Sen. David Koehler
Filed: 5/4/2010
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1 | AMENDMENT TO HOUSE BILL 5085
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2 | AMENDMENT NO. ______. Amend House Bill 5085 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||
10 | policy of accident and health insurance under Section 356t of | ||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||
12 | shall provide the coverage
required under Sections 356g, | ||||||
13 | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | ||||||
14 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | ||||||
15 | 356z.13, and 356z.14, 356z.15 and 356z.14 , and 356z.17 356z.15 , | ||||||
16 | and 364.01 of the
Illinois Insurance Code.
The program of |
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1 | health benefits must comply with Section 155.37 of the
Illinois | ||||||
2 | Insurance Code.
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3 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
4 | amendatory Act of the 95th General Assembly , if any, is | ||||||
5 | conditioned on the rules being adopted in accordance with all | ||||||
6 | provisions of the Illinois Administrative Procedure Act and all | ||||||
7 | rules and procedures of the Joint Committee on Administrative | ||||||
8 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
9 | is unauthorized. | ||||||
10 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
11 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
12 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044, | ||||||
13 | eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
14 | 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; | ||||||
15 | revised 10-22-09.) | ||||||
16 | Section 10. The Counties Code is amended by changing | ||||||
17 | Section 5-1069.3 as follows: | ||||||
18 | (55 ILCS 5/5-1069.3)
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19 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
20 | including a home
rule
county, is a self-insurer for purposes of | ||||||
21 | providing health insurance coverage
for its employees, the | ||||||
22 | coverage shall include coverage for the post-mastectomy
care | ||||||
23 | benefits required to be covered by a policy of accident and | ||||||
24 | health
insurance under Section 356t and the coverage required |
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1 | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | ||||||
2 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, and | ||||||
3 | 356z.13, and 356z.14, and 356z.15 356z.14 , and 364.01 of
the | ||||||
4 | Illinois Insurance Code. The requirement that health benefits | ||||||
5 | be covered
as provided in this Section is an
exclusive power | ||||||
6 | and function of the State and is a denial and limitation under
| ||||||
7 | Article VII, Section 6, subsection (h) of the Illinois | ||||||
8 | Constitution. A home
rule county to which this Section applies | ||||||
9 | must comply with every provision of
this Section.
| ||||||
10 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
11 | amendatory Act of the 95th General Assembly , if any, is | ||||||
12 | conditioned on the rules being adopted in accordance with all | ||||||
13 | provisions of the Illinois Administrative Procedure Act and all | ||||||
14 | rules and procedures of the Joint Committee on Administrative | ||||||
15 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
16 | is unauthorized. | ||||||
17 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
18 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
19 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, | ||||||
20 | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | ||||||
21 | 96-328, eff. 8-11-09; revised 10-22-09.) | ||||||
22 | Section 15. The Illinois Municipal Code is amended by | ||||||
23 | changing Section 10-4-2.3 as follows: | ||||||
24 | (65 ILCS 5/10-4-2.3)
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1 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
2 | municipality, including a
home rule municipality, is a | ||||||
3 | self-insurer for purposes of providing health
insurance | ||||||
4 | coverage for its employees, the coverage shall include coverage | ||||||
5 | for
the post-mastectomy care benefits required to be covered by | ||||||
6 | a policy of
accident and health insurance under Section 356t | ||||||
7 | and the coverage required
under Sections 356g, 356g.5, | ||||||
8 | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | ||||||
9 | 356z.11, 356z.12, and 356z.13, and 356z.14, and 356z.15 | ||||||
10 | 356z.14 , and 364.01 of the Illinois
Insurance
Code. The | ||||||
11 | requirement that health
benefits be covered as provided in this | ||||||
12 | is an exclusive power and function of
the State and is a denial | ||||||
13 | and limitation under Article VII, Section 6,
subsection (h) of | ||||||
14 | the Illinois Constitution. A home rule municipality to which
| ||||||
15 | this Section applies must comply with every provision of this | ||||||
16 | Section.
| ||||||
17 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
18 | amendatory Act of the 95th General Assembly , if any, is | ||||||
19 | conditioned on the rules being adopted in accordance with all | ||||||
20 | provisions of the Illinois Administrative Procedure Act and all | ||||||
21 | rules and procedures of the Joint Committee on Administrative | ||||||
22 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
23 | is unauthorized. | ||||||
24 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
25 | 95-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff. | ||||||
26 | 6-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045, |
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1 | eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10; | ||||||
2 | 96-328, eff. 8-11-09; revised 10-23-09.) | ||||||
3 | Section 20. The School Code is amended by changing Section | ||||||
4 | 10-22.3f as follows: | ||||||
5 | (105 ILCS 5/10-22.3f)
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6 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
7 | protection and
benefits
for employees shall provide the | ||||||
8 | post-mastectomy care benefits required to be
covered by a | ||||||
9 | policy of accident and health insurance under Section 356t and | ||||||
10 | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | ||||||
11 | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | ||||||
12 | 356z.13, and 356z.14, and 356z.15 356z.14 , and 364.01 of
the
| ||||||
13 | Illinois Insurance Code.
| ||||||
14 | Rulemaking authority to implement Public Act 95-1045 this | ||||||
15 | amendatory Act of the 95th General Assembly , if any, is | ||||||
16 | conditioned on the rules being adopted in accordance with all | ||||||
17 | provisions of the Illinois Administrative Procedure Act and all | ||||||
18 | rules and procedures of the Joint Committee on Administrative | ||||||
19 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
20 | is unauthorized. | ||||||
21 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
22 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
23 | 95-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
24 | 1-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; revised |
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1 | 10-23-09.) | ||||||
2 | Section 25. The Illinois Insurance Code is amended by | ||||||
3 | changing Sections 356z.3 and 364.01 and by adding Section | ||||||
4 | 356z.3a as follows: | ||||||
5 | (215 ILCS 5/356z.3) | ||||||
6 | Sec. 356z.3. Disclosure of limited benefit. An insurer that
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7 | issues,
delivers,
amends, or
renews an individual or group | ||||||
8 | policy of accident and health insurance in this
State after the
| ||||||
9 | effective date of this amendatory Act of the 92nd General | ||||||
10 | Assembly and
arranges, contracts
with, or administers | ||||||
11 | contracts with a provider whereby beneficiaries are
provided an | ||||||
12 | incentive to
use the services of such provider must include the | ||||||
13 | following disclosure on its
contracts and
evidences of | ||||||
14 | coverage: "WARNING, LIMITED BENEFITS WILL BE PAID WHEN
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15 | NON-PARTICIPATING PROVIDERS ARE USED. You should be aware that | ||||||
16 | when you elect
to
utilize the services of a non-participating | ||||||
17 | provider for a covered service in non-emergency
situations, | ||||||
18 | benefit payments to such non-participating provider are not | ||||||
19 | based upon the amount
billed. The basis of your benefit payment | ||||||
20 | will be determined according to your policy's fee
schedule, | ||||||
21 | usual and customary charge (which is determined by comparing | ||||||
22 | charges for similar
services adjusted to the geographical area | ||||||
23 | where the services are performed), or other method as
defined | ||||||
24 | by the policy. YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE
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1 | AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS | ||||||
2 | REQUIRED
PORTION. Non-participating providers may bill members | ||||||
3 | for any amount up to the
billed
charge after the plan has paid | ||||||
4 | its portion of the bill as provided in Section 356z.3a of this | ||||||
5 | Code . Participating providers
have agreed to accept
discounted | ||||||
6 | payments for services with no additional billing to the member | ||||||
7 | other
than co-insurance and deductible amounts. You may obtain | ||||||
8 | further information
about the
participating
status of | ||||||
9 | professional providers and information on out-of-pocket | ||||||
10 | expenses by
calling the toll
free telephone number on your | ||||||
11 | identification card.". | ||||||
12 | (Source: P.A. 95-331, eff. 8-21-07.) | ||||||
13 | (215 ILCS 5/356z.3a new) | ||||||
14 | Sec. 356z.3a. Nonparticipating facility-based physicians | ||||||
15 | and providers. | ||||||
16 | (a) For purposes of this Section, "facility-based | ||||||
17 | provider" means a physician or other provider who provide | ||||||
18 | radiology, anesthesiology, pathology, neonatology, or | ||||||
19 | emergency department services to insureds, beneficiaries, or | ||||||
20 | enrollees in a participating hospital or participating | ||||||
21 | ambulatory surgical treatment center. | ||||||
22 | (b) When a beneficiary, insured, or enrollee utilizes a | ||||||
23 | participating network hospital or a participating network | ||||||
24 | ambulatory surgery center and, due to any reason, in network | ||||||
25 | services for radiology, anesthesiology, pathology, emergency |
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1 | physician, or neonatology are unavailable and are provided by a | ||||||
2 | nonparticipating facility-based physician or provider, the | ||||||
3 | insurer or health plan shall ensure that the beneficiary, | ||||||
4 | insured, or enrollee shall incur no greater out-of-pocket costs | ||||||
5 | than the beneficiary, insured, or enrollee would have incurred | ||||||
6 | with a participating physician or provider for covered | ||||||
7 | services. | ||||||
8 | (c) If a beneficiary, insured, or enrollee agrees in | ||||||
9 | writing, notwithstanding any other provision of this Code, any | ||||||
10 | benefits a beneficiary, insured, or enrollee receives for | ||||||
11 | services under the situation in subsection (b) are assigned to | ||||||
12 | the nonparticipating facility-based providers. The insurer or | ||||||
13 | health plan shall provide the nonparticipating provider with a | ||||||
14 | written explanation of benefits that specifies the proposed | ||||||
15 | reimbursement and the applicable deductible, copayment or | ||||||
16 | coinsurance amounts owed by the insured, beneficiary or | ||||||
17 | enrollee. The insurer or health plan shall pay any | ||||||
18 | reimbursement directly to the nonparticipating facility-based | ||||||
19 | provider. The nonparticipating facility-based physician or | ||||||
20 | provider shall not bill the beneficiary, insured, or enrollee, | ||||||
21 | except for applicable deductible, copayment, or coinsurance | ||||||
22 | amounts that would apply if the beneficiary, insured, or | ||||||
23 | enrollee utilized a participating physician or provider for | ||||||
24 | covered services. If a beneficiary, insured, or enrollee | ||||||
25 | specifically rejects assignment under this Section in writing | ||||||
26 | to the nonparticipating facility-based provider, then the |
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1 | nonparticipating facility-based provider may bill the | ||||||
2 | beneficiary, insured, or enrollee for the services rendered. | ||||||
3 | (d) For bills assigned under subsection (c), the | ||||||
4 | nonparticipating facility-based provider may bill the insurer | ||||||
5 | or health plan for the services rendered, and the insurer or | ||||||
6 | health plan may pay the billed amount or attempt to negotiate | ||||||
7 | reimbursement with the nonparticipating facility-based | ||||||
8 | provider. If attempts to negotiate reimbursement for services | ||||||
9 | provided by a nonparticipating facility-based provider do not | ||||||
10 | result in a resolution of the payment dispute within 30 days | ||||||
11 | after receipt of written explanation of benefits by the insurer | ||||||
12 | or health plan, then an insurer or health plan or | ||||||
13 | nonparticipating facility-based physician or provider may | ||||||
14 | initiate binding arbitration to determine payment for services | ||||||
15 | provided on a per bill basis. The party requesting arbitration | ||||||
16 | shall notify the other party arbitration has been initiated and | ||||||
17 | state its final offer before arbitration. In response to this | ||||||
18 | notice, the nonrequesting party shall inform the requesting | ||||||
19 | party of its final offer before the arbitration occurs. | ||||||
20 | Arbitration shall be initiated by filing a request with the | ||||||
21 | Department of Insurance. | ||||||
22 | (e) The Department of Insurance shall publish a list of | ||||||
23 | approved arbitrators or entities that shall provide binding | ||||||
24 | arbitration. These arbitrators shall be American Arbitration | ||||||
25 | Association or American Health Lawyers Association trained | ||||||
26 | arbitrators. Both parties must agree on an arbitrator from the |
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1 | Department of Insurance's list of arbitrators. If no agreement | ||||||
2 | can be reached, then a list of 5 arbitrators shall be provided | ||||||
3 | by the Department of Insurance. From the list of 5 arbitrators, | ||||||
4 | the insurer can veto 2 arbitrators and the provider can veto 2 | ||||||
5 | arbitrators. The remaining arbitrator shall be the chosen | ||||||
6 | arbitrator. This arbitration shall consist of a review of the | ||||||
7 | written submissions by both parties. Binding arbitration shall | ||||||
8 | provide for a written decision within 45 days after the request | ||||||
9 | is filed with the Department of Insurance. Both parties shall | ||||||
10 | be bound by the arbitrator's decision. The arbitrator's | ||||||
11 | expenses and fees, together with other expenses, not including | ||||||
12 | attorney's fees, incurred in the conduct of the arbitration, | ||||||
13 | shall be paid as provided in the decision. | ||||||
14 | (f) This Section 356z.3a does not apply to a beneficiary, | ||||||
15 | insured, or enrollee who willfully chooses to access a | ||||||
16 | nonparticipating facility-based physician or provider for | ||||||
17 | health care services available through the insurer's or plan's | ||||||
18 | network of participating physicians and providers. In these | ||||||
19 | circumstances, the contractual requirements for | ||||||
20 | nonparticipating facility-based provider reimbursements will | ||||||
21 | apply. | ||||||
22 | (g) Section 368a of this Act shall not apply during the | ||||||
23 | pendency of a decision under subsection (d) any interest | ||||||
24 | required to be paid a provider under Section 368a shall not | ||||||
25 | accrue until after 30 days of an arbitrator's decision as | ||||||
26 | provided in subsection (d), but in no circumstances longer than |
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| |||||||
1 | 150 days from date the nonparticipating facility-based | ||||||
2 | provider billed for services rendered. ". | ||||||
3 | (215 ILCS 5/364.01) | ||||||
4 | Sec. 364.01. Qualified clinical cancer trials. | ||||||
5 | (a) No individual or group policy of accident and health | ||||||
6 | insurance issued or renewed in this State may be cancelled or | ||||||
7 | non-renewed for any individual based on that individual's | ||||||
8 | participation in a qualified clinical cancer trial. | ||||||
9 | (b) Qualified clinical cancer trials must meet the | ||||||
10 | following criteria: | ||||||
11 | (1) the effectiveness of the treatment has not been | ||||||
12 | determined relative to established therapies; | ||||||
13 | (2) the trial is under clinical investigation as part | ||||||
14 | of an approved cancer research trial in Phase II, Phase | ||||||
15 | III, or Phase IV of investigation; | ||||||
16 | (3) the trial is: | ||||||
17 | (A) approved by the Food and Drug Administration; | ||||||
18 | or | ||||||
19 | (B) approved and funded by the National Institutes | ||||||
20 | of Health, the Centers for Disease Control and | ||||||
21 | Prevention, the Agency for Healthcare Research and | ||||||
22 | Quality, the United States Department of Defense, the | ||||||
23 | United States Department of Veterans Affairs, or the | ||||||
24 | United States Department of Energy in the form of an | ||||||
25 | investigational new drug application, or a cooperative |
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1 | group or center of any entity described in this | ||||||
2 | subdivision (B); and
| ||||||
3 | (4) the patient's primary care physician, if any, is | ||||||
4 | involved in the coordination of care.
| ||||||
5 | (c) No group policy of accident and health insurance shall | ||||||
6 | exclude coverage for any routine patient care administered to | ||||||
7 | an insured who is a qualified individual participating in a | ||||||
8 | qualified clinical cancer trial, if the policy covers that same | ||||||
9 | routine patient care of insureds not enrolled in a qualified | ||||||
10 | clinical cancer trial. | ||||||
11 | (d) The coverage that may not be excluded under subsection | ||||||
12 | (c) of this Section is subject to all terms, conditions, | ||||||
13 | restrictions, exclusions, and limitations that apply to the | ||||||
14 | same routine patient care received by an insured not enrolled | ||||||
15 | in a qualified clinical cancer trial, including the application | ||||||
16 | of any authorization requirement, utilization review, or | ||||||
17 | medical management practices. The insured or enrollee shall | ||||||
18 | incur no greater out-of-pocket liability than had the insured | ||||||
19 | or enrollee not enrolled in a qualified clinical cancer trial. | ||||||
20 | (e) If the group policy of accident and health insurance | ||||||
21 | uses a preferred provider program and a preferred provider | ||||||
22 | provides routine patient care in connection with a qualified | ||||||
23 | clinical cancer trial, then the insurer may require the insured | ||||||
24 | to use the preferred provider if the preferred provider agrees | ||||||
25 | to provide to the insured that routine patient care. | ||||||
26 | (f) A qualified clinical cancer trial may not pay or refuse |
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1 | to pay for routine patient care of a individual participating | ||||||
2 | in the trial, based in whole or in part on the person's having | ||||||
3 | or not having coverage for routine patient care under a group | ||||||
4 | policy of accident and health insurance. | ||||||
5 | (g) Nothing in this Section shall be construed to limit an | ||||||
6 | insurer's coverage with respect to clinical trials. | ||||||
7 | (h) Nothing in this Section shall require coverage for | ||||||
8 | out-of-network services where the underlying health benefit | ||||||
9 | plan does not provide coverage for out-of-network services. | ||||||
10 | (i) As used in this Section, "routine patient care" means | ||||||
11 | all health care services provided in the qualified clinical | ||||||
12 | cancer trial that are otherwise generally covered under the | ||||||
13 | policy if those items or services were not provided in | ||||||
14 | connection with a qualified clinical cancer trial consistent | ||||||
15 | with the standard of care for the treatment of cancer, | ||||||
16 | including the type and frequency of any diagnostic modality, | ||||||
17 | that a provider typically provides to a cancer patient who is | ||||||
18 | not enrolled in a qualified clinical cancer trial. "Routine | ||||||
19 | patient care" does not include, and a group policy of accident | ||||||
20 | and health insurance may exclude, coverage for: | ||||||
21 | (1) a health care service, item, or drug that is the | ||||||
22 | subject of the cancer clinical trial; | ||||||
23 | (2) a health care service, item, or drug provided | ||||||
24 | solely to satisfy data collection and analysis needs for | ||||||
25 | the qualified clinical cancer trial that is not used in the | ||||||
26 | direct clinical management of the patient; |
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| |||||||
1 | (3) an investigational drug or device that has not been | ||||||
2 | approved for market by the United States Food and Drug | ||||||
3 | Administration; | ||||||
4 | (4) transportation, lodging, food, or other expenses | ||||||
5 | for the patient or a family member or companion of the | ||||||
6 | patient that are associated with the travel to or from a | ||||||
7 | facility providing the qualified clinical cancer trial, | ||||||
8 | unless the policy covers these expenses for a cancer | ||||||
9 | patient who is not enrolled in a qualified clinical cancer | ||||||
10 | trial; | ||||||
11 | (5) a health care service, item, or drug customarily | ||||||
12 | provided by the qualified clinical cancer trial sponsors | ||||||
13 | free of charge for any patient; | ||||||
14 | (6) a health care service or item, which except for the | ||||||
15 | fact that it is being provided in a qualified clinical | ||||||
16 | cancer trial, is otherwise specifically excluded from | ||||||
17 | coverage under the insured's policy, including: | ||||||
18 | (A) costs of extra treatments, services, | ||||||
19 | procedures, tests, or drugs that would not be performed | ||||||
20 | or administered except for the fact that the insured is | ||||||
21 | participating in the cancer clinical trial; and | ||||||
22 | (B) costs of nonhealth care services that the | ||||||
23 | patient is required to receive as a result of | ||||||
24 | participation in the approved cancer clinical trial; | ||||||
25 | (7) costs for services, items, or drugs that are | ||||||
26 | eligible for reimbursement from a source other than a |
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| |||||||
1 | patient's contract or policy providing for third-party | ||||||
2 | payment or prepayment of health or medical expenses, | ||||||
3 | including the sponsor of the approved cancer clinical | ||||||
4 | trial; or | ||||||
5 | (8) costs associated with approved cancer clinical | ||||||
6 | trials designed exclusively to test toxicity or disease | ||||||
7 | pathophysiology, unless the policy covers these expenses | ||||||
8 | for a cancer patient who is not enrolled in a qualified | ||||||
9 | clinical cancer trial; or | ||||||
10 | (9) a health care service or item that is eligible for | ||||||
11 | reimbursement by a source other than the insured's policy, | ||||||
12 | including the sponsor of the qualified clinical cancer | ||||||
13 | trial. | ||||||
14 | The definitions of the terms "health care services", | ||||||
15 | "Non-Preferred Provider", "Preferred Provider", and "Preferred | ||||||
16 | Provider Program", stated in 50 IL Adm. Code Part 2051 | ||||||
17 | Preferred Provider Programs apply to these terms in this | ||||||
18 | Section. | ||||||
19 | (j) The external review procedures established under the | ||||||
20 | Health Carrier External Review Act shall apply to the | ||||||
21 | provisions under this Section. | ||||||
22 | (Source: P.A. 93-1000, eff. 1-1-05.) | ||||||
23 | Section 30. The Health Maintenance Organization Act is | ||||||
24 | amended by changing Section 5-3 as follows:
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| |||||||
1 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
2 | (Text of Section before amendment by P.A. 96-833 ) | ||||||
3 | Sec. 5-3. Insurance Code provisions.
| ||||||
4 | (a) Health Maintenance Organizations
shall be subject to | ||||||
5 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
6 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
7 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
8 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
9 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15 356z.14 , | ||||||
10 | 356z.17 356z.15 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, | ||||||
11 | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
12 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
13 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
14 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
15 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
16 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
17 | Maintenance Organizations in
the following categories are | ||||||
18 | deemed to be "domestic companies":
| ||||||
19 | (1) a corporation authorized under the
Dental Service | ||||||
20 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
21 | (2) a corporation organized under the laws of this | ||||||
22 | State; or
| ||||||
23 | (3) a corporation organized under the laws of another | ||||||
24 | state, 30% or more
of the enrollees of which are residents | ||||||
25 | of this State, except a
corporation subject to | ||||||
26 | substantially the same requirements in its state of
|
| |||||||
| |||||||
1 | organization as is a "domestic company" under Article VIII | ||||||
2 | 1/2 of the
Illinois Insurance Code.
| ||||||
3 | (c) In considering the merger, consolidation, or other | ||||||
4 | acquisition of
control of a Health Maintenance Organization | ||||||
5 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
6 | (1) the Director shall give primary consideration to | ||||||
7 | the continuation of
benefits to enrollees and the financial | ||||||
8 | conditions of the acquired Health
Maintenance Organization | ||||||
9 | after the merger, consolidation, or other
acquisition of | ||||||
10 | control takes effect;
| ||||||
11 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
12 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
13 | apply and (ii) the Director, in making
his determination | ||||||
14 | with respect to the merger, consolidation, or other
| ||||||
15 | acquisition of control, need not take into account the | ||||||
16 | effect on
competition of the merger, consolidation, or | ||||||
17 | other acquisition of control;
| ||||||
18 | (3) the Director shall have the power to require the | ||||||
19 | following
information:
| ||||||
20 | (A) certification by an independent actuary of the | ||||||
21 | adequacy
of the reserves of the Health Maintenance | ||||||
22 | Organization sought to be acquired;
| ||||||
23 | (B) pro forma financial statements reflecting the | ||||||
24 | combined balance
sheets of the acquiring company and | ||||||
25 | the Health Maintenance Organization sought
to be | ||||||
26 | acquired as of the end of the preceding year and as of |
| |||||||
| |||||||
1 | a date 90 days
prior to the acquisition, as well as pro | ||||||
2 | forma financial statements
reflecting projected | ||||||
3 | combined operation for a period of 2 years;
| ||||||
4 | (C) a pro forma business plan detailing an | ||||||
5 | acquiring party's plans with
respect to the operation | ||||||
6 | of the Health Maintenance Organization sought to
be | ||||||
7 | acquired for a period of not less than 3 years; and
| ||||||
8 | (D) such other information as the Director shall | ||||||
9 | require.
| ||||||
10 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
11 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
12 | any health maintenance
organization of greater than 10% of its
| ||||||
13 | enrollee population (including without limitation the health | ||||||
14 | maintenance
organization's right, title, and interest in and to | ||||||
15 | its health care
certificates).
| ||||||
16 | (e) In considering any management contract or service | ||||||
17 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
18 | Code, the Director (i) shall, in
addition to the criteria | ||||||
19 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
20 | into account the effect of the management contract or
service | ||||||
21 | agreement on the continuation of benefits to enrollees and the
| ||||||
22 | financial condition of the health maintenance organization to | ||||||
23 | be managed or
serviced, and (ii) need not take into account the | ||||||
24 | effect of the management
contract or service agreement on | ||||||
25 | competition.
| ||||||
26 | (f) Except for small employer groups as defined in the |
| |||||||
| |||||||
1 | Small Employer
Rating, Renewability and Portability Health | ||||||
2 | Insurance Act and except for
medicare supplement policies as | ||||||
3 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
4 | Maintenance Organization may by contract agree with a
group or | ||||||
5 | other enrollment unit to effect refunds or charge additional | ||||||
6 | premiums
under the following terms and conditions:
| ||||||
7 | (i) the amount of, and other terms and conditions with | ||||||
8 | respect to, the
refund or additional premium are set forth | ||||||
9 | in the group or enrollment unit
contract agreed in advance | ||||||
10 | of the period for which a refund is to be paid or
| ||||||
11 | additional premium is to be charged (which period shall not | ||||||
12 | be less than one
year); and
| ||||||
13 | (ii) the amount of the refund or additional premium | ||||||
14 | shall not exceed 20%
of the Health Maintenance | ||||||
15 | Organization's profitable or unprofitable experience
with | ||||||
16 | respect to the group or other enrollment unit for the | ||||||
17 | period (and, for
purposes of a refund or additional | ||||||
18 | premium, the profitable or unprofitable
experience shall | ||||||
19 | be calculated taking into account a pro rata share of the
| ||||||
20 | Health Maintenance Organization's administrative and | ||||||
21 | marketing expenses, but
shall not include any refund to be | ||||||
22 | made or additional premium to be paid
pursuant to this | ||||||
23 | subsection (f)). The Health Maintenance Organization and | ||||||
24 | the
group or enrollment unit may agree that the profitable | ||||||
25 | or unprofitable
experience may be calculated taking into | ||||||
26 | account the refund period and the
immediately preceding 2 |
| |||||||
| |||||||
1 | plan years.
| ||||||
2 | The Health Maintenance Organization shall include a | ||||||
3 | statement in the
evidence of coverage issued to each enrollee | ||||||
4 | describing the possibility of a
refund or additional premium, | ||||||
5 | and upon request of any group or enrollment unit,
provide to | ||||||
6 | the group or enrollment unit a description of the method used | ||||||
7 | to
calculate (1) the Health Maintenance Organization's | ||||||
8 | profitable experience with
respect to the group or enrollment | ||||||
9 | unit and the resulting refund to the group
or enrollment unit | ||||||
10 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
11 | experience with respect to the group or enrollment unit and the | ||||||
12 | resulting
additional premium to be paid by the group or | ||||||
13 | enrollment unit.
| ||||||
14 | In no event shall the Illinois Health Maintenance | ||||||
15 | Organization
Guaranty Association be liable to pay any | ||||||
16 | contractual obligation of an
insolvent organization to pay any | ||||||
17 | refund authorized under this Section.
| ||||||
18 | (g) Rulemaking authority to implement Public Act 95-1045 | ||||||
19 | this amendatory Act of the 95th General Assembly , if any, is | ||||||
20 | conditioned on the rules being adopted in accordance with all | ||||||
21 | provisions of the Illinois Administrative Procedure Act and all | ||||||
22 | rules and procedures of the Joint Committee on Administrative | ||||||
23 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
24 | is unauthorized. | ||||||
25 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
26 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; |
| |||||||
| |||||||
1 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
2 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; revised | ||||||
3 | 10-23-09.) | ||||||
4 | (Text of Section after amendment by P.A. 96-833 ) | ||||||
5 | Sec. 5-3. Insurance Code provisions.
| ||||||
6 | (a) Health Maintenance Organizations
shall be subject to | ||||||
7 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
8 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
9 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
10 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
11 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | ||||||
12 | 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | ||||||
13 | 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | ||||||
14 | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | ||||||
15 | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | ||||||
16 | and XXVI of the Illinois Insurance Code.
| ||||||
17 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
18 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
19 | Maintenance Organizations in
the following categories are | ||||||
20 | deemed to be "domestic companies":
| ||||||
21 | (1) a corporation authorized under the
Dental Service | ||||||
22 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
23 | (2) a corporation organized under the laws of this | ||||||
24 | State; or
| ||||||
25 | (3) a corporation organized under the laws of another |
| |||||||
| |||||||
1 | state, 30% or more
of the enrollees of which are residents | ||||||
2 | of this State, except a
corporation subject to | ||||||
3 | substantially the same requirements in its state of
| ||||||
4 | organization as is a "domestic company" under Article VIII | ||||||
5 | 1/2 of the
Illinois Insurance Code.
| ||||||
6 | (c) In considering the merger, consolidation, or other | ||||||
7 | acquisition of
control of a Health Maintenance Organization | ||||||
8 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
9 | (1) the Director shall give primary consideration to | ||||||
10 | the continuation of
benefits to enrollees and the financial | ||||||
11 | conditions of the acquired Health
Maintenance Organization | ||||||
12 | after the merger, consolidation, or other
acquisition of | ||||||
13 | control takes effect;
| ||||||
14 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
15 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
16 | apply and (ii) the Director, in making
his determination | ||||||
17 | with respect to the merger, consolidation, or other
| ||||||
18 | acquisition of control, need not take into account the | ||||||
19 | effect on
competition of the merger, consolidation, or | ||||||
20 | other acquisition of control;
| ||||||
21 | (3) the Director shall have the power to require the | ||||||
22 | following
information:
| ||||||
23 | (A) certification by an independent actuary of the | ||||||
24 | adequacy
of the reserves of the Health Maintenance | ||||||
25 | Organization sought to be acquired;
| ||||||
26 | (B) pro forma financial statements reflecting the |
| |||||||
| |||||||
1 | combined balance
sheets of the acquiring company and | ||||||
2 | the Health Maintenance Organization sought
to be | ||||||
3 | acquired as of the end of the preceding year and as of | ||||||
4 | a date 90 days
prior to the acquisition, as well as pro | ||||||
5 | forma financial statements
reflecting projected | ||||||
6 | combined operation for a period of 2 years;
| ||||||
7 | (C) a pro forma business plan detailing an | ||||||
8 | acquiring party's plans with
respect to the operation | ||||||
9 | of the Health Maintenance Organization sought to
be | ||||||
10 | acquired for a period of not less than 3 years; and
| ||||||
11 | (D) such other information as the Director shall | ||||||
12 | require.
| ||||||
13 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
14 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
15 | any health maintenance
organization of greater than 10% of its
| ||||||
16 | enrollee population (including without limitation the health | ||||||
17 | maintenance
organization's right, title, and interest in and to | ||||||
18 | its health care
certificates).
| ||||||
19 | (e) In considering any management contract or service | ||||||
20 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
21 | Code, the Director (i) shall, in
addition to the criteria | ||||||
22 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
23 | into account the effect of the management contract or
service | ||||||
24 | agreement on the continuation of benefits to enrollees and the
| ||||||
25 | financial condition of the health maintenance organization to | ||||||
26 | be managed or
serviced, and (ii) need not take into account the |
| |||||||
| |||||||
1 | effect of the management
contract or service agreement on | ||||||
2 | competition.
| ||||||
3 | (f) Except for small employer groups as defined in the | ||||||
4 | Small Employer
Rating, Renewability and Portability Health | ||||||
5 | Insurance Act and except for
medicare supplement policies as | ||||||
6 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
7 | Maintenance Organization may by contract agree with a
group or | ||||||
8 | other enrollment unit to effect refunds or charge additional | ||||||
9 | premiums
under the following terms and conditions:
| ||||||
10 | (i) the amount of, and other terms and conditions with | ||||||
11 | respect to, the
refund or additional premium are set forth | ||||||
12 | in the group or enrollment unit
contract agreed in advance | ||||||
13 | of the period for which a refund is to be paid or
| ||||||
14 | additional premium is to be charged (which period shall not | ||||||
15 | be less than one
year); and
| ||||||
16 | (ii) the amount of the refund or additional premium | ||||||
17 | shall not exceed 20%
of the Health Maintenance | ||||||
18 | Organization's profitable or unprofitable experience
with | ||||||
19 | respect to the group or other enrollment unit for the | ||||||
20 | period (and, for
purposes of a refund or additional | ||||||
21 | premium, the profitable or unprofitable
experience shall | ||||||
22 | be calculated taking into account a pro rata share of the
| ||||||
23 | Health Maintenance Organization's administrative and | ||||||
24 | marketing expenses, but
shall not include any refund to be | ||||||
25 | made or additional premium to be paid
pursuant to this | ||||||
26 | subsection (f)). The Health Maintenance Organization and |
| |||||||
| |||||||
1 | the
group or enrollment unit may agree that the profitable | ||||||
2 | or unprofitable
experience may be calculated taking into | ||||||
3 | account the refund period and the
immediately preceding 2 | ||||||
4 | plan years.
| ||||||
5 | The Health Maintenance Organization shall include a | ||||||
6 | statement in the
evidence of coverage issued to each enrollee | ||||||
7 | describing the possibility of a
refund or additional premium, | ||||||
8 | and upon request of any group or enrollment unit,
provide to | ||||||
9 | the group or enrollment unit a description of the method used | ||||||
10 | to
calculate (1) the Health Maintenance Organization's | ||||||
11 | profitable experience with
respect to the group or enrollment | ||||||
12 | unit and the resulting refund to the group
or enrollment unit | ||||||
13 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
14 | experience with respect to the group or enrollment unit and the | ||||||
15 | resulting
additional premium to be paid by the group or | ||||||
16 | enrollment unit.
| ||||||
17 | In no event shall the Illinois Health Maintenance | ||||||
18 | Organization
Guaranty Association be liable to pay any | ||||||
19 | contractual obligation of an
insolvent organization to pay any | ||||||
20 | refund authorized under this Section.
| ||||||
21 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
22 | if any, is conditioned on the rules being adopted in accordance | ||||||
23 | with all provisions of the Illinois Administrative Procedure | ||||||
24 | Act and all rules and procedures of the Joint Committee on | ||||||
25 | Administrative Rules; any purported rule not so adopted, for | ||||||
26 | whatever reason, is unauthorized. |
| |||||||
| |||||||
1 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
2 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
3 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
4 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | ||||||
5 | 6-1-10.) | ||||||
6 | Section 35. The Voluntary Health Services Plans Act is | ||||||
7 | amended by changing Section 10 as follows:
| ||||||
8 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
9 | (Text of Section before amendment by P.A. 96-833 ) | ||||||
10 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
11 | services
plan corporations and all persons interested therein | ||||||
12 | or dealing therewith
shall be subject to the provisions of | ||||||
13 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
14 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | ||||||
15 | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | ||||||
16 | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | ||||||
17 | 356z.14, 356z.15
356z.14 , 364.01, 367.2, 368a, 401, 401.1,
402,
| ||||||
18 | 403, 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | ||||||
19 | Section 367 of the Illinois
Insurance Code.
| ||||||
20 | Rulemaking authority to implement Public Act 95-1045
this | ||||||
21 | amendatory Act of the 95th General Assembly , if any, is | ||||||
22 | conditioned on the rules being adopted in accordance with all | ||||||
23 | provisions of the Illinois Administrative Procedure Act and all | ||||||
24 | rules and procedures of the Joint Committee on Administrative |
| |||||||
| |||||||
1 | Rules; any purported rule not so adopted, for whatever reason, | ||||||
2 | is unauthorized. | ||||||
3 | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; | ||||||
4 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
5 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
6 | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
7 | 96-328, eff. 8-11-09; revised 9-25-09.) | ||||||
8 | (Text of Section after amendment by P.A. 96-833 ) | ||||||
9 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
10 | services
plan corporations and all persons interested therein | ||||||
11 | or dealing therewith
shall be subject to the provisions of | ||||||
12 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
13 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t, | ||||||
14 | 356u, 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, | ||||||
15 | 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, | ||||||
16 | 356z.14, 356z.15, 356z.18, 364.01, 367.2, 368a, 401, 401.1,
| ||||||
17 | 402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) and | ||||||
18 | (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
19 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
20 | any, is conditioned on the rules being adopted in accordance | ||||||
21 | with all provisions of the Illinois Administrative Procedure | ||||||
22 | Act and all rules and procedures of the Joint Committee on | ||||||
23 | Administrative Rules; any purported rule not so adopted, for | ||||||
24 | whatever reason, is unauthorized. | ||||||
25 | (Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07; |
| |||||||
| |||||||
1 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff. | ||||||
2 | 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005, | ||||||
3 | eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10; | ||||||
4 | 96-328, eff. 8-11-09; 96-833, eff. 6-1-10.) | ||||||
5 | Section 97. No acceleration or delay. Where this Act makes | ||||||
6 | changes in a statute that is represented in this Act by text | ||||||
7 | that is not yet or no longer in effect (for example, a Section | ||||||
8 | represented by multiple versions), the use of that text does | ||||||
9 | not accelerate or delay the taking effect of (i) the changes | ||||||
10 | made by this Act or (ii) provisions derived from any other | ||||||
11 | Public Act.
| ||||||
12 | Section 99. Effective date. This Act takes effect January | ||||||
13 | 1, 2011.".
|