99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB0122

 

Introduced , by Rep. Mary E. Flowers

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Illinois Insurance Code to provide that accident and health insurance policies and managed care plans must provide coverage for intravenous feeding, prescription nutritional supplements, and hospital patient assessments. Makes corresponding changes in the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Health Maintenance Organization Act, Voluntary Health Services Plans Act, and Illinois Public Aid Code. Amends the Emergency Medical Treatment Act to provide that every hospital licensed under the Hospital Licensing Act shall comply with the Hospital Emergency Service Act. Amends the Hospital Emergency Service Act in a provision concerning the Department of Public Health's rules regarding hospital emergency services. Repeals the provision concerning long-term acute care hospitals. Amends the Health Carrier External Review Act. Sets forth provisions concerning standard information for application forms; medical underwriting; the requirement to send to the applicant a copy of the health care service plan contract along with a notice; rescission and cancellation; postcontract investigation; and continuation. Makes changes in the provision concerning standard external review. Amends the Medical Patient Rights Act. Provides that each patient has a right to be informed of his or her inpatient or outpatient status. Amends the State Mandates Act to require implementation without reimbursement by the State. Effective immediately.


LRB099 03611 MLM 23619 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

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1    AN ACT concerning insurance.
 
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 provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, 356z.17, and 356z.22, 356z.23, 356z.24, and
16356z.25 of the Illinois Insurance Code. The program of health
17benefits must comply with Sections 155.22a, 155.37, 355b, and
18356z.19 of the Illinois Insurance Code.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
3eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
4    Section 10. The Counties Code is amended by changing
5Section 5-1069.3 as follows:
 
6    (55 ILCS 5/5-1069.3)
7    Sec. 5-1069.3. Required health benefits. If a county,
8including a home rule county, is a self-insurer for purposes of
9providing health insurance coverage for its employees, the
10coverage shall include coverage for the post-mastectomy care
11benefits required to be covered by a policy of accident and
12health insurance under Section 356t and the coverage required
13under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.22, 356z.23, 356z.24, and 356z.25 of
16the Illinois Insurance Code. The coverage shall comply with
17Sections 155.22a, 355b, and 356z.19 of the Illinois Insurance
18Code. The requirement that health benefits be covered as
19provided in this Section is an exclusive power and function of
20the State and is a denial and limitation under Article VII,
21Section 6, subsection (h) of the Illinois Constitution. A home
22rule county to which this Section applies must comply with
23every provision of this Section.
24    Rulemaking authority to implement Public Act 95-1045, if

 

 

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1any, is conditioned on the rules being adopted in accordance
2with all provisions of the Illinois Administrative Procedure
3Act and all rules and procedures of the Joint Committee on
4Administrative Rules; any purported rule not so adopted, for
5whatever reason, is unauthorized.
6(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
7eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
8    Section 15. The Illinois Municipal Code is amended by
9changing Section 10-4-2.3 as follows:
 
10    (65 ILCS 5/10-4-2.3)
11    Sec. 10-4-2.3. Required health benefits. If a
12municipality, including a home rule municipality, is a
13self-insurer for purposes of providing health insurance
14coverage for its employees, the coverage shall include coverage
15for the post-mastectomy care benefits required to be covered by
16a policy of accident and health insurance under Section 356t
17and the coverage required under Sections 356g, 356g.5,
18356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
19356z.11, 356z.12, 356z.13, 356z.14, 356z.15, and 356z.22,
20356z.23, 356z.24, and 356z.25 of the Illinois Insurance Code.
21The coverage shall comply with Sections 155.22a, 355b, and
22356z.19 of the Illinois Insurance Code. The requirement that
23health benefits be covered as provided in this is an exclusive
24power and function of the State and is a denial and limitation

 

 

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1under Article VII, Section 6, subsection (h) of the Illinois
2Constitution. A home rule municipality to which this Section
3applies must comply with every provision of this Section.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
11eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
12    Section 20. The School Code is amended by changing Section
1310-22.3f as follows:
 
14    (105 ILCS 5/10-22.3f)
15    Sec. 10-22.3f. Required health benefits. Insurance
16protection and benefits for employees shall provide the
17post-mastectomy care benefits required to be covered by a
18policy of accident and health insurance under Section 356t and
19the coverage required under Sections 356g, 356g.5, 356g.5-1,
20356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
21356z.13, 356z.14, 356z.15, and 356z.22, 356z.23, and 356z.24 of
22the Illinois Insurance Code. Insurance policies shall comply
23with Section 356z.19 of the Illinois Insurance Code. The
24coverage shall comply with Sections 155.22a and 355b of the

 

 

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1Illinois Insurance Code.
2    Rulemaking authority to implement Public Act 95-1045, if
3any, is conditioned on the rules being adopted in accordance
4with all provisions of the Illinois Administrative Procedure
5Act and all rules and procedures of the Joint Committee on
6Administrative Rules; any purported rule not so adopted, for
7whatever reason, is unauthorized.
8(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
9eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
10    Section 25. The Emergency Medical Treatment Act is amended
11by changing Section 1 as follows:
 
12    (210 ILCS 70/1)  (from Ch. 111 1/2, par. 6151)
13    Sec. 1. No hospital, physician, dentist or other provider
14of professional health care licensed under the laws of this
15State may refuse to provide needed emergency treatment to any
16person whose life would be threatened in the absence of such
17treatment, because of that person's inability to pay therefor,
18nor because of the source of any payment promised therefor.
19Every hospital licensed under the Hospital Licensing Act shall
20comply with the Hospital Emergency Service Act.
21(Source: P.A. 83-723.)
 
22    Section 30. The Hospital Emergency Service Act is amended
23by changing Section 1 as follows:
 

 

 

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1    (210 ILCS 80/1)  (from Ch. 111 1/2, par. 86)
2    Sec. 1. Every hospital required to be licensed by the
3Department of Public Health pursuant to the Hospital Licensing
4Act which provides general medical and surgical hospital
5services, except long-term acute care hospitals and
6rehabilitation hospitals identified in Section 1.3 of this Act,
7shall provide a hospital emergency service in accordance with
8rules and regulations adopted by the Department of Public
9Health which shall be consistent with the federal Emergency
10Medical Treatment and Active Labor Act (42 U.S.C. 1395dd) and
11shall furnish such hospital emergency services to any applicant
12who applies for the same in case of injury or acute medical
13condition where the same is liable to cause death or severe
14injury or serious illness. For purposes of this Act,
15"applicant" includes any person who is brought to a hospital by
16ambulance or specialized emergency medical services vehicle as
17defined in the Emergency Medical Services (EMS) Systems Act.
18(Source: P.A. 97-667, eff. 1-13-12; 98-683, eff. 6-30-14.)
 
19    Section 35. The Illinois Insurance Code is amended by
20adding Sections 356z.23, 356z.24, and 356z.25 as follows:
 
21    (215 ILCS 5/356z.23 new)
22    Sec. 356z.23. Intravenous feeding. A group or individual
23policy of accident and health insurance or managed care plan

 

 

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1amended, delivered, issued, or renewed after the effective date
2of this amendatory Act of the 99th General Assembly must
3provide coverage for intravenous feeding. The benefits under
4this Section shall be at least as favorable as for other
5coverages under the policy and may be subject to the same
6dollar amount limits, deductibles, and co-insurance
7requirements applicable generally to other coverages under the
8policy.
 
9    (215 ILCS 5/356z.24 new)
10    Sec. 356z.24. Prescription nutritional supplements. A
11group or individual policy of accident and health insurance or
12managed care plan amended, delivered, issued, or renewed after
13the effective date of this amendatory Act of the 99th General
14Assembly that provides coverage for prescription drugs must
15provide coverage for reimbursement for medically appropriate
16prescription nutritional supplements when ordered by a
17physician licensed to practice medicine in all its branches and
18the insured suffers from a condition that prevents him or her
19from taking sufficient oral nourishment to sustain life.
 
20    (215 ILCS 5/356z.25 new)
21    Sec. 356z.25. Hospital patient assessments. A group or
22individual policy of accident and health insurance or managed
23care plan amended, delivered, issued, or renewed after the
24effective date of this amendatory Act of the 99th General

 

 

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1Assembly that provides coverage for hospital care shall include
2in that coverage all services ordered by a physician and
3provided in the hospital that are considered medically
4necessary for the evaluation, assessment, and diagnosis of the
5illness or condition that resulted in the hospital stay of the
6enrollee or recipient. Such services are subject to reasonable
7review and utilization standards required by the policy or plan
8for all hospital services, as defined by the Department of
9Insurance or its successor agency.
 
10    Section 40. The Health Maintenance Organization Act is
11amended by changing Section 5-3 as follows:
 
12    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
13    Sec. 5-3. Insurance Code provisions.
14    (a) Health Maintenance Organizations shall be subject to
15the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
16141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
17154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 355.2, 355.3,
18355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y, 356z.2, 356z.4,
19356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
20356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21,
21356z.22, 356z.23, 356z.24, 364.01, 367.2, 367.2-5, 367i, 368a,
22368b, 368c, 368d, 368e, 370c, 370c.1, 401, 401.1, 402, 403,
23403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
24subsection (2) of Section 367, and Articles IIA, VIII 1/2, XII,

 

 

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1XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
2Insurance Code.
3    (b) For purposes of the Illinois Insurance Code, except for
4Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
5Maintenance Organizations in the following categories are
6deemed to be "domestic companies":
7        (1) a corporation authorized under the Dental Service
8    Plan Act or the Voluntary Health Services Plans Act;
9        (2) a corporation organized under the laws of this
10    State; or
11        (3) a corporation organized under the laws of another
12    state, 30% or more of the enrollees of which are residents
13    of this State, except a corporation subject to
14    substantially the same requirements in its state of
15    organization as is a "domestic company" under Article VIII
16    1/2 of the Illinois Insurance Code.
17    (c) In considering the merger, consolidation, or other
18acquisition of control of a Health Maintenance Organization
19pursuant to Article VIII 1/2 of the Illinois Insurance Code,
20        (1) the Director shall give primary consideration to
21    the continuation of benefits to enrollees and the financial
22    conditions of the acquired Health Maintenance Organization
23    after the merger, consolidation, or other acquisition of
24    control takes effect;
25        (2)(i) the criteria specified in subsection (1)(b) of
26    Section 131.8 of the Illinois Insurance Code shall not

 

 

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1    apply and (ii) the Director, in making his determination
2    with respect to the merger, consolidation, or other
3    acquisition of control, need not take into account the
4    effect on competition of the merger, consolidation, or
5    other acquisition of control;
6        (3) the Director shall have the power to require the
7    following information:
8            (A) certification by an independent actuary of the
9        adequacy of the reserves of the Health Maintenance
10        Organization sought to be acquired;
11            (B) pro forma financial statements reflecting the
12        combined balance sheets of the acquiring company and
13        the Health Maintenance Organization sought to be
14        acquired as of the end of the preceding year and as of
15        a date 90 days prior to the acquisition, as well as pro
16        forma financial statements reflecting projected
17        combined operation for a period of 2 years;
18            (C) a pro forma business plan detailing an
19        acquiring party's plans with respect to the operation
20        of the Health Maintenance Organization sought to be
21        acquired for a period of not less than 3 years; and
22            (D) such other information as the Director shall
23        require.
24    (d) The provisions of Article VIII 1/2 of the Illinois
25Insurance Code and this Section 5-3 shall apply to the sale by
26any health maintenance organization of greater than 10% of its

 

 

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1enrollee population (including without limitation the health
2maintenance organization's right, title, and interest in and to
3its health care certificates).
4    (e) In considering any management contract or service
5agreement subject to Section 141.1 of the Illinois Insurance
6Code, the Director (i) shall, in addition to the criteria
7specified in Section 141.2 of the Illinois Insurance Code, take
8into account the effect of the management contract or service
9agreement on the continuation of benefits to enrollees and the
10financial condition of the health maintenance organization to
11be managed or serviced, and (ii) need not take into account the
12effect of the management contract or service agreement on
13competition.
14    (f) Except for small employer groups as defined in the
15Small Employer Rating, Renewability and Portability Health
16Insurance Act and except for medicare supplement policies as
17defined in Section 363 of the Illinois Insurance Code, a Health
18Maintenance Organization may by contract agree with a group or
19other enrollment unit to effect refunds or charge additional
20premiums under the following terms and conditions:
21        (i) the amount of, and other terms and conditions with
22    respect to, the refund or additional premium are set forth
23    in the group or enrollment unit contract agreed in advance
24    of the period for which a refund is to be paid or
25    additional premium is to be charged (which period shall not
26    be less than one year); and

 

 

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1        (ii) the amount of the refund or additional premium
2    shall not exceed 20% of the Health Maintenance
3    Organization's profitable or unprofitable experience with
4    respect to the group or other enrollment unit for the
5    period (and, for purposes of a refund or additional
6    premium, the profitable or unprofitable experience shall
7    be calculated taking into account a pro rata share of the
8    Health Maintenance Organization's administrative and
9    marketing expenses, but shall not include any refund to be
10    made or additional premium to be paid pursuant to this
11    subsection (f)). The Health Maintenance Organization and
12    the group or enrollment unit may agree that the profitable
13    or unprofitable experience may be calculated taking into
14    account the refund period and the immediately preceding 2
15    plan years.
16    The Health Maintenance Organization shall include a
17statement in the evidence of coverage issued to each enrollee
18describing the possibility of a refund or additional premium,
19and upon request of any group or enrollment unit, provide to
20the group or enrollment unit a description of the method used
21to calculate (1) the Health Maintenance Organization's
22profitable experience with respect to the group or enrollment
23unit and the resulting refund to the group or enrollment unit
24or (2) the Health Maintenance Organization's unprofitable
25experience with respect to the group or enrollment unit and the
26resulting additional premium to be paid by the group or

 

 

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1enrollment unit.
2    In no event shall the Illinois Health Maintenance
3Organization Guaranty Association be liable to pay any
4contractual obligation of an insolvent organization to pay any
5refund authorized under this Section.
6    (g) Rulemaking authority to implement Public Act 95-1045,
7if any, 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. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-437,
13eff. 8-18-11; 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805,
14eff. 1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14;
1598-1091, eff. 1-1-15.)
 
16    Section 45. The Voluntary Health Services Plans Act is
17amended by changing Section 10 as follows:
 
18    (215 ILCS 165/10)  (from Ch. 32, par. 604)
19    Sec. 10. Application of Insurance Code provisions. Health
20services plan corporations and all persons interested therein
21or dealing therewith shall be subject to the provisions of
22Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
23143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
24356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,

 

 

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1356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
2356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
3356z.19, 356z.21, 356z.22, 356z.23, 356z.24, 364.01, 367.2,
4368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
5paragraphs (7) and (15) of Section 367 of the Illinois
6Insurance Code.
7    Rulemaking authority to implement Public Act 95-1045, if
8any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
14eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,
15eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
 
16    Section 50. The Health Carrier External Review Act is
17amended by changing Section 35 and by adding Sections 25.1,
1825.2, 25.3, 25.4, 25.5, and 25.6 as follows:
 
19    (215 ILCS 180/25.1 new)
20    Sec. 25.1. Standard information for application forms.
21    (a) The Director shall establish standard information and
22health history questions that shall be used by all health care
23service plans for their individual health care coverage
24application forms for individual health plan contracts and

 

 

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1individual health insurance policies. The health care service
2plan and health insurance application forms for individual
3health plan contracts and health insurance policies may only
4contain questions approved by the Director.
5    (b) The standard information and health history questions
6developed by the Director shall contain clear and unambiguous
7information and questions designed to ascertain the health
8history of the applicant and shall be based on the medical
9information that is reasonable and necessary for medical
10underwriting purposes.
11    (c) The application form shall include a prominently
12displayed notice that shall read: "Illinois law prohibits an
13HIV test from being required or used by health care service
14plans as a condition of obtaining coverage.".
15    (d) No later than 6 months after the adoption of the
16regulation under subsection (a) of this Section, all individual
17health care service plan application forms shall utilize only
18the pool of approved questions and the standardized information
19established pursuant to subsection (a).
20    (e) On and after January 1, 2015, all individual health
21care service plan applications shall be reviewed and approved
22by the Director before they may be used by a health care
23service plan.
 
24    (215 ILCS 180/25.2 new)
25    Sec. 25.2. Medical underwriting.

 

 

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1    (a) "Medical underwriting" means the completion of a
2reasonable investigation of the applicant's health history
3information, which includes, but is not limited to, the
4following:
5        (1) Ensuring that the information submitted on the
6    application form and the material submitted with the
7    application form are complete and accurate.
8        (2) Resolving all reasonable questions arising from
9    the application form or any materials submitted with the
10    application form or any information obtained by the health
11    care service plan as part of its verification of the
12    accuracy and completeness of the application form.
13    (b) A health care service plan shall complete medical
14underwriting prior to issuing an enrollee or subscriber health
15care service plan contract.
16    (c) A health care service plan shall adopt and implement
17written medical underwriting policies and procedures to ensure
18that the health care service plan does all of the following
19with respect to an application for health care coverage:
20        (1) Reviews all of the following:
21            (A) Information on the application and any
22        materials submitted with the application form for
23        accuracy and completeness.
24            (B) Claims information about the applicant that is
25        within the health care service plan's own claims
26        information.

 

 

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1            (C) At least one commercially available
2        prescription drug database for information about the
3        applicant.
4        (2) Identifies and makes inquiries, including
5    contacting the applicant about any questions raised by
6    omissions, ambiguities, or inconsistencies based upon the
7    information collected pursuant to item (1) of this
8    subsection (c).
9    (d) The plan shall document all information collected
10during the underwriting review process.
11    (e) On or before January 1, 2015, a health care service
12plan shall file its medical underwriting policies and
13procedures with the Department.
 
14    (215 ILCS 180/25.3 new)
15    Sec. 25.3. Copies of application and contract; notice.
16    (a) Within 10 business days after issuing a health care
17service plan contract, the health care service plan shall send
18a copy of the completed written application to the applicant
19with a copy of the health care service plan contract issued by
20the health care service plan, along with a notice that states
21all of the following:
22        (1) The applicant should review the completed
23    application carefully and notify the health care service
24    plan within 30 days of any inaccuracy in the application.
25        (2) Any intentional material misrepresentation or

 

 

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1    intentional material omission in the information submitted
2    in the application may result in the cancellation or
3    rescission of the plan contract.
4        (3) The applicant should retain a copy of the completed
5    written application for the applicant's records.
6    (b) If new information is provided by the applicant within
7the 30-day period permitted by subsection (a), then the
8provisions concerning medical underwriting shall apply to the
9new information.
 
10    (215 ILCS 180/25.4 new)
11    Sec. 25.4. Rescission; cancellation.
12    (a) Once a plan has issued an individual health care
13service plan contract, the health care service plan shall not
14rescind or cancel the health care service plan contract unless
15all of the following apply:
16        (1) There was a material misrepresentation or material
17    omission in the information submitted by the applicant in
18    the written application to the health care service plan
19    prior to the issuance of the health care service plan
20    contract that would have prevented the contract from being
21    entered into.
22        (2) The health care service plan completed medical
23    underwriting before issuing the plan contract.
24        (3) The health care service plan demonstrates that the
25    applicant intentionally misrepresented or intentionally

 

 

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1    omitted material information on the application prior to
2    the issuance of the plan contract with the purpose of
3    misrepresenting his or her health history in order to
4    obtain health care coverage.
5        (4) The application form was approved by the
6    Department.
7        (5) The health care service plan sent a copy of the
8    completed written application to the applicant with a copy
9    of the health care service plan contract issued by the
10    health care service plan.
11    (b) Notwithstanding subsection (a) of this Section, an
12enrollment or subscription may be canceled or not renewed for
13failure to pay the fees for that coverage.
 
14    (215 ILCS 180/25.5 new)
15    Sec. 25.5. Postcontract investigation.
16    (a) If a health care service plan obtains information after
17issuing an individual health care service plan contract that
18the subscriber or enrollee may have intentionally omitted or
19intentionally misrepresented material information during the
20application for coverage process, then the health care service
21plan may investigate the potential omissions or
22misrepresentations in order to determine whether the
23subscriber's or enrollee's health care service plan contract
24may be rescinded or canceled.
25    (b) The following provisions shall apply to a postcontract

 

 

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1issuance investigation:
2        (1) Upon initiating a postcontract issuance
3    investigation for potential rescission or cancellation of
4    health care coverage, the plan shall provide a written
5    notice to the enrollee or subscriber by regular and
6    certified mail that it has initiated an investigation of
7    intentional material misrepresentation or intentional
8    material omission on the part of the enrollee or subscriber
9    and that the investigation could lead to the rescission or
10    cancellation of the enrollee's or subscriber's health care
11    service plan contract. The notice shall be provided by the
12    health care service plan within 5 days of the initiation of
13    the investigation.
14        (2) The written notice required under item (1) of this
15    subsection (b) shall include full disclosure of the
16    allegedly intentional material omission or
17    misrepresentation and a clear and concise explanation of
18    why the information has resulted in the health care service
19    plan's initiation of an investigation to determine whether
20    rescission or cancellation is warranted. The notice shall
21    invite the enrollee or subscriber to provide any evidence
22    or information within 45 business days to negate the plan's
23    reasons for initiating the postissuance investigation.
24        (3) The plan shall complete its investigation no later
25    than 90 days after the date that the notice is sent to the
26    enrollee or subscriber pursuant to item (1) of this

 

 

HB0122- 21 -LRB099 03611 MLM 23619 b

1    subsection (b).
2        (4) Upon completion of its postissuance investigation,
3    the plan shall provide written notice by regular and
4    certified mail to the subscriber or enrollee that it has
5    concluded its investigation and has made one of the
6    following determinations:
7            (A) The plan has determined that the enrollee or
8        subscriber did not intentionally misrepresent or
9        intentionally omit material information during the
10        application process and that the subscriber's or
11        enrollee's health care coverage will not be canceled or
12        rescinded.
13            (B) The plan intends to seek approval from the
14        Director to cancel or rescind the enrollee's or
15        subscriber's health care service plan contract for
16        intentional misrepresentation or intentional omission
17        of material information during the application for
18        coverage process.
19        (5) The written notice required under paragraph (B) of
20    item (4) of this subsection (b) shall do all of the
21    following:
22            (A) Include full disclosure of the nature and
23        substance of any information that led to the plan's
24        determination that the enrollee or subscriber
25        intentionally misrepresented or intentionally omitted
26        material information on the application form.

 

 

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1            (B) Provide the enrollee or subscriber with
2        information indicating that the health plan's
3        determination shall not become final until it is
4        reviewed and approved by the Department's independent
5        review process.
6            (C) Provide the enrollee or subscriber with
7        information regarding the Department's independent
8        review process and the right of the enrollee or
9        subscriber to opt out of that review process within 45
10        days of the date upon which an independent review
11        organization receives a request for independent
12        review.
13            (D) Provide a statement that the health care
14        service plan's proposed decision to cancel or rescind
15        the health care service plan contract shall not become
16        effective unless the Department's independent review
17        organization upholds the health care service plan's
18        decision or unless the enrollee or subscriber has opted
19        out of the independent review.
 
20    (215 ILCS 180/25.6 new)
21    Sec. 25.6. Continuation.
22    (a) A health care service plan shall continue to authorize
23and provide all medically necessary health care services
24required to be covered under an enrollee's or subscriber's
25health care service plan contract until the effective date of

 

 

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1cancellation or rescission.
2    (b) The effective date of the health care service plan's
3cancellation or the date upon which the plan may initiate a
4rescission shall be no earlier than the date that the enrollee
5or subscriber receives notification via regular and certified
6mail that the independent review organization has made a
7determination upholding the health care service plan's
8decision to rescind or cancel.
 
9    (215 ILCS 180/35)
10    Sec. 35. Standard external review.
11    (a) Within 4 months after the date of receipt of a notice
12of an adverse determination or final adverse determination, a
13covered person or the covered person's authorized
14representative may file a request for an external review with
15the Director. Within one business day after the date of receipt
16of a request for external review, the Director shall send a
17copy of the request to the health carrier.
18    (b) Within 5 business days following the date of receipt of
19the external review request, the health carrier shall complete
20a preliminary review of the request to determine whether:
21        (1) the individual is or was a covered person in the
22    health benefit plan at the time the health care service was
23    requested or at the time the health care service was
24    provided;
25        (2) the health care service that is the subject of the

 

 

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1    adverse determination or the final adverse determination
2    is a covered service under the covered person's health
3    benefit plan, but the health carrier has determined that
4    the health care service is not covered;
5        (3) the covered person has exhausted the health
6    carrier's internal appeal process unless the covered
7    person is not required to exhaust the health carrier's
8    internal appeal process pursuant to this Act;
9        (4) (blank); and
10        (5) the covered person has provided all the information
11    and forms required to process an external review, as
12    specified in this Act.
13    (c) Within one business day after completion of the
14preliminary review, the health carrier shall notify the
15Director and covered person and, if applicable, the covered
16person's authorized representative in writing whether the
17request is complete and eligible for external review. If the
18request:
19        (1) is not complete, the health carrier shall inform
20    the Director and covered person and, if applicable, the
21    covered person's authorized representative in writing and
22    include in the notice what information or materials are
23    required by this Act to make the request complete; or
24        (2) is not eligible for external review, the health
25    carrier shall inform the Director and covered person and,
26    if applicable, the covered person's authorized

 

 

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1    representative in writing and include in the notice the
2    reasons for its ineligibility.
3    The Department may specify the form for the health
4carrier's notice of initial determination under this
5subsection (c) and any supporting information to be included in
6the notice.
7    The notice of initial determination of ineligibility shall
8include a statement informing the covered person and, if
9applicable, the covered person's authorized representative
10that a health carrier's initial determination that the external
11review request is ineligible for review may be appealed to the
12Director by filing a complaint with the Director.
13    Notwithstanding a health carrier's initial determination
14that the request is ineligible for external review, the
15Director may determine that a request is eligible for external
16review and require that it be referred for external review. In
17making such determination, the Director's decision shall be in
18accordance with the terms of the covered person's health
19benefit plan, unless such terms are inconsistent with
20applicable law, and shall be subject to all applicable
21provisions of this Act.
22    (d) Whenever the Director receives notice that a request is
23eligible for external review following the preliminary review
24conducted pursuant to this Section, within one business day
25after the date of receipt of the notice, the Director shall:
26        (1) assign an independent review organization from the

 

 

HB0122- 26 -LRB099 03611 MLM 23619 b

1    list of approved independent review organizations compiled
2    and maintained by the Director pursuant to this Act and
3    notify the health carrier of the name of the assigned
4    independent review organization; and
5        (2) notify in writing the covered person and, if
6    applicable, the covered person's authorized representative
7    of the request's eligibility and acceptance for external
8    review and the name of the independent review organization.
9    The Director shall include in the notice provided to the
10covered person and, if applicable, the covered person's
11authorized representative a statement that the covered person
12or the covered person's authorized representative may, within 5
13business days following the date of receipt of the notice
14provided pursuant to item (2) of this subsection (d), submit in
15writing to the assigned independent review organization
16additional information that the independent review
17organization shall consider when conducting the external
18review. The independent review organization is not required to,
19but may, accept and consider additional information submitted
20after 5 business days.
21    (e) The assignment by the Director of an approved
22independent review organization to conduct an external review
23in accordance with this Section shall be done on a random basis
24among those independent review organizations approved by the
25Director pursuant to this Act.
26    (f) Within 5 business days after the date of receipt of the

 

 

HB0122- 27 -LRB099 03611 MLM 23619 b

1notice provided pursuant to item (1) of subsection (d) of this
2Section, the health carrier or its designee utilization review
3organization shall provide to the assigned independent review
4organization the documents and any information considered in
5making the adverse determination or final adverse
6determination; in such cases, the following provisions shall
7apply:
8        (1) Except as provided in item (2) of this subsection
9    (f), failure by the health carrier or its utilization
10    review organization to provide the documents and
11    information within the specified time frame shall not delay
12    the conduct of the external review.
13        (2) If the health carrier or its utilization review
14    organization fails to provide the documents and
15    information within the specified time frame, the assigned
16    independent review organization may terminate the external
17    review and make a decision to reverse the adverse
18    determination or final adverse determination.
19        (3) Within one business day after making the decision
20    to terminate the external review and make a decision to
21    reverse the adverse determination or final adverse
22    determination under item (2) of this subsection (f), the
23    independent review organization shall notify the Director,
24    the health carrier, the covered person and, if applicable,
25    the covered person's authorized representative, of its
26    decision to reverse the adverse determination.

 

 

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1    (g) Upon receipt of the information from the health carrier
2or its utilization review organization, the assigned
3independent review organization shall review all of the
4information and documents and any other information submitted
5in writing to the independent review organization by the
6covered person and the covered person's authorized
7representative.
8    (h) Upon receipt of any information submitted by the
9covered person or the covered person's authorized
10representative, the independent review organization shall
11forward the information to the health carrier within 1 business
12day.
13        (1) Upon receipt of the information, if any, the health
14    carrier may reconsider its adverse determination or final
15    adverse determination that is the subject of the external
16    review.
17        (2) Reconsideration by the health carrier of its
18    adverse determination or final adverse determination shall
19    not delay or terminate the external review.
20        (3) The external review may only be terminated if the
21    health carrier decides, upon completion of its
22    reconsideration, to reverse its adverse determination or
23    final adverse determination and provide coverage or
24    payment for the health care service that is the subject of
25    the adverse determination or final adverse determination.
26    In such cases, the following provisions shall apply:

 

 

HB0122- 29 -LRB099 03611 MLM 23619 b

1            (A) Within one business day after making the
2        decision to reverse its adverse determination or final
3        adverse determination, the health carrier shall notify
4        the Director, the covered person and, if applicable,
5        the covered person's authorized representative, and
6        the assigned independent review organization in
7        writing of its decision.
8            (B) Upon notice from the health carrier that the
9        health carrier has made a decision to reverse its
10        adverse determination or final adverse determination,
11        the assigned independent review organization shall
12        terminate the external review.
13    (i) In addition to the documents and information provided
14by the health carrier or its utilization review organization
15and the covered person and the covered person's authorized
16representative, if any, the independent review organization,
17to the extent the information or documents are available and
18the independent review organization considers them
19appropriate, shall consider the following in reaching a
20decision:
21        (1) the covered person's pertinent medical records;
22        (2) the covered person's health care provider's
23    recommendation;
24        (3) consulting reports from appropriate health care
25    providers and other documents submitted by the health
26    carrier or its designee utilization review organization,

 

 

HB0122- 30 -LRB099 03611 MLM 23619 b

1    the covered person, the covered person's authorized
2    representative, or the covered person's treating provider;
3        (4) the terms of coverage under the covered person's
4    health benefit plan with the health carrier to ensure that
5    the independent review organization's decision is not
6    contrary to the terms of coverage under the covered
7    person's health benefit plan with the health carrier,
8    unless the terms are inconsistent with applicable law;
9        (5) the most appropriate practice guidelines, which
10    shall include applicable evidence-based standards and may
11    include any other practice guidelines developed by the
12    federal government, national or professional medical
13    societies, boards, and associations;
14        (6) any applicable clinical review criteria developed
15    and used by the health carrier or its designee utilization
16    review organization;
17        (7) the opinion of the independent review
18    organization's clinical reviewer or reviewers after
19    considering items (1) through (6) of this subsection (i) to
20    the extent the information or documents are available and
21    the clinical reviewer or reviewers considers the
22    information or documents appropriate; and
23        (8) (blank).
24    (j) Within 5 days after the date of receipt of all
25necessary information, but in no event more than 45 days after
26the date of receipt of the request for an external review, the

 

 

HB0122- 31 -LRB099 03611 MLM 23619 b

1assigned independent review organization shall provide written
2notice of its decision to uphold or reverse the adverse
3determination or the final adverse determination to the
4Director, the health carrier, the covered person, and, if
5applicable, the covered person's authorized representative. In
6reaching a decision, the assigned independent review
7organization is not bound by any claim determinations reached
8prior to the submission of information to the independent
9review organization. The assigned independent review
10organization shall independently determine if the health care
11services under review are the medically necessary health care
12services that a physician, exercising prudent clinical
13judgment, would provide to a patient for the purpose of
14preventing, evaluating, diagnosing, or treating an illness,
15injury, disease, or its symptoms and are: (i) in accordance
16with generally accepted standards of medical practice; (ii)
17clinically appropriate, in terms of type, frequency, extent,
18site, and duration and considered effective for the patient's
19illness, injury, or disease; and (iii) not primarily for the
20convenience of the patient, physician, or other health care
21provider. For the purposes of this subsection (j), "generally
22accepted standards of medical practice" means standards that
23are based on credible scientific evidence published in
24peer-reviewed medical literature generally recognized by the
25relevant medical community, physician specialty society
26recommendations, and the views of physicians practicing in

 

 

HB0122- 32 -LRB099 03611 MLM 23619 b

1relevant clinical areas and any other relevant factors. In such
2cases, the following provisions shall apply:
3        (1) The independent review organization shall include
4    in the notice:
5            (A) a general description of the reason for the
6        request for external review;
7            (B) the date the independent review organization
8        received the assignment from the Director to conduct
9        the external review;
10            (C) the time period during which the external
11        review was conducted;
12            (D) references to the evidence or documentation,
13        including the evidence-based standards, considered in
14        reaching its decision;
15            (E) the date of its decision;
16            (F) the principal reason or reasons for its
17        decision, including what applicable, if any,
18        evidence-based standards that were a basis for its
19        decision; and
20            (G) the rationale for its decision.
21        (2) (Blank).
22        (3) (Blank).
23        (4) Upon receipt of a notice of a decision reversing
24    the adverse determination or final adverse determination,
25    the health carrier immediately shall approve the coverage
26    that was the subject of the adverse determination or final

 

 

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1    adverse determination.
2(Source: P.A. 96-857, eff. 7-1-10; 96-967, eff. 1-1-11; 97-574,
3eff. 8-26-11.)
 
4    Section 55. The Illinois Public Aid Code is amended by
5changing Section 5-16.8 as follows:
 
6    (305 ILCS 5/5-16.8)
7    Sec. 5-16.8. Required health benefits. The medical
8assistance program shall (i) provide the post-mastectomy care
9benefits required to be covered by a policy of accident and
10health insurance under Section 356t and the coverage required
11under Sections 356g.5, 356u, 356w, 356x, and 356z.6, and
12356z.25 of the Illinois Insurance Code and (ii) be subject to
13the provisions of Sections 356z.19 and 364.01 of the Illinois
14Insurance Code.
15    On and after July 1, 2012, the Department shall reduce any
16rate of reimbursement for services or other payments or alter
17any methodologies authorized by this Code to reduce any rate of
18reimbursement for services or other payments in accordance with
19Section 5-5e.
20(Source: P.A. 97-282, eff. 8-9-11; 97-689, eff. 6-14-12.)
 
21    Section 60. The Medical Patient Rights Act is amended by
22changing Sections 2.04 and 3 and by adding Section 2.06 as
23follows:
 

 

 

HB0122- 34 -LRB099 03611 MLM 23619 b

1    (410 ILCS 50/2.04)  (from Ch. 111 1/2, par. 5402.04)
2    Sec. 2.04. "Insurance company" means (1) an insurance
3company, fraternal benefit society, and any other insurer
4subject to regulation under the Illinois Insurance Code; or (2)
5a health maintenance organization, a limited health service
6organization under the Limited Health Service Organization
7Act, or a voluntary health services plan under the Voluntary
8Health Services Plans Act.
9(Source: P.A. 85-677; 85-679.)
 
10    (410 ILCS 50/2.06 new)
11    Sec. 2.06. Health insurance policy or health care plan.
12"Health insurance policy or health care plan" means any policy
13of health or accident insurance provided by a health insurance
14company or under the Counties Code, the Municipal Code, the
15State Employees Group Insurance Act or Medical Assistance
16provided under the Public Aid Code.
 
17    (410 ILCS 50/3)  (from Ch. 111 1/2, par. 5403)
18    Sec. 3. The following rights are hereby established:
19    (a) The right of each patient to care consistent with sound
20nursing and medical practices, to be informed of the name of
21the physician responsible for coordinating his or her care, to
22receive information concerning his or her condition and
23proposed treatment, to refuse any treatment to the extent

 

 

HB0122- 35 -LRB099 03611 MLM 23619 b

1permitted by law, and to privacy and confidentiality of records
2except as otherwise provided by law. Each patient has a right
3to be informed of his or her inpatient or outpatient status
4while undergoing evaluation, assessment, diagnosis, treatment,
5or observation in a hospital. The patient must be informed of
6this status and put on notice that this admission status may
7affect coverage by his or her health insurance policy or health
8care plan or his or her personal responsibility for payment.
9    (b) The right of each patient, regardless of source of
10payment, to examine and receive a reasonable explanation of his
11total bill for services rendered by his physician or health
12care provider, including the itemized charges for specific
13services received. Each physician or health care provider shall
14be responsible only for a reasonable explanation of those
15specific services provided by such physician or health care
16provider.
17    (c) In the event an insurance company or health services
18corporation cancels or refuses to renew an individual policy or
19plan, the insured patient shall be entitled to timely, prior
20notice of the termination of such policy or plan.
21    An insurance company or health services corporation that
22requires any insured patient or applicant for new or continued
23insurance or coverage to be tested for infection with human
24immunodeficiency virus (HIV) or any other identified causative
25agent of acquired immunodeficiency syndrome (AIDS) shall (1)
26give the patient or applicant prior written notice of such

 

 

HB0122- 36 -LRB099 03611 MLM 23619 b

1requirement, (2) proceed with such testing only upon the
2written authorization of the applicant or patient, and (3) keep
3the results of such testing confidential. Notice of an adverse
4underwriting or coverage decision may be given to any
5appropriately interested party, but the insurer may only
6disclose the test result itself to a physician designated by
7the applicant or patient, and any such disclosure shall be in a
8manner that assures confidentiality.
9    The Department of Insurance shall enforce the provisions of
10this subsection.
11    (d) The right of each patient to privacy and
12confidentiality in health care. Each physician, health care
13provider, health services corporation and insurance company
14shall refrain from disclosing the nature or details of services
15provided to patients, except that such information may be
16disclosed: (1) to the patient, (2) to the party making
17treatment decisions if the patient is incapable of making
18decisions regarding the health services provided, (3) for
19treatment in accordance with 45 CFR 164.501 and 164.506, (4)
20for payment in accordance with 45 CFR 164.501 and 164.506, (5)
21to those parties responsible for peer review, utilization
22review, and quality assurance, (6) for health care operations
23in accordance with 45 CFR 164.501 and 164.506, (7) to those
24parties required to be notified under the Abused and Neglected
25Child Reporting Act or the Illinois Sexually Transmissible
26Disease Control Act, or (8) as otherwise permitted, authorized,

 

 

HB0122- 37 -LRB099 03611 MLM 23619 b

1or required by State or federal law. This right may be waived
2in writing by the patient or the patient's guardian or legal
3representative, but a physician or other health care provider
4may not condition the provision of services on the patient's,
5guardian's, or legal representative's agreement to sign such a
6waiver. In the interest of public health, safety, and welfare,
7patient information, including, but not limited to, health
8information, demographic information, and information about
9the services provided to patients, may be transmitted to or
10through a health information exchange, as that term is defined
11in Section 2 of the Mental Health and Developmental
12Disabilities Confidentiality Act, in accordance with the
13disclosures permitted pursuant to this Section. Patients shall
14be provided the opportunity to opt out of their health
15information being transmitted to or through a health
16information exchange in accordance with the regulations,
17standards, or contractual obligations adopted by the Illinois
18Health Information Exchange Authority in accordance with
19Section 9.6 of the Mental Health and Developmental Disabilities
20Confidentiality Act, Section 9.6 of the AIDS Confidentiality
21Act, or Section 31.8 of the Genetic Information Privacy Act, as
22applicable. In the case of a patient choosing to opt out of
23having his or her information available on an HIE, nothing in
24this Act shall cause the physician or health care provider to
25be liable for the release of a patient's health information by
26other entities that may possess such information, including,

 

 

HB0122- 38 -LRB099 03611 MLM 23619 b

1but not limited to, other health professionals, providers,
2laboratories, pharmacies, hospitals, ambulatory surgical
3centers, and nursing homes.
4(Source: P.A. 98-1046, eff. 1-1-15.)
 
5    Section 90. The State Mandates Act is amended by adding
6Section 8.39 as follows:
 
7    (30 ILCS 805/8.39 new)
8    Sec. 8.39. Exempt mandate. Notwithstanding Sections 6 and 8
9of this Act, no reimbursement by the State is required for the
10implementation of any mandate created by this amendatory Act of
11the 99th General Assembly.
 
12    (210 ILCS 80/1.3 rep.)
13    Section 95. The Hospital Emergency Service Act is amended
14by repealing Section 1.3.
 
15    Section 99. Effective date. This Act takes effect upon
16becoming law.

 

 

HB0122- 39 -LRB099 03611 MLM 23619 b

1 INDEX
2 Statutes amended in order of appearance
3    5 ILCS 375/6.11
4    55 ILCS 5/5-1069.3
5    65 ILCS 5/10-4-2.3
6    105 ILCS 5/10-22.3f
7    210 ILCS 70/1from Ch. 111 1/2, par. 6151
8    210 ILCS 80/1from Ch. 111 1/2, par. 86
9    215 ILCS 5/356z.23 new
10    215 ILCS 5/356z.24 new
11    215 ILCS 5/356z.25 new
12    215 ILCS 125/5-3from Ch. 111 1/2, par. 1411.2
13    215 ILCS 165/10from Ch. 32, par. 604
14    215 ILCS 180/25.1 new
15    215 ILCS 180/25.2 new
16    215 ILCS 180/25.3 new
17    215 ILCS 180/25.4 new
18    215 ILCS 180/25.5 new
19    215 ILCS 180/25.6 new
20    215 ILCS 180/35
21    305 ILCS 5/5-16.8
22    410 ILCS 50/2.04from Ch. 111 1/2, par. 5402.04
23    410 ILCS 50/2.06 new
24    410 ILCS 50/3from Ch. 111 1/2, par. 5403
25    30 ILCS 805/8.39 new

 

 

HB0122- 40 -LRB099 03611 MLM 23619 b

1    210 ILCS 80/1.3 rep.