DURATION OF SUCH PERSON'S LIFE, SUCH SERVICES
42 SELECTED BY THE INDIVIDUAL WHICH MAY INCLUDE SERVICES PROVIDED TO THE
43 INDIVIDUAL IN HIS OR HER RESIDENCE.
44 7-C. A. "LIFE CARE AT HOME" CORPORATIONS PROVIDING HOSPITAL CARE AS
45 DEFINED IN SECTION TWENTY-EIGHT HUNDRED ONE OF THIS CHAPTER MUST BE
46 LICENSED UNDER ARTICLE TWENTY-EIGHT AND SHALL BE SUBJECT TO THE
47 PROVISIONS AND STANDARDS OF SUCH ARTICLE.
48 B. "LIFE CARE AT HOME" CORPORATIONS PROVIDING HOME CARE SERVICES AS
49 DEFINED IN SECTION THIRTY-SIX HUNDRED TWO OF THIS CHAPTER MUST BE
50 LICENSED UNDER ARTICLE THIRTY-SIX AND SHALL BE SUBJECT TO THE PROVISIONS
51 AND STANDARDS OF SUCH ARTICLE.
52 8. "Life care contract" shall mean a single continuing care retirement
53 contract to provide a person, for the duration of such person's life,
54 the services provided by the continuing care retirement community, which
55 services shall include unlimited services of an on-site or affiliated
56 nursing facility AND UNLIMITED SERVICES OF AN ON-SITE OR AFFILIATED
S. 5224--B 3
1 ADULT CARE FACILITY. Such term also shall mean a single continuing care
2 retirement contract to provide a person, for the duration of such
3 person's life, the services provided by the continuing care retirement
4 community under an arrangement in which the costs of the residents'
5 unlimited nursing home or home health care services are paid for in
6 whole or in part by a long term care insurance policy approved by the
7 superintendent in accordance with applicable regulations or by long term
8 care insurance or medical assistance payments in accordance with the
9 partnership for long term care program pursuant to the provisions of
10 section three hundred sixty-seven-f of the social services law, section
11 three thousand two hundred twenty-nine of the insurance law and section
12 four thousand six hundred twenty-three of this chapter.
13 9. "Life care" shall mean those services provided pursuant to a ["life
14 care contract"] "CONTINUING CARE RETIREMENT CONTRACT".
15 10. "Living unit" shall mean an apartment, room, cottage, or other
16 area within a community set aside for the exclusive use of one or more
17 residents, OR THE CONTRACT HOLDER'S PRIVATE RESIDENCE.
18 10-a. "Meal plan" shall mean an arrangement whereby the person enter-
19 ing into the continuing care retirement contract is provided with [no
20 fewer than five meals per month. Additional meals shall be available on
21 a fee-for-service basis] OPTIONS REGARDING THE INCLUSION OF MEALS WITHIN
22 THE CONTRACT.
23 S 2. The opening paragraph of subdivision 2 of section 4602 of the
24 public health law, as amended by chapter 659 of the laws of 1997, is
25 amended to read as follows:
26 The council shall meet as often as may be deemed necessary to fulfill
27 its responsibilities[, but in no event less than four times per year].
28 The council shall have the following powers and duties:
29 S 3. Subdivision 1 of section 4603-a of the public health law, as
30 added by chapter 393 of the laws of 1991, is amended to read as follows:
31 1. The commissioner, upon approval of the [life care] CONTINUING CARE
32 RETIREMENT community council and the public health council shall issue a
33 certificate of incorporation of up to three residential health care
34 demonstration facilities. Notwithstanding any provision of article twen-
35 ty-eight of this chapter or any other provisions of law to the contrary,
36 the public health council may approve without regard to the requirement
37 of public need as set forth in subdivision three of section twenty-eight
38 hundred one-a of this chapter, a certificate of incorporation or appli-
39 cation for establishment of such facilities.
40 S 4. Paragraphs d and e and clause (C) of subparagraph (iv) of para-
41 graph j of subdivision 2 of section 4604 of the public health law, para-
42 graph d as added by chapter 689 of the laws of 1989 and paragraph e and
43 clause (C) of subparagraph (iv) of paragraph j as amended by chapter 659
44 of the laws of 1997, are amended to read as follows:
45 d. a copy of the proposed forms of CONTINUING CARE RETIREMENT
46 contracts to be entered into with residents of the community;
47 e. complete details of any agreements with a licensed insurer, includ-
48 ing copies of proposed contracts, requiring the insurer to assume, whol-
49 ly or in part, the cost of medical or health related services to be
50 provided to a resident pursuant to a continuing care retirement
51 [contract] CONTRACTUAL AGREEMENT;
52 (C) is or was subject to a currently effective injunctive or restric-
53 tive order or federal or state administrative order relating to business
54 activity or health care as a result of an action brought by a public
55 agency or department, including, without limitation, actions affecting a
56 license to operate a hospital as defined by section twenty-eight hundred
S. 5224--B 4
1 one of this chapter, or a facility required to be licensed or certified
2 by the department of [social services] HEALTH. The statement shall set
3 forth the court or agency, date of conviction or judgment, the penalty
4 imposed or damages assessed, or the date, nature and issuer of the
5 order;
6 S 5. Paragraph b of subdivision 4 and subdivisions 5 and 8 of section
7 4604 of the public health law, paragraph b of subdivision 4 as amended
8 by chapter 659 of the laws of 1997, subdivision 5 as amended by chapter
9 700 of the laws of 2006 and subdivision 8 as added by chapter 689 of the
10 laws of 1989, are amended to read as follows:
11 b. the commissioner [of social services] as to those aspects of the
12 application relating to adult care facility beds, if any;
13 5. Up to two thousand residential health care facility beds, as
14 authorized herein, that may be approved as components of continuing care
15 retirement communities shall not be considered by the department and the
16 health systems agencies in the determination of public need for residen-
17 tial health care facility services; provided, however, that if the
18 community seeking to construct such beds does not provide A life care OR
19 LIFE CARE AT HOME CONTRACT to all residents, it must adequately make the
20 assurances required by subdivision two of section forty-six hundred
21 twenty-four of this article.
22 8. The operator shall designate and make knowledgeable personnel
23 available to prospective residents to answer questions about any infor-
24 mation contained in the disclosure statement or contract. The disclosure
25 statement and the CONTINUING CARE RETIREMENT contract shall each state
26 on the cover or top of the first page in bold twelve point print the
27 following "This matter involves a substantial financial investment and a
28 legally binding contract. In evaluating the disclosure statement and the
29 contract prior to any commitment, it is recommended that you consult
30 with an attorney and financial advisor of your choice, if you so elect,
31 who can review these documents with you."
32 S 6. Paragraph g of subdivision 2 of section 4604-a of the public
33 health law, as added by chapter 659 of the laws of 1997, is amended to
34 read as follows:
35 g. Unless all residents have EITHER life care OR LIFE CARE AT HOME
36 contracts, the operator has adequately made the assurances required by
37 subdivision two of section forty-six hundred twenty-four of this article
38 and has agreed to fund the liability in the event that resident assets
39 are insufficient to pay for nursing facility services for a one year
40 period.
41 S 7. Paragraph d of subdivision 1 of section 4605 of the public health
42 law, as amended by chapter 659 of the laws of 1997, is amended to read
43 as follows:
44 d. to offer and execute CONTINUING CARE RETIREMENT contracts, includ-
45 ing the collection of entrance fees and deposits pursuant to section
46 forty-six hundred eight of this article.
47 S 8. The opening paragraph, paragraph d of subdivision 11 and subdivi-
48 sion 13 of section 4606 of the public health law, the opening paragraph
49 as amended by chapter 120 of the laws of 1993, paragraph d of subdivi-
50 sion 11 as added by chapter 689 of the laws of 1989 and subdivision 13
51 as added by chapter 659 of the laws of 1997, are amended to read as
52 follows:
53 Prior to the execution of a CONTINUING CARE RETIREMENT contract, or
54 before the transfer of any money, other than a refundable priority
55 reservation fee or non-refundable priority reservation agreement appli-
56 cation fee, to an operator by or on behalf of a prospective resident,
S. 5224--B 5
1 whichever occurs first, the operator shall deliver to the person with
2 whom the contract is to be entered into or the person's legal represen-
3 tative the most recent annual statement as required by section forty-six
4 hundred seven of this article, and an initial disclosure statement which
5 contains the following:
6 d. an estimate of any funds which are anticipated to be necessary to
7 fund start-up losses and to assure full performance of the obligations
8 of the operator pursuant to [life care] CONTINUING CARE contracts
9 including, but not limited to, any reserves required pursuant to section
10 forty-six hundred eleven of this article;
11 13. The initial disclosure statement and marketing materials of a
12 continuing care retirement community must clearly include a description
13 of the services offered as part of its contract, including, but not
14 limited to, any limitations on nursing facility services. The initial
15 disclosure statement and marketing materials of a continuing care
16 retirement community which offers various types of contracts, which may
17 include life care, MODIFIED AND LIFE CARE AT HOME contracts, must clear-
18 ly differentiate among the various types of contracts which it may
19 offer.
20 S 9. Paragraphs e, f and g of subdivision 14 of section 4606 of the
21 public health law are relettered paragraphs f, g and h and a new para-
22 graph e is added to read as follows:
23 E. THE TYPES OF MEAL PLANS AVAILABLE;
24 S 10. Section 4608 of the public health law, as added by chapter 689
25 of the laws of 1989, the section heading, the opening paragraph and
26 subdivision 6 as amended and subdivision 17 as added by chapter 659 of
27 the laws of 1997, subdivision 2 as amended by chapter 120 of the laws of
28 1993, subdivision 8 as amended by chapter 66 of the laws of 1994 and
29 subdivision 15 as further amended by section 104 of part A of chapter 62
30 of the laws of 2011, is amended to read as follows:
31 S 4608. Continuing care retirement contract. A LIFE CARE, MODIFIED OR
32 LIFE CARE AT HOME continuing care retirement contract shall contain all
33 of the following information in no less than twelve point type and in
34 plain language, in addition to any other terms or matter as may be
35 required by regulations adopted by the council and issued by the super-
36 intendent, EXCEPT WHEN SPECIFICALLY NOTED:
37 1. The amount of all money transferred, including, but not limited to,
38 donations, subscriptions, deposits, fees, and any other amounts paid or
39 payable by, or on behalf of, the resident or residents;
40 2. A description of all services which are to be furnished by the
41 operator, a description of any fees in addition to the entrance fee and
42 periodic charges provided for in the contract, and the conditions under
43 which the fees may be adjusted, provided that an operator shall not
44 charge any non-refundable application fee to a prospective resident who
45 has paid a non-refundable priority reservation agreement application
46 fee;
47 3. The procedures of the community relating to a resident's failure to
48 pay the required monthly fees;
49 4. A statement of the figures and terms concerning the entry of a
50 spouse to the community and the consequences if the spouse does not meet
51 the requirements for entry;
52 5. A statement of the terms and conditions under which a contract may
53 be cancelled by the operator or by a resident and the conditions under
54 which all or any portion of the entrance fee will be refunded by the
55 operator, including the mandatory refund provisions set forth in
S. 5224--B 6
1 sections forty-six hundred nine and forty-six hundred ten of this arti-
2 cle;
3 6. a. [The] FOR LIFE CARE AND MODIFIED CONTRACTS ONLY THE procedures
4 and conditions under which a resident may be transferred from his or her
5 living unit including a statement that, at the time of transfer, the
6 resident will be given the reasons for the transfer; the process by
7 which a transfer decision is made; the persons with the authority to
8 make the decision to transfer; a description of any change in charges to
9 be paid by the resident for services not covered by the contract fees as
10 a result of the transfer; and a statement regarding the disposition of
11 and the right to return to the living unit in cases of temporary and
12 permanent transfers.
13 b. [The] FOR LIFE CARE AND MODIFIED CONTRACTS ONLY THE circumstances
14 under which a living unit may be considered vacant and eligible for
15 transfer or resale to a new resident, either due to the permanent trans-
16 fer of a resident to the community's nursing or other specialized facil-
17 ity or due to the permanent transfer of a resident to a hospital or
18 other facility outside of the community; provided, however, that nothing
19 therein shall relieve a community from its obligations to provide or to
20 insure provision of all contractually required care pursuant to the
21 terms of a continuing care retirement contract. Should a resident's
22 chronic condition require placement in a more specialized chronic care
23 facility that provides services beyond those provided through the commu-
24 nity's nursing facility, the liability of THE community pursuant to the
25 terms of a continuing care retirement contract shall be equal to the
26 current per diem rate of the nursing facility minus the pro rata appor-
27 tionment of the resident's monthly fee for the period of care required
28 by the contract. Nothing herein shall obligate a continuing care
29 retirement community which does not have a life care contract with a
30 resident to provide or pay for a level of nursing facility services nor
31 for any duration beyond what is specifically described in its continuing
32 care retirement contract with that resident. This section shall not
33 affect the operator's obligation under subdivision two of section
34 forty-six hundred twenty-four of this article;
35 7. [A] FOR LIFE CARE AND MODIFIED CONTRACTS ONLY A statement that, if
36 the resident dies prior to occupancy date or, through illness, injury,
37 or incapacity is precluded from becoming a resident under the terms of
38 the contract, the contract is automatically rescinded and the resident
39 or his or her legal representative shall receive a full refund of all
40 moneys paid to the facility, except for those costs specifically
41 incurred by the facility at the request of the resident and set forth in
42 writing in a separate addendum, signed by the parties to the contract;
43 8. FOR LIFE CARE AT HOME CONTRACTS THE CIRCUMSTANCES UNDER WHICH THE
44 CONTRACT HOLDER MAY MOVE INTO A CAMPUS INDEPENDENT LIVING UNIT;
45 9. A statement of the conditions under which all or any portion of the
46 entrance fee will be released to the operator before the living unit
47 becomes available for occupancy, and a statement of the conditions under
48 which all or any portion of that fee will be refunded in the event of
49 the death of the resident and/or spouse following occupancy of a living
50 unit, including the mandatory refund provisions set forth in section
51 forty-six hundred nine of this article;
52 [9.] 10. A statement of the advance notice to be provided the resi-
53 dent, of not less than sixty days, of any change in fees or charges or
54 scope of care or services;
55 [10.] 11. A statement that no act, agreement, or statement of any
56 resident, or of an individual purchasing care for a resident under any
S. 5224--B 7
1 agreement to furnish care to the resident, shall constitute a valid
2 waiver of any provision of this article or of any regulation enacted
3 pursuant thereto intended for the benefit or protection of the resident
4 or the individual purchasing care for the resident;
5 [11. A] 12. FOR LIFE CARE AND MODIFIED CONTRACTS A description of the
6 reinstatement policies if a resident leaves the facility or the contract
7 is cancelled;
8 [12.] 13. FOR LIFE CARE AT HOME CONTRACTS A DESCRIPTION OF POLICIES IF
9 THE CONTRACT IS CANCELLED.
10 14. A statement that internal procedures to resolve disputes and
11 grievances have been established, and residents notified of them;
12 [13.] 15. A statement of the grace period, if any, for the payment of
13 periodic fees without a penalty, and the extent of any penalty for the
14 late payment thereof;
15 [14.] 16. A statement that: a. the resident shall, if eligible, enroll
16 in medicare parts a and b or the equivalent and shall continue to main-
17 tain that coverage, together with medicare supplement coverage at least
18 equivalent in benefits to those established by the superintendent as
19 minimum benefits for medicare supplement policies;
20 b. if the resident fails to maintain medicare coverage and a medicare
21 supplement coverage, or is ineligible for such coverage and fails to
22 purchase the equivalent of such coverage, the community shall purchase
23 the coverage or equivalent coverage on behalf and at the expense of the
24 resident and shall have the authority to require an appropriate adjust-
25 ment in payments by the resident to the community;
26 c. if the community cannot purchase medicare coverage and medicare
27 supplement coverage or the equivalent, the community shall have the
28 authority to require an adjustment in monthly fees, subject to the
29 approval of the superintendent, to fund the additional risk to the
30 facility; and
31 d. if the resident fails to purchase or maintain medicare coverage and
32 medicare supplement coverage or the equivalent, and the community has
33 not purchased such coverage, the community will be responsible for any
34 expenses which would have been covered by medicare and medicare supple-
35 ment coverage. The community may add the amount of such expenses to the
36 resident's monthly fees.
37 [15.] 17. A statement that any amendment to the contract and any
38 change in fees or charges, other than those within the guidelines of an
39 approved rating system, must be approved by the superintendent of finan-
40 cial services; and
41 [16.] 18. A statement that property shall not be substituted as
42 payment for either the entrance fee or monthly fee.
43 [17.] 19. A statement whether the continuing care retirement contract
44 includes any ownership, beneficial or trust interest in the assets of
45 the operator, the assets of the facility, or both. Assets shall include,
46 but are not limited to, property, trusts, reserves, interest and other
47 assets.
48 S 11. Subdivision 1 of section 4612 of the public health law, as added
49 by chapter 689 of the laws of 1989, is amended to read as follows:
50 1. Residents [living] in a community authorized by this article shall
51 have the right of self-organization, the right to be represented by one
52 or more individuals of their own choosing, and the right to engage in
53 concerted activities for the purpose of keeping informed of the opera-
54 tion of the community in which they live.
55 S 12. Subdivisions 1 and 2 of section 4614 of the public health law,
56 as amended by chapter 659 of the laws of 1997 and subdivision 2 as
S. 5224--B 8
1 further amended by section 104 of part A of chapter 62 of the laws of
2 2011, are amended to read as follows:
3 1. The commissioner, or designee; AND the superintendent, or designee;
4 [and, with regard to communities for which the department of social
5 services has regulatory responsibility, the commissioner of social
6 services, or designee,] may at any time, and shall at least once every
7 three years, visit each community and examine the business of any appli-
8 cant for a certificate of authority and any operator engaged in the
9 execution of continuing care retirement contracts or engaged in the
10 performance of obligations under such contracts. Routine examinations
11 may be conducted by having documents designated by and submitted to such
12 commissioners or superintendent, which shall include financial documents
13 and records conforming to commonly accepted accounting principles and
14 practices. The final written report of each such examination conducted
15 by such commissioners or superintendent shall be filed with the commis-
16 sioner and, when so filed, shall constitute a public record. A copy of
17 each report shall be provided to members of the continuing care retire-
18 ment community council. Any operator being examined shall, upon request,
19 give reasonable and timely access to all of its records. The represen-
20 tative or examiner designated by the commissioners or superintendent,
21 respectively, may, at any time, examine the records and affairs and
22 inspect the community's facilities, whether in connection with a formal
23 examination or not.
24 2. Any duly authorized officer, employee, or agent of the health
25 department, [social services department,] or department of financial
26 services may, upon presentation of proper identification, have access
27 to, and inspect, any records maintained by the community relevant to the
28 respective agency's regulatory authority, with or without advance
29 notice, to secure compliance with, or to prevent a violation of, any
30 provision of this article.
31 S 13. Paragraph k of subdivision 1 of section 4615 of the public
32 health law, as amended by chapter 659 of the laws of 1997, is amended to
33 read as follows:
34 k. The commissioner [or the commissioner of social services] has found
35 violations of applicable statutes, rules or regulations which threaten
36 to affect directly the health, safety, or welfare of a resident of a
37 continuing care retirement community.
38 S 14. The section heading of section 4623 of the public health law, as
39 amended by chapter 659 of the laws of 1997, is amended to read as
40 follows:
41 Long term care insurance [for] AND continuing care retirement
42 contracts.
43 S 15. This act shall take effect on the one hundred eightieth day
44 after it shall have become a law; provided, however, that effective
45 immediately the department of health is authorized to take such steps in
46 advance of such effective date, including the addition, amendment and/or
47 repeal of any rule or regulation as may be necessary to ensure the time-
48 ly implementation of this act on such effective date.