HB4335 EngrossedLRB102 22718 BMS 31864 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall
9provide the post-mastectomy care benefits required to be
10covered by a policy of accident and health insurance under
11Section 356t of the Illinois Insurance Code. The program of
12health benefits shall provide the coverage required under
13Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356w, 356x,
14356z.2, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10,
15356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22,
16356z.25, 356z.26, 356z.29, 356z.30a, 356z.32, 356z.33,
17356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51,
18and 356z.53 and 356z.43 of the Illinois Insurance Code. The
19program of health benefits must comply with Sections 155.22a,
20155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of
21the Illinois Insurance Code. The Department of Insurance shall
22enforce the requirements of this Section with respect to
23Sections 370c and 370c.1 of the Illinois Insurance Code; all

 

 

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1other requirements of this Section shall be enforced by the
2Department of Central Management Services.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 101-13, eff. 6-12-19; 101-281, eff. 1-1-20;
10101-393, eff. 1-1-20; 101-452, eff. 1-1-20; 101-461, eff.
111-1-20; 101-625, eff. 1-1-21; 102-30, eff. 1-1-22; 102-103,
12eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
13102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
1410-26-21.)
 
15    Section 10. The Counties Code is amended by changing
16Section 5-1069.3 as follows:
 
17    (55 ILCS 5/5-1069.3)
18    Sec. 5-1069.3. Required health benefits. If a county,
19including a home rule county, is a self-insurer for purposes
20of providing health insurance coverage for its employees, the
21coverage shall include coverage for the post-mastectomy care
22benefits required to be covered by a policy of accident and
23health insurance under Section 356t and the coverage required
24under Sections 356g, 356g.5, 356g.5-1, 356q, 356u, 356w, 356x,

 

 

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1356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
2356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 356z.29,
3356z.30a, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
4356z.45, 356z.46, 356z.47, 356z.48, 356z.51, and 356.53 and
5356z.43 of the Illinois Insurance Code. The coverage shall
6comply with Sections 155.22a, 355b, 356z.19, and 370c of the
7Illinois Insurance Code. The Department of Insurance shall
8enforce the requirements of this Section. The requirement that
9health benefits be covered as provided in this Section is an
10exclusive power and function of the State and is a denial and
11limitation under Article VII, Section 6, subsection (h) of the
12Illinois Constitution. A home rule county to which this
13Section applies must comply with every provision of this
14Section.
15    Rulemaking authority to implement Public Act 95-1045, if
16any, is conditioned on the rules being adopted in accordance
17with all provisions of the Illinois Administrative Procedure
18Act and all rules and procedures of the Joint Committee on
19Administrative Rules; any purported rule not so adopted, for
20whatever reason, is unauthorized.
21(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
22101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
231-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
24eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
25102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
2610-26-21.)
 

 

 

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1    Section 15. The Illinois Municipal Code is amended by
2changing Section 10-4-2.3 as follows:
 
3    (65 ILCS 5/10-4-2.3)
4    Sec. 10-4-2.3. Required health benefits. If a
5municipality, including a home rule municipality, is a
6self-insurer for purposes of providing health insurance
7coverage for its employees, the coverage shall include
8coverage for the post-mastectomy care benefits required to be
9covered by a policy of accident and health insurance under
10Section 356t and the coverage required under Sections 356g,
11356g.5, 356g.5-1, 356q, 356u, 356w, 356x, 356z.6, 356z.8,
12356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
13356z.22, 356z.25, 356z.26, 356z.29, 356z.30a, 356z.32,
14356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
15356z.48, 356z.51, and 356z.53 and 356z.43 of the Illinois
16Insurance Code. The coverage shall comply with Sections
17155.22a, 355b, 356z.19, and 370c of the Illinois Insurance
18Code. The Department of Insurance shall enforce the
19requirements of this Section. The requirement that health
20benefits be covered as provided in this is an exclusive power
21and function of the State and is a denial and limitation under
22Article VII, Section 6, subsection (h) of the Illinois
23Constitution. A home rule municipality to which this Section
24applies must comply with every provision of this Section.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
8101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
91-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
10eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 1-1-22;
11102-642, eff. 1-1-22; 102-665, eff. 10-8-21; revised
1210-26-21.)
 
13    Section 20. The School Code is amended by changing Section
1410-22.3f as follows:
 
15    (105 ILCS 5/10-22.3f)
16    Sec. 10-22.3f. Required health benefits. Insurance
17protection and benefits for employees shall provide the
18post-mastectomy care benefits required to be covered by a
19policy of accident and health insurance under Section 356t and
20the coverage required under Sections 356g, 356g.5, 356g.5-1,
21356q, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11,
22356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
23356z.29, 356z.30a, 356z.32, 356z.33, 356z.36, 356z.40,
24356z.41, 356z.45, 356z.46, 356z.47, 356z.51, and 356z.53 and

 

 

HB4335 Engrossed- 6 -LRB102 22718 BMS 31864 b

1356z.43 of the Illinois Insurance Code. Insurance policies
2shall comply with Section 356z.19 of the Illinois Insurance
3Code. The coverage shall comply with Sections 155.22a, 355b,
4and 370c of the Illinois Insurance Code. The Department of
5Insurance shall enforce the requirements of this Section.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
13101-393, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625, eff.
141-1-21; 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 102-203,
15eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 1-1-22;
16102-665, eff. 10-8-21; revised 10-27-21.)
 
17    Section 25. The Illinois Insurance Code is amended by
18adding Section 356z.53 as follows:
 
19    (215 ILCS 5/356z.53 new)
20    Sec. 356z.53. Coverage of prescription estrogen.
21    (a) A group or individual policy of accident and health
22insurance or a managed care plan that is amended, delivered,
23issued, or renewed on or after January 1, 2024 and that
24provides coverage for prescription drugs shall include

 

 

HB4335 Engrossed- 7 -LRB102 22718 BMS 31864 b

1coverage for one or more therapeutic equivalent versions of
2vaginal estrogen in its formulary. A policy is not required to
3include all therapeutic equivalent versions of vaginal
4estrogen in its formulary so long as at least one is included
5and covered without cost sharing and in accordance with this
6Section.
7    (b) If an individual's attending provider recommends a
8particular vaginal estrogen product or its therapeutic
9equivalent version approved by the United States Food and Drug
10Administration based on the provider's determination, the
11issuer must cover that service or item without cost sharing.
12    (c) A policy subject to this Section shall not impose a
13deductible, coinsurance, copayment, or any other cost-sharing
14requirement on the coverage provided; except that this
15subsection does not apply to coverage of vaginal estrogen to
16the extent such coverage would disqualify a high-deductible
17health plan from eligibility for a health savings account
18pursuant to Section 223 of the Internal Revenue Code.
19    (d) As used in this Section, "therapeutic equivalent
20version" has the meaning given to that term in paragraph (2) of
21subsection (a) of Section 356z.4.
 
22    Section 30. The Health Maintenance Organization Act is
23amended by changing Section 5-3 as follows:
 
24    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)

 

 

HB4335 Engrossed- 8 -LRB102 22718 BMS 31864 b

1    Sec. 5-3. Insurance Code provisions.
2    (a) Health Maintenance Organizations shall be subject to
3the provisions of Sections 133, 134, 136, 137, 139, 140,
4141.1, 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153,
5154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2,
6355.3, 355b, 356g.5-1, 356m, 356q, 356v, 356w, 356x, 356y,
7356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
8356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
9356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29,
10356z.30, 356z.30a, 356z.32, 356z.33, 356z.35, 356z.36,
11356z.40, 356z.41, 356z.43, 356z.46, 356z.47, 356z.48, 356z.50,
12356z.51, 356z.53, 364, 364.01, 367.2, 367.2-5, 367i, 368a,
13368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403,
14403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
15subsection (2) of Section 367, and Articles IIA, VIII 1/2,
16XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
17Illinois Insurance Code.
18    (b) For purposes of the Illinois Insurance Code, except
19for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
20Health Maintenance Organizations in the following categories
21are deemed to be "domestic companies":
22        (1) a corporation authorized under the Dental Service
23    Plan Act or the Voluntary Health Services Plans Act;
24        (2) a corporation organized under the laws of this
25    State; or
26        (3) a corporation organized under the laws of another

 

 

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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
7acquisition of control of a Health Maintenance Organization
8pursuant 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
11    financial conditions of the acquired Health Maintenance
12    Organization after the merger, consolidation, or other
13    acquisition of 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

 

 

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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
14Insurance Code and this Section 5-3 shall apply to the sale by
15any health maintenance organization of greater than 10% of its
16enrollee population (including without limitation the health
17maintenance organization's right, title, and interest in and
18to its health care certificates).
19    (e) In considering any management contract or service
20agreement subject to Section 141.1 of the Illinois Insurance
21Code, the Director (i) shall, in addition to the criteria
22specified in Section 141.2 of the Illinois Insurance Code,
23take into account the effect of the management contract or
24service agreement on the continuation of benefits to enrollees
25and the financial condition of the health maintenance
26organization to be managed or serviced, and (ii) need not take

 

 

HB4335 Engrossed- 11 -LRB102 22718 BMS 31864 b

1into account the effect of the management contract or service
2agreement on competition.
3    (f) Except for small employer groups as defined in the
4Small Employer Rating, Renewability and Portability Health
5Insurance Act and except for medicare supplement policies as
6defined in Section 363 of the Illinois Insurance Code, a
7Health Maintenance Organization may by contract agree with a
8group or other enrollment unit to effect refunds or charge
9additional 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
15    not 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

 

 

HB4335 Engrossed- 12 -LRB102 22718 BMS 31864 b

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
6statement in the evidence of coverage issued to each enrollee
7describing the possibility of a refund or additional premium,
8and upon request of any group or enrollment unit, provide to
9the group or enrollment unit a description of the method used
10to calculate (1) the Health Maintenance Organization's
11profitable experience with respect to the group or enrollment
12unit and the resulting refund to the group or enrollment unit
13or (2) the Health Maintenance Organization's unprofitable
14experience with respect to the group or enrollment unit and
15the resulting additional premium to be paid by the group or
16enrollment unit.
17    In no event shall the Illinois Health Maintenance
18Organization Guaranty Association be liable to pay any
19contractual obligation of an insolvent organization to pay any
20refund authorized under this Section.
21    (g) Rulemaking authority to implement Public Act 95-1045,
22if any, is conditioned on the rules being adopted in
23accordance with all provisions of the Illinois Administrative
24Procedure Act and all rules and procedures of the Joint
25Committee on Administrative Rules; any purported rule not so
26adopted, for whatever reason, is unauthorized.

 

 

HB4335 Engrossed- 13 -LRB102 22718 BMS 31864 b

1(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
2101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-393, eff.
31-1-20; 101-452, eff. 1-1-20; 101-461, eff. 1-1-20; 101-625,
4eff. 1-1-21; 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
5102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
61-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
7eff. 10-8-21; revised 10-27-21.)
 
8    Section 35. The Limited Health Service Organization Act is
9amended by changing Section 4003 as follows:
 
10    (215 ILCS 130/4003)  (from Ch. 73, par. 1504-3)
11    Sec. 4003. Illinois Insurance Code provisions. Limited
12health service organizations shall be subject to the
13provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
14141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
15154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 355.2, 355.3,
16355b, 356q, 356v, 356z.10, 356z.21, 356z.22, 356z.25, 356z.26,
17356z.29, 356z.30a, 356z.32, 356z.33, 356z.41, 356z.46,
18356z.47, 356z.51, 356z.53, 356z.43, 368a, 401, 401.1, 402,
19403, 403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles
20IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of
21the Illinois Insurance Code. For purposes of the Illinois
22Insurance Code, except for Sections 444 and 444.1 and Articles
23XIII and XIII 1/2, limited health service organizations in the
24following categories are deemed to be domestic companies:

 

 

HB4335 Engrossed- 14 -LRB102 22718 BMS 31864 b

1        (1) a corporation under the laws of this State; or
2        (2) a corporation organized under the laws of another
3    state, 30% or more of the enrollees of which are residents
4    of this State, except a corporation subject to
5    substantially the same requirements in its state of
6    organization as is a domestic company under Article VIII
7    1/2 of the Illinois Insurance Code.
8(Source: P.A. 101-81, eff. 7-12-19; 101-281, eff. 1-1-20;
9101-393, eff. 1-1-20; 101-625, eff. 1-1-21; 102-30, eff.
101-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642,
11eff. 1-1-22; revised 10-27-21.)
 
12    Section 40. The Voluntary Health Services Plans Act is
13amended by changing Section 10 as follows:
 
14    (215 ILCS 165/10)  (from Ch. 32, par. 604)
15    Sec. 10. Application of Insurance Code provisions. Health
16services plan corporations and all persons interested therein
17or dealing therewith shall be subject to the provisions of
18Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
19143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
20356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v, 356w,
21356x, 356y, 356z.1, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6,
22356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14,
23356z.15, 356z.18, 356z.19, 356z.21, 356z.22, 356z.25, 356z.26,
24356z.29, 356z.30, 356z.30a, 356z.32, 356z.33, 356z.40,

 

 

HB4335 Engrossed- 15 -LRB102 22718 BMS 31864 b

1356z.41, 356z.46, 356z.47, 356z.51, 356z.53, 356z.43, 364.01,
2367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
3and paragraphs (7) and (15) of Section 367 of the Illinois
4Insurance Code.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11(Source: P.A. 101-13, eff. 6-12-19; 101-81, eff. 7-12-19;
12101-281, eff. 1-1-20; 101-393, eff. 1-1-20; 101-625, eff.
131-1-21; 102-30, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306,
14eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21;
15revised 10-27-21.)
 
16    Section 45. The Illinois Public Aid Code is amended by
17changing Section 5-16.8 as follows:
 
18    (305 ILCS 5/5-16.8)
19    Sec. 5-16.8. Required health benefits. The medical
20assistance program shall (i) provide the post-mastectomy care
21benefits required to be covered by a policy of accident and
22health insurance under Section 356t and the coverage required
23under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6,
24356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46,

 

 

HB4335 Engrossed- 16 -LRB102 22718 BMS 31864 b

1356z.47, 356z.51, and 356z.53 and 356z.43 of the Illinois
2Insurance Code, (ii) be subject to the provisions of Sections
3356z.19, 356z.43, 356z.44, 356z.49, 364.01, 370c, and 370c.1
4of the Illinois Insurance Code, and (iii) be subject to the
5provisions of subsection (d-5) of Section 10 of the Network
6Adequacy and Transparency Act.
7    The Department, by rule, shall adopt a model similar to
8the requirements of Section 356z.39 of the Illinois Insurance
9Code.
10    On and after July 1, 2012, the Department shall reduce any
11rate of reimbursement for services or other payments or alter
12any methodologies authorized by this Code to reduce any rate
13of reimbursement for services or other payments in accordance
14with Section 5-5e.
15    To ensure full access to the benefits set forth in this
16Section, on and after January 1, 2016, the Department shall
17ensure that provider and hospital reimbursement for
18post-mastectomy care benefits required under this Section are
19no lower than the Medicare reimbursement rate.
20(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20;
21101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff.
221-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144,
23eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22;
24102-530, eff. 1-1-22; 102-642, eff. 1-1-22; revised 10-27-21.)