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       Florida Senate - 2010                             CS for SB 1256
       By the Committee on Health Regulation; and Senator Peaden
       588-03196-10                                          20101256c1
    1                        A bill to be entitled                      
    2         An act relating to the physician workforce; repealing
    3         s. 381.0403, F.S., relating to the Community Hospital
    4         Education Act and the Community Hospital Education
    5         Council; amending s. 381.4018, F.S.; providing
    6         definitions; requiring the Department of Health to
    7         coordinate and enhance activities regarding the
    8         reentry of retired military and other physicians into
    9         the physician workforce; revising the list of
   10         governmental stakeholders that the Department of
   11         Health is required to work with regarding the state
   12         strategic plan and in assessing the state’s physician
   13         workforce; creating the Physician Workforce Advisory
   14         Council; providing membership of the council;
   15         providing for appointments to the council; providing
   16         terms of membership; providing for removal of a
   17         council member; providing for the chair and vice chair
   18         of the council; providing that council members are not
   19         entitled to receive compensation or reimbursement for
   20         per diem or travel expenses; providing the duties of
   21         the council; establishing the physician workforce
   22         graduate medical education innovation pilot projects
   23         under the department; providing the purposes of the
   24         pilot projects; providing for the appropriation of
   25         state funds for the pilot projects; requiring the
   26         pilot projects to meet certain policy needs of the
   27         physician workforce in this state; providing criteria
   28         for prioritizing proposals for pilot projects;
   29         requiring the department to adopt by rule appropriate
   30         performance measures; requiring participating pilot
   31         projects to submit an annual report to the department;
   32         requiring state funds to be used to supplement funds
   33         from other sources; requiring the department to adopt
   34         rules; amending ss. 458.3192 and 459.0082, F.S.;
   35         requiring the department to determine by geographic
   36         area and specialty the number of physicians and
   37         osteopathic physicians who plan to relocate outside
   38         the state, practice medicine in this state, and reduce
   39         or modify the scope of their practice; authorizing the
   40         department to report additional information in its
   41         findings to the Governor and the Legislature; amending
   42         s. 409.908, F.S.; conforming a cross-reference;
   43         providing an effective date.
   45  Be It Enacted by the Legislature of the State of Florida:
   47         Section 1. Section 381.0403, Florida Statutes, is repealed.
   48         Section 2. Section 381.4018, Florida Statutes, is amended
   49  to read:
   50         381.4018 Physician workforce assessment and development.—
   51         (1) DEFINITIONS.—As used in this section, the term:
   52         (a) “Consortium” or “consortia” means a combination of
   53  statutory teaching hospitals, statutory rural hospitals, other
   54  hospitals, accredited medical schools, clinics operated by the
   55  Department of Health, clinics operated by the Department of
   56  Veterans’ Affairs, area health education centers, community
   57  health centers, federally qualified health centers, prison
   58  clinics, local community clinics, or other programs. At least
   59  one member of the consortium shall be a sponsoring institution
   60  accredited or currently seeking accreditation by the
   61  Accreditation Council for Graduate Medical Education or the
   62  American Osteopathic Association.
   63         (b) “Council” means the Physician Workforce Advisory
   64  Council.
   65         (c) “Department” means the Department of Health.
   66         (d) “Graduate medical education program” means a program
   67  accredited by the Accreditation Council for Graduate Medical
   68  Education or the American Osteopathic Association.
   69         (e) “Primary care specialty” means emergency medicine,
   70  family practice, internal medicine, pediatrics, psychiatry,
   71  geriatrics, general surgery, obstetrics and gynecology, and
   72  combined pediatrics and internal medicine and other specialties
   73  as determined by the Physician Workforce Advisory Council or the
   74  Department of Health.
   75         (2)(1) LEGISLATIVE INTENT.—The Legislature recognizes that
   76  physician workforce planning is an essential component of
   77  ensuring that there is an adequate and appropriate supply of
   78  well-trained physicians to meet this state’s future health care
   79  service needs as the general population and elderly population
   80  of the state increase. The Legislature finds that items to
   81  consider relative to assessing the physician workforce may
   82  include physician practice status; specialty mix; geographic
   83  distribution; demographic information, including, but not
   84  limited to, age, gender, race, and cultural considerations; and
   85  needs of current or projected medically underserved areas in the
   86  state. Long-term strategic planning is essential as the period
   87  from the time a medical student enters medical school to
   88  completion of graduate medical education may range from 7 to 10
   89  years or longer. The Legislature recognizes that strategies to
   90  provide for a well-trained supply of physicians must include
   91  ensuring the availability and capacity of quality graduate
   92  medical schools and graduate medical education programs in this
   93  state, as well as using new or existing state and federal
   94  programs providing incentives for physicians to practice in
   95  needed specialties and in underserved areas in a manner that
   96  addresses projected needs for physician manpower.
   97         (3)(2) PURPOSE.—The department of Health shall serve as a
   98  coordinating and strategic planning body to actively assess the
   99  state’s current and future physician workforce needs and work
  100  with multiple stakeholders to develop strategies and
  101  alternatives to address current and projected physician
  102  workforce needs.
  103         (4)(3) GENERAL FUNCTIONS.—The department shall maximize the
  104  use of existing programs under the jurisdiction of the
  105  department and other state agencies and coordinate governmental
  106  and nongovernmental stakeholders and resources in order to
  107  develop a state strategic plan and assess the implementation of
  108  such strategic plan. In developing the state strategic plan, the
  109  department shall:
  110         (a) Monitor, evaluate, and report on the supply and
  111  distribution of physicians licensed under chapter 458 or chapter
  112  459. The department shall maintain a database to serve as a
  113  statewide source of data concerning the physician workforce.
  114         (b) Develop a model and quantify, on an ongoing basis, the
  115  adequacy of the state’s current and future physician workforce
  116  as reliable data becomes available. Such model must take into
  117  account demographics, physician practice status, place of
  118  education and training, generational changes, population growth,
  119  economic indicators, and issues concerning the “pipeline” into
  120  medical education.
  121         (c) Develop and recommend strategies to determine whether
  122  the number of qualified medical school applicants who might
  123  become competent, practicing physicians in this state will be
  124  sufficient to meet the capacity of the state’s medical schools.
  125  If appropriate, the department shall, working with
  126  representatives of appropriate governmental and nongovernmental
  127  entities, develop strategies and recommendations and identify
  128  best practice programs that introduce health care as a
  129  profession and strengthen skills needed for medical school
  130  admission for elementary, middle, and high school students, and
  131  improve premedical education at the precollege and college level
  132  in order to increase this state’s potential pool of medical
  133  students.
  134         (d) Develop strategies to ensure that the number of
  135  graduates from the state’s public and private allopathic and
  136  osteopathic medical schools is are adequate to meet physician
  137  workforce needs, based on the analysis of the physician
  138  workforce data, so as to provide a high-quality medical
  139  education to students in a manner that recognizes the uniqueness
  140  of each new and existing medical school in this state.
  141         (e) Pursue strategies and policies to create, expand, and
  142  maintain graduate medical education positions in the state based
  143  on the analysis of the physician workforce data. Such strategies
  144  and policies must take into account the effect of federal
  145  funding limitations on the expansion and creation of positions
  146  in graduate medical education. The department shall develop
  147  options to address such federal funding limitations. The
  148  department shall consider options to provide direct state
  149  funding for graduate medical education positions in a manner
  150  that addresses requirements and needs relative to accreditation
  151  of graduate medical education programs. The department shall
  152  consider funding residency positions as a means of addressing
  153  needed physician specialty areas, rural areas having a shortage
  154  of physicians, and areas of ongoing critical need, and as a
  155  means of addressing the state’s physician workforce needs based
  156  on an ongoing analysis of physician workforce data.
  157         (f) Develop strategies to maximize federal and state
  158  programs that provide for the use of incentives to attract
  159  physicians to this state or retain physicians within the state.
  160  Such strategies should explore and maximize federal-state
  161  partnerships that provide incentives for physicians to practice
  162  in federally designated shortage areas. Strategies shall also
  163  consider the use of state programs, such as the Florida Health
  164  Service Corps established pursuant to s. 381.0302 and the
  165  Medical Education Reimbursement and Loan Repayment Program
  166  pursuant to s. 1009.65, which provide for education loan
  167  repayment or loan forgiveness and provide monetary incentives
  168  for physicians to relocate to underserved areas of the state.
  169         (g) Coordinate and enhance activities relative to physician
  170  workforce needs, undergraduate medical education, and graduate
  171  medical education, and reentry of retired military and other
  172  physicians into the physician workforce provided by the Division
  173  of Medical Quality Assurance, the Community Hospital Education
  174  Program and the Graduate Medical Education Committee established
  175  pursuant to s. 381.0403, area health education center networks
  176  established pursuant to s. 381.0402, and other offices and
  177  programs within the department of Health as designated by the
  178  State Surgeon General.
  179         (h) Work in conjunction with and act as a coordinating body
  180  for governmental and nongovernmental stakeholders to address
  181  matters relating to the state’s physician workforce assessment
  182  and development for the purpose of ensuring an adequate supply
  183  of well-trained physicians to meet the state’s future needs.
  184  Such governmental stakeholders shall include, but need not be
  185  limited to, the State Surgeon General or his or her designee,
  186  the Commissioner of Education or his or her designee, the
  187  Secretary of Health Care Administration or his or her designee,
  188  and the Chancellor of the State University System or his or her
  189  designee from the Board of Governors of the State University
  190  System, and, at the discretion of the department, other
  191  representatives of state and local agencies that are involved in
  192  assessing, educating, or training the state’s current or future
  193  physicians. Other stakeholders shall include, but need not be
  194  limited to, organizations representing the state’s public and
  195  private allopathic and osteopathic medical schools;
  196  organizations representing hospitals and other institutions
  197  providing health care, particularly those that currently provide
  198  or have an interest in providing accredited medical education
  199  and graduate medical education to medical students and medical
  200  residents; organizations representing allopathic and osteopathic
  201  practicing physicians; and, at the discretion of the department,
  202  representatives of other organizations or entities involved in
  203  assessing, educating, or training the state’s current or future
  204  physicians.
  205         (i) Serve as a liaison with other states and federal
  206  agencies and programs in order to enhance resources available to
  207  the state’s physician workforce and medical education continuum.
  208         (j) Act as a clearinghouse for collecting and disseminating
  209  information concerning the physician workforce and medical
  210  education continuum in this state.
  211         (5) PHYSICIAN WORKFORCE ADVISORY COUNCIL.—There is created
  212  in the department the Physician Workforce Advisory Council, an
  213  advisory council as defined in s. 20.03. The council shall
  214  comply with the requirements of s. 20.052, except as otherwise
  215  provided in this section.
  216         (a) The council shall consist of 18 members. Members
  217  appointed by the State Surgeon General shall include:
  218         1. A designee from the department who is a physician
  219  licensed under chapter 458 or chapter 459 and recommended by the
  220  State Surgeon General.
  221         2. An individual who is affiliated with the Science
  222  Students Together Reaching Instructional Diversity and
  223  Excellence program and recommended by the area health education
  224  center network.
  225         3. Two individuals recommended by the Council of Florida
  226  Medical School Deans, one representing a college of allopathic
  227  medicine and one representing a college of osteopathic medicine.
  228         4. One individual recommended by the Florida Hospital
  229  Association, representing a hospital that is licensed under
  230  chapter 395, has an accredited graduate medical education
  231  program, and is not a statutory teaching hospital.
  232         5.One individual representing a statutory teaching
  233  hospital as defined in s. 408.07 and recommended by the Safety
  234  Net Hospital Alliance.
  235         6.One individual representing a family practice teaching
  236  hospital as defined in s. 395.805 and recommended by the Council
  237  of Family Medicine and Community Teaching Hospitals.
  238         7. Two individuals recommended by the Florida Medical
  239  Association, one representing a primary care specialty and one
  240  representing a nonprimary care specialty.
  241         8. Two individuals recommended by the Florida Osteopathic
  242  Medical Association, one representing a primary care specialty
  243  and one representing a nonprimary care specialty.
  244         9. Two individuals who are program directors of accredited
  245  graduate medical education programs, one representing a program
  246  that is accredited by the Accreditation Council for Graduate
  247  Medical Education and one representing a program that is
  248  accredited by the American Osteopathic Association.
  249         10. An individual recommended by the Florida Rural Health
  250  Association.
  251         11. An individual recommended by the Florida Alliance for
  252  Health Professions Diversity.
  253         12.The Chancellor of the State University System or his or
  254  her designee.
  255         13. A layperson member as determined by the State Surgeon
  256  General.
  258  Appointments to the council shall be made by the State Surgeon
  259  General. Each entity authorized to make recommendations under
  260  this subsection shall make at least two recommendations to the
  261  State Surgeon General for each appointment to the council. The
  262  State Surgeon General shall name one appointee for each position
  263  from the recommendations made by each authorized entity.
  264         (b) Each council member shall be appointed to a 4-year
  265  term. An individual may not serve more than two terms. Any
  266  council member may be removed from office for malfeasance;
  267  misfeasance; neglect of duty; incompetence; permanent inability
  268  to perform official duties; or pleading guilty or nolo
  269  contendere to, or being found guilty of, a felony. Any council
  270  member who meets the criteria for removal, or who is otherwise
  271  unwilling or unable to properly fulfill the duties of the
  272  office, shall be succeeded by an individual chosen by the State
  273  Surgeon General to serve out the remainder of the council
  274  member’s term. If the remainder of the replaced council member’s
  275  term is less than 18 months, notwithstanding the provisions of
  276  this paragraph, the succeeding council member may be reappointed
  277  twice by the State Surgeon General.
  278         (c) The chair of the council is the State Surgeon General,
  279  who shall designate a vice chair from the membership of the
  280  council to serve in the absence of the State Surgeon General. A
  281  vacancy shall be filled for the remainder of the unexpired term
  282  in the same manner as the original appointment.
  283         (d) Council members are not entitled to receive
  284  compensation or reimbursement for per diem or travel expenses.
  285         (e) The council shall meet at least twice a year in person
  286  or by teleconference.
  287         (f) The council shall:
  288         1. Advise the State Surgeon General and the department on
  289  matters concerning current and future physician workforce needs
  290  in this state;
  291         2. Review survey materials and the compilation of survey
  292  information;
  293         3.Annually review the number, location, cost, and
  294  reimbursement of graduate medical education programs and
  295  positions;
  296         4. Provide recommendations to the department regarding the
  297  survey completed by physicians licensed under chapter 458 or
  298  chapter 459;
  299         5. Assist the department in preparing the annual report to
  300  the Legislature pursuant to ss. 458.3192 and 459.0082;
  301         6. Assist the department in preparing an initial strategic
  302  plan, conduct ongoing strategic planning in accordance with this
  303  section, and provide ongoing advice on implementing the
  304  recommendations;
  305         7. Monitor and provide recommendations regarding the need
  306  for an increased number of primary care or other physician
  307  specialties to provide the necessary current and projected
  308  health and medical services for the state; and
  309         8. Monitor and make recommendations regarding the status of
  310  the needs relating to graduate medical education in this state.
  313         (a) The Legislature finds that:
  314         1. In order to ensure a physician workforce that is
  315  adequate to meet the needs of this state’s residents and its
  316  health care system, policymakers must consider the education and
  317  training of future generations of well-trained health care
  318  providers.
  319         2. Physicians are likely to practice in the state where
  320  they complete their graduate medical education.
  321         3. It can directly affect the makeup of the physician
  322  workforce by selectively funding graduate medical education
  323  programs to provide needed specialists in geographic areas of
  324  the state which have a deficient number of such specialists.
  325         4. Developing additional positions in graduate medical
  326  education programs is essential to the future of this state’s
  327  health care system.
  328         5. It was necessary in 2007 to pass legislation that
  329  provided for an assessment of the status of this state’s current
  330  and future physician workforce. The department is collecting and
  331  analyzing information on an ongoing basis to assess this state’s
  332  physician workforce needs, and such assessment may facilitate
  333  the determination of graduate medical education needs and
  334  strategies for the state.
  335         (b) There is established under the department a program to
  336  foster innovative graduate medical education pilot projects that
  337  are designed to promote the expansion of graduate medical
  338  education programs or positions to prepare physicians to
  339  practice in needed specialties and underserved areas or settings
  340  and to provide demographic and cultural representation in a
  341  manner that addresses current and projected needs for this
  342  state’s physician workforce. Funds appropriated annually by the
  343  Legislature for this purpose shall be distributed to
  344  participating hospitals, medical schools, other sponsors of
  345  graduate medical education programs, consortia engaged in
  346  developing new graduate medical education programs or positions
  347  in those programs, or pilot projects providing innovative
  348  graduate medical education in community-based clinical settings.
  349  Pilot projects shall be selected on a competitive grant basis,
  350  subject to available funds.
  351         (c) Pilot projects shall be designed to meet one or more of
  352  this state’s physician workforce needs, as determined pursuant
  353  to this section, including, but not limited to:
  354         1. Increasing the number of residencies or fellowships in
  355  primary care or other needed specialties.
  356         2. Enhancing the retention of primary care physicians or
  357  other needed specialties in this state.
  358         3. Promoting practice in rural or medically underserved
  359  areas of the state.
  360         4. Encouraging racial and ethnic diversity within the
  361  state’s physician workforce.
  362         5. Encouraging practice in community health care or other
  363  ambulatory care settings.
  364         6. Encouraging practice in clinics operated by the
  365  department, including, but not limited to, county health
  366  departments, clinics operated by the Department of Veterans’
  367  Affairs, prison clinics, or similar settings of need.
  368         7. Encouraging the increased production of geriatricians.
  369         (d) Priority shall be given to a proposal for a pilot
  370  project that:
  371         1. Demonstrates a collaboration of federal, state, and
  372  local entities that are public or private.
  373         2. Obtains funding from multiple sources.
  374         3. Focuses on enhancing graduate medical education in rural
  375  or underserved areas.
  376         4. Focuses on enhancing graduate medical education in
  377  ambulatory or community-based settings other than a hospital
  378  environment.
  379         5. Includes the use of technology, such as electronic
  380  medical records, distance consultation, and telemedicine, to
  381  ensure that residents are better prepared to care for patients
  382  in this state, regardless of the community in which the
  383  residents practice.
  384         6. Is designed to meet multiple policy needs as enumerated
  385  in subsection (3).
  386         7. Uses a consortium to provide for graduate medical
  387  education experiences.
  388         (e) The department shall adopt by rule appropriate
  389  performance measures to use in order to consistently evaluate
  390  the effectiveness, safety, and quality of the programs, as well
  391  as the impact of each program on meeting this state’s physician
  392  workforce needs.
  393         (f) Participating pilot projects shall submit to the
  394  department an annual report on the project in a manner required
  395  by the department.
  396         (g) Funding provided to a pilot project may be used only
  397  for the direct costs of providing graduate medical education.
  398  Accounting of such costs and expenditures shall be documented in
  399  the annual report.
  400         (h) State funds shall be used to supplement funds from any
  401  local government, community, or private source. The state may
  402  provide up to 50 percent of the funds, and local governmental
  403  grants or community or private sources shall provide the
  404  remainder of the funds.
  405         (7) RULEMAKING.—The department shall adopt rules as
  406  necessary to administer this section.
  407         Section 3. Section 458.3192, Florida Statutes, is amended
  408  to read:
  409         458.3192 Analysis of survey results; report.—
  410         (1) Each year, the Department of Health shall analyze the
  411  results of the physician survey required by s. 458.3191 and
  412  determine by geographic area and specialty the number of
  413  physicians who:
  414         (a) Perform deliveries of children in this state Florida.
  415         (b) Read mammograms and perform breast-imaging-guided
  416  procedures in this state Florida.
  417         (c) Perform emergency care on an on-call basis for a
  418  hospital emergency department.
  419         (d) Plan to reduce or increase emergency on-call hours in a
  420  hospital emergency department.
  421         (e) Plan to relocate their allopathic or osteopathic
  422  practice outside the state.
  423         (f) Practice medicine in this state.
  424         (g) Plan to reduce or modify the scope of their practice.
  425         (2) The Department of Health must report its findings to
  426  the Governor, the President of the Senate, and the Speaker of
  427  the House of Representatives by November 1 each year. The
  428  department shall also include in its report findings,
  429  recommendations, and strategic planning activities as provided
  430  in s. 381.4018. The department may also include other
  431  information requested by the Physician Workforce Advisory
  432  Council.
  433         Section 4. Section 459.0082, Florida Statutes, is amended
  434  to read:
  435         459.0082 Analysis of survey results; report.—
  436         (1) Each year, the Department of Health shall analyze the
  437  results of the physician survey required by s. 459.0081 and
  438  determine by geographic area and specialty the number of
  439  physicians who:
  440         (a) Perform deliveries of children in this state Florida.
  441         (b) Read mammograms and perform breast-imaging-guided
  442  procedures in this state Florida.
  443         (c) Perform emergency care on an on-call basis for a
  444  hospital emergency department.
  445         (d) Plan to reduce or increase emergency on-call hours in a
  446  hospital emergency department.
  447         (e) Plan to relocate their allopathic or osteopathic
  448  practice outside the state.
  449         (f) Practice medicine in this state.
  450         (g)Plan to reduce or modify the scope of their practice.
  451         (2) The Department of Health must report its findings to
  452  the Governor, the President of the Senate, and the Speaker of
  453  the House of Representatives by November 1 each year. The
  454  department shall also include in its report findings,
  455  recommendations, and strategic planning activities as provided
  456  in s. 381.4018. The department may also include other
  457  information requested by the Physician Workforce Advisory
  458  Council.
  459         Section 5. Paragraph (a) of subsection (1) of section
  460  409.908, Florida Statutes, is amended to read:
  461         409.908 Reimbursement of Medicaid providers.—Subject to
  462  specific appropriations, the agency shall reimburse Medicaid
  463  providers, in accordance with state and federal law, according
  464  to methodologies set forth in the rules of the agency and in
  465  policy manuals and handbooks incorporated by reference therein.
  466  These methodologies may include fee schedules, reimbursement
  467  methods based on cost reporting, negotiated fees, competitive
  468  bidding pursuant to s. 287.057, and other mechanisms the agency
  469  considers efficient and effective for purchasing services or
  470  goods on behalf of recipients. If a provider is reimbursed based
  471  on cost reporting and submits a cost report late and that cost
  472  report would have been used to set a lower reimbursement rate
  473  for a rate semester, then the provider’s rate for that semester
  474  shall be retroactively calculated using the new cost report, and
  475  full payment at the recalculated rate shall be effected
  476  retroactively. Medicare-granted extensions for filing cost
  477  reports, if applicable, shall also apply to Medicaid cost
  478  reports. Payment for Medicaid compensable services made on
  479  behalf of Medicaid eligible persons is subject to the
  480  availability of moneys and any limitations or directions
  481  provided for in the General Appropriations Act or chapter 216.
  482  Further, nothing in this section shall be construed to prevent
  483  or limit the agency from adjusting fees, reimbursement rates,
  484  lengths of stay, number of visits, or number of services, or
  485  making any other adjustments necessary to comply with the
  486  availability of moneys and any limitations or directions
  487  provided for in the General Appropriations Act, provided the
  488  adjustment is consistent with legislative intent.
  489         (1) Reimbursement to hospitals licensed under part I of
  490  chapter 395 must be made prospectively or on the basis of
  491  negotiation.
  492         (a) Reimbursement for inpatient care is limited as provided
  493  for in s. 409.905(5), except for:
  494         1. The raising of rate reimbursement caps, excluding rural
  495  hospitals.
  496         2. Recognition of the costs of graduate medical education.
  497         3. Other methodologies recognized in the General
  498  Appropriations Act.
  500  During the years funds are transferred from the Department of
  501  Health, any reimbursement supported by such funds shall be
  502  subject to certification by the Department of Health that the
  503  hospital has complied with s. 381.0403. The agency may is
  504  authorized to receive funds from state entities, including, but
  505  not limited to, the Department of Health, local governments, and
  506  other local political subdivisions, for the purpose of making
  507  special exception payments, including federal matching funds,
  508  through the Medicaid inpatient reimbursement methodologies.
  509  Funds received from state entities or local governments for this
  510  purpose shall be separately accounted for and shall not be
  511  commingled with other state or local funds in any manner. The
  512  agency may certify all local governmental funds used as state
  513  match under Title XIX of the Social Security Act, to the extent
  514  that the identified local health care provider that is otherwise
  515  entitled to and is contracted to receive such local funds is the
  516  benefactor under the state’s Medicaid program as determined
  517  under the General Appropriations Act and pursuant to an
  518  agreement between the Agency for Health Care Administration and
  519  the local governmental entity. The local governmental entity
  520  shall use a certification form prescribed by the agency. At a
  521  minimum, the certification form shall identify the amount being
  522  certified and describe the relationship between the certifying
  523  local governmental entity and the local health care provider.
  524  The agency shall prepare an annual statement of impact which
  525  documents the specific activities undertaken during the previous
  526  fiscal year pursuant to this paragraph, to be submitted to the
  527  Legislature no later than January 1, annually.
  528         Section 6. This act shall take effect July 1, 2010.

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