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1 | AN ACT concerning health care coverage.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by | ||||||||||||||||||||||||||
5 | changing Section 356z.4, as added by Public Act 93-529, as | ||||||||||||||||||||||||||
6 | follows:
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7 | (215 ILCS 5/356z.5)
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8 | Sec. 356z.5
356z.4 . Prescription inhalants , spacers, and | ||||||||||||||||||||||||||
9 | peak flow meters . A group or individual
policy of
accident and | ||||||||||||||||||||||||||
10 | health insurance or managed care plan amended, delivered, | ||||||||||||||||||||||||||
11 | issued,
or renewed
after the effective date of this amendatory | ||||||||||||||||||||||||||
12 | Act of the 93rd General Assembly
that provides
coverage for | ||||||||||||||||||||||||||
13 | prescription drugs may not deny or limit coverage
for | ||||||||||||||||||||||||||
14 | prescription inhalants and at least 2 spacers and peak flow | ||||||||||||||||||||||||||
15 | meters per year to enable persons to breathe when suffering | ||||||||||||||||||||||||||
16 | from
asthma or other life-threatening bronchial ailments based | ||||||||||||||||||||||||||
17 | upon any restriction
on the number of days before an inhaler | ||||||||||||||||||||||||||
18 | refill may be obtained if, contrary to
those restrictions, the | ||||||||||||||||||||||||||
19 | inhalants have been ordered or prescribed by the
treating | ||||||||||||||||||||||||||
20 | physician and are medically appropriate.
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21 | (Source: P.A. 93-529, eff. 8-14-03; revised 9-25-03.)
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22 | Section 10. The Illinois Public Aid Code is amended by | ||||||||||||||||||||||||||
23 | changing Section 5-5 as follows: | ||||||||||||||||||||||||||
24 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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25 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||||||||||||||||||||||
26 | rule, shall
determine the quantity and quality of and the rate | ||||||||||||||||||||||||||
27 | of reimbursement for the
medical assistance for which
payment | ||||||||||||||||||||||||||
28 | will be authorized, and the medical services to be provided,
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29 | which may include all or part of the following: (1) inpatient | ||||||||||||||||||||||||||
30 | hospital
services; (2) outpatient hospital services; (3) other |
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1 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
2 | services; (5) physicians'
services whether furnished in the | ||||||
3 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
4 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
5 | care furnished by licensed practitioners; (7)
home health care | ||||||
6 | services; (8) private duty nursing service; (9) clinic
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7 | services; (10) dental services; (11) physical therapy and | ||||||
8 | related
services; (12) prescribed drugs, dentures, and | ||||||
9 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
10 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
11 | whichever the person may select; (13) other
diagnostic, | ||||||
12 | screening, preventive, and rehabilitative services; (14)
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13 | transportation and such other expenses as may be necessary; | ||||||
14 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
15 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
16 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
17 | assault, including
examinations and laboratory tests to | ||||||
18 | discover evidence which may be used in
criminal proceedings | ||||||
19 | arising from the sexual assault; (16) the
diagnosis and | ||||||
20 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
21 | care, and any other type of remedial care recognized
under the | ||||||
22 | laws of this State, but not including abortions, or induced
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23 | miscarriages or premature births, unless, in the opinion of a | ||||||
24 | physician,
such procedures are necessary for the preservation | ||||||
25 | of the life of the
woman seeking such treatment, or except an | ||||||
26 | induced premature birth
intended to produce a live viable child | ||||||
27 | and such procedure is necessary
for the health of the mother or | ||||||
28 | her unborn child. The Illinois Department,
by rule, shall | ||||||
29 | prohibit any physician from providing medical assistance
to | ||||||
30 | anyone eligible therefor under this Code where such physician | ||||||
31 | has been
found guilty of performing an abortion procedure in a | ||||||
32 | wilful and wanton
manner upon a woman who was not pregnant at | ||||||
33 | the time such abortion
procedure was performed. The term "any | ||||||
34 | other type of remedial care" shall
include nursing care and | ||||||
35 | nursing home service for persons who rely on
treatment by | ||||||
36 | spiritual means alone through prayer for healing ; and (18) |
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1 | coverage
for prescription inhalants and and at least 2 spacers | ||||||
2 | and peak flow meters per year to enable persons to breathe when | ||||||
3 | suffering from
asthma or other life-threatening bronchial | ||||||
4 | ailments based upon any restriction
on the number of days | ||||||
5 | before an inhaler refill may be obtained if, contrary to
those | ||||||
6 | restrictions, the inhalants have been ordered or prescribed by | ||||||
7 | the
treating physician and are medically appropriate .
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8 | Notwithstanding any other provision of this Section, a | ||||||
9 | comprehensive
tobacco use cessation program that includes | ||||||
10 | purchasing prescription drugs or
prescription medical devices | ||||||
11 | approved by the Food and Drug administration shall
be covered | ||||||
12 | under the medical assistance
program under this Article for | ||||||
13 | persons who are otherwise eligible for
assistance under this | ||||||
14 | Article.
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15 | Notwithstanding any other provision of this Code, the | ||||||
16 | Illinois
Department may not require, as a condition of payment | ||||||
17 | for any laboratory
test authorized under this Article, that a | ||||||
18 | physician's handwritten signature
appear on the laboratory | ||||||
19 | test order form. The Illinois Department may,
however, impose | ||||||
20 | other appropriate requirements regarding laboratory test
order | ||||||
21 | documentation.
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22 | The Illinois Department of Public Aid shall provide the | ||||||
23 | following services to
persons
eligible for assistance under | ||||||
24 | this Article who are participating in
education, training or | ||||||
25 | employment programs operated by the Department of Human
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26 | Services as successor to the Department of Public Aid:
| ||||||
27 | (1) dental services, which shall include but not be | ||||||
28 | limited to
prosthodontics; and
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29 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
30 | diseases of the
eye, or by an optometrist, whichever the | ||||||
31 | person may select.
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32 | The Illinois Department, by rule, may distinguish and | ||||||
33 | classify the
medical services to be provided only in accordance | ||||||
34 | with the classes of
persons designated in Section 5-2.
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35 | The Illinois Department shall authorize the provision of, | ||||||
36 | and shall
authorize payment for, screening by low-dose |
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1 | mammography for the presence of
occult breast cancer for women | ||||||
2 | 35 years of age or older who are eligible
for medical | ||||||
3 | assistance under this Article, as follows: a baseline
mammogram | ||||||
4 | for women 35 to 39 years of age and an
annual mammogram for | ||||||
5 | women 40 years of age or older. All screenings
shall
include a | ||||||
6 | physical breast exam, instruction on self-examination and
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7 | information regarding the frequency of self-examination and | ||||||
8 | its value as a
preventative tool. As used in this Section, | ||||||
9 | "low-dose mammography" means
the x-ray examination of the | ||||||
10 | breast using equipment dedicated specifically
for mammography, | ||||||
11 | including the x-ray tube, filter, compression device,
image | ||||||
12 | receptor, and cassettes, with an average radiation exposure | ||||||
13 | delivery
of less than one rad mid-breast, with 2 views for each | ||||||
14 | breast.
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15 | Any medical or health care provider shall immediately | ||||||
16 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
17 | services and is suspected
of drug abuse or is addicted as | ||||||
18 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
19 | Act, referral to a local substance abuse treatment provider
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20 | licensed by the Department of Human Services or to a licensed
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21 | hospital which provides substance abuse treatment services. | ||||||
22 | The Department of
Public Aid shall assure coverage for the cost | ||||||
23 | of treatment of the drug abuse or
addiction for pregnant | ||||||
24 | recipients in accordance with the Illinois Medicaid
Program in | ||||||
25 | conjunction with the Department of Human Services.
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26 | All medical providers providing medical assistance to | ||||||
27 | pregnant women
under this Code shall receive information from | ||||||
28 | the Department on the
availability of services under the Drug | ||||||
29 | Free Families with a Future or any
comparable program providing | ||||||
30 | case management services for addicted women,
including | ||||||
31 | information on appropriate referrals for other social services
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32 | that may be needed by addicted women in addition to treatment | ||||||
33 | for addiction.
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34 | The Illinois Department, in cooperation with the | ||||||
35 | Departments of Human
Services (as successor to the Department | ||||||
36 | of Alcoholism and Substance
Abuse) and Public Health, through a |
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1 | public awareness campaign, may
provide information concerning | ||||||
2 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
3 | health care, and other pertinent programs directed at
reducing | ||||||
4 | the number of drug-affected infants born to recipients of | ||||||
5 | medical
assistance.
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6 | Neither the Illinois Department of Public Aid nor the | ||||||
7 | Department of Human
Services shall sanction the recipient | ||||||
8 | solely on the basis of
her substance abuse.
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9 | The Illinois Department shall establish such regulations | ||||||
10 | governing
the dispensing of health services under this Article | ||||||
11 | as it shall deem
appropriate. The Department
should
seek the | ||||||
12 | advice of formal professional advisory committees appointed by
| ||||||
13 | the Director of the Illinois Department for the purpose of | ||||||
14 | providing regular
advice on policy and administrative matters, | ||||||
15 | information dissemination and
educational activities for | ||||||
16 | medical and health care providers, and
consistency in | ||||||
17 | procedures to the Illinois Department.
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18 | The Illinois Department may develop and contract with | ||||||
19 | Partnerships of
medical providers to arrange medical services | ||||||
20 | for persons eligible under
Section 5-2 of this Code. | ||||||
21 | Implementation of this Section may be by
demonstration projects | ||||||
22 | in certain geographic areas. The Partnership shall
be | ||||||
23 | represented by a sponsor organization. The Department, by rule, | ||||||
24 | shall
develop qualifications for sponsors of Partnerships. | ||||||
25 | Nothing in this
Section shall be construed to require that the | ||||||
26 | sponsor organization be a
medical organization.
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27 | The sponsor must negotiate formal written contracts with | ||||||
28 | medical
providers for physician services, inpatient and | ||||||
29 | outpatient hospital care,
home health services, treatment for | ||||||
30 | alcoholism and substance abuse, and
other services determined | ||||||
31 | necessary by the Illinois Department by rule for
delivery by | ||||||
32 | Partnerships. Physician services must include prenatal and
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33 | obstetrical care. The Illinois Department shall reimburse | ||||||
34 | medical services
delivered by Partnership providers to clients | ||||||
35 | in target areas according to
provisions of this Article and the | ||||||
36 | Illinois Health Finance Reform Act,
except that:
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1 | (1) Physicians participating in a Partnership and | ||||||
2 | providing certain
services, which shall be determined by | ||||||
3 | the Illinois Department, to persons
in areas covered by the | ||||||
4 | Partnership may receive an additional surcharge
for such | ||||||
5 | services.
| ||||||
6 | (2) The Department may elect to consider and negotiate | ||||||
7 | financial
incentives to encourage the development of | ||||||
8 | Partnerships and the efficient
delivery of medical care.
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9 | (3) Persons receiving medical services through | ||||||
10 | Partnerships may receive
medical and case management | ||||||
11 | services above the level usually offered
through the | ||||||
12 | medical assistance program.
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13 | Medical providers shall be required to meet certain | ||||||
14 | qualifications to
participate in Partnerships to ensure the | ||||||
15 | delivery of high quality medical
services. These | ||||||
16 | qualifications shall be determined by rule of the Illinois
| ||||||
17 | Department and may be higher than qualifications for | ||||||
18 | participation in the
medical assistance program. Partnership | ||||||
19 | sponsors may prescribe reasonable
additional qualifications | ||||||
20 | for participation by medical providers, only with
the prior | ||||||
21 | written approval of the Illinois Department.
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22 | Nothing in this Section shall limit the free choice of | ||||||
23 | practitioners,
hospitals, and other providers of medical | ||||||
24 | services by clients.
In order to ensure patient freedom of | ||||||
25 | choice, the Illinois Department shall
immediately promulgate | ||||||
26 | all rules and take all other necessary actions so that
provided | ||||||
27 | services may be accessed from therapeutically certified | ||||||
28 | optometrists
to the full extent of the Illinois Optometric | ||||||
29 | Practice Act of 1987 without
discriminating between service | ||||||
30 | providers.
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31 | The Department shall apply for a waiver from the United | ||||||
32 | States Health
Care Financing Administration to allow for the | ||||||
33 | implementation of
Partnerships under this Section.
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34 | The Illinois Department shall require health care | ||||||
35 | providers to maintain
records that document the medical care | ||||||
36 | and services provided to recipients
of Medical Assistance under |
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1 | this Article. The Illinois Department shall
require health care | ||||||
2 | providers to make available, when authorized by the
patient, in | ||||||
3 | writing, the medical records in a timely fashion to other
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4 | health care providers who are treating or serving persons | ||||||
5 | eligible for
Medical Assistance under this Article. All | ||||||
6 | dispensers of medical services
shall be required to maintain | ||||||
7 | and retain business and professional records
sufficient to | ||||||
8 | fully and accurately document the nature, scope, details and
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9 | receipt of the health care provided to persons eligible for | ||||||
10 | medical
assistance under this Code, in accordance with | ||||||
11 | regulations promulgated by
the Illinois Department. The rules | ||||||
12 | and regulations shall require that proof
of the receipt of | ||||||
13 | prescription drugs, dentures, prosthetic devices and
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14 | eyeglasses by eligible persons under this Section accompany | ||||||
15 | each claim
for reimbursement submitted by the dispenser of such | ||||||
16 | medical services.
No such claims for reimbursement shall be | ||||||
17 | approved for payment by the Illinois
Department without such | ||||||
18 | proof of receipt, unless the Illinois Department
shall have put | ||||||
19 | into effect and shall be operating a system of post-payment
| ||||||
20 | audit and review which shall, on a sampling basis, be deemed | ||||||
21 | adequate by
the Illinois Department to assure that such drugs, | ||||||
22 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
23 | is being made are actually being
received by eligible | ||||||
24 | recipients. Within 90 days after the effective date of
this | ||||||
25 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
26 | a
current list of acquisition costs for all prosthetic devices | ||||||
27 | and any
other items recognized as medical equipment and | ||||||
28 | supplies reimbursable under
this Article and shall update such | ||||||
29 | list on a quarterly basis, except that
the acquisition costs of | ||||||
30 | all prescription drugs shall be updated no
less frequently than | ||||||
31 | every 30 days as required by Section 5-5.12.
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32 | The rules and regulations of the Illinois Department shall | ||||||
33 | require
that a written statement including the required opinion | ||||||
34 | of a physician
shall accompany any claim for reimbursement for | ||||||
35 | abortions, or induced
miscarriages or premature births. This | ||||||
36 | statement shall indicate what
procedures were used in providing |
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1 | such medical services.
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2 | The Illinois Department shall require all dispensers of | ||||||
3 | medical
services, other than an individual practitioner or | ||||||
4 | group of practitioners,
desiring to participate in the Medical | ||||||
5 | Assistance program
established under this Article to disclose | ||||||
6 | all financial, beneficial,
ownership, equity, surety or other | ||||||
7 | interests in any and all firms,
corporations, partnerships, | ||||||
8 | associations, business enterprises, joint
ventures, agencies, | ||||||
9 | institutions or other legal entities providing any
form of | ||||||
10 | health care services in this State under this Article.
| ||||||
11 | The Illinois Department may require that all dispensers of | ||||||
12 | medical
services desiring to participate in the medical | ||||||
13 | assistance program
established under this Article disclose, | ||||||
14 | under such terms and conditions as
the Illinois Department may | ||||||
15 | by rule establish, all inquiries from clients
and attorneys | ||||||
16 | regarding medical bills paid by the Illinois Department, which
| ||||||
17 | inquiries could indicate potential existence of claims or liens | ||||||
18 | for the
Illinois Department.
| ||||||
19 | Enrollment of a vendor that provides non-emergency medical | ||||||
20 | transportation,
defined by the Department by rule,
shall be
| ||||||
21 | conditional for 180 days. During that time, the Department of | ||||||
22 | Public Aid may
terminate the vendor's eligibility to | ||||||
23 | participate in the medical assistance
program without cause. | ||||||
24 | That termination of eligibility is not subject to the
| ||||||
25 | Department's hearing process.
| ||||||
26 | The Illinois Department shall establish policies, | ||||||
27 | procedures,
standards and criteria by rule for the acquisition, | ||||||
28 | repair and replacement
of orthotic and prosthetic devices and | ||||||
29 | durable medical equipment. Such
rules shall provide, but not be | ||||||
30 | limited to, the following services: (1)
immediate repair or | ||||||
31 | replacement of such devices by recipients without
medical | ||||||
32 | authorization; and (2) rental, lease, purchase or | ||||||
33 | lease-purchase of
durable medical equipment in a | ||||||
34 | cost-effective manner, taking into
consideration the | ||||||
35 | recipient's medical prognosis, the extent of the
recipient's | ||||||
36 | needs, and the requirements and costs for maintaining such
|
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1 | equipment. Such rules shall enable a recipient to temporarily | ||||||
2 | acquire and
use alternative or substitute devices or equipment | ||||||
3 | pending repairs or
replacements of any device or equipment | ||||||
4 | previously authorized for such
recipient by the Department. | ||||||
5 | Rules under clause (2) above shall not provide
for purchase or | ||||||
6 | lease-purchase of durable medical equipment or supplies
used | ||||||
7 | for the purpose of oxygen delivery and respiratory care.
| ||||||
8 | The Department shall execute, relative to the nursing home | ||||||
9 | prescreening
project, written inter-agency agreements with the | ||||||
10 | Department of Human
Services and the Department on Aging, to | ||||||
11 | effect the following: (i) intake
procedures and common | ||||||
12 | eligibility criteria for those persons who are receiving
| ||||||
13 | non-institutional services; and (ii) the establishment and | ||||||
14 | development of
non-institutional services in areas of the State | ||||||
15 | where they are not currently
available or are undeveloped.
| ||||||
16 | The Illinois Department shall develop and operate, in | ||||||
17 | cooperation
with other State Departments and agencies and in | ||||||
18 | compliance with
applicable federal laws and regulations, | ||||||
19 | appropriate and effective
systems of health care evaluation and | ||||||
20 | programs for monitoring of
utilization of health care services | ||||||
21 | and facilities, as it affects
persons eligible for medical | ||||||
22 | assistance under this Code.
| ||||||
23 | The Illinois Department shall report annually to the | ||||||
24 | General Assembly,
no later than the second Friday in April of | ||||||
25 | 1979 and each year
thereafter, in regard to:
| ||||||
26 | (a) actual statistics and trends in utilization of | ||||||
27 | medical services by
public aid recipients;
| ||||||
28 | (b) actual statistics and trends in the provision of | ||||||
29 | the various medical
services by medical vendors;
| ||||||
30 | (c) current rate structures and proposed changes in | ||||||
31 | those rate structures
for the various medical vendors; and
| ||||||
32 | (d) efforts at utilization review and control by the | ||||||
33 | Illinois Department.
| ||||||
34 | The period covered by each report shall be the 3 years | ||||||
35 | ending on the June
30 prior to the report. The report shall | ||||||
36 | include suggested legislation
for consideration by the General |
| |||||||
| |||||||
1 | Assembly. The filing of one copy of the
report with the | ||||||
2 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
3 | the Clerk of the House of Representatives, one copy with the | ||||||
4 | President,
one copy with the Minority Leader and one copy with | ||||||
5 | the Secretary of the
Senate, one copy with the Legislative | ||||||
6 | Research Unit, and such additional
copies
with the State | ||||||
7 | Government Report Distribution Center for the General
Assembly | ||||||
8 | as is required under paragraph (t) of Section 7 of the State
| ||||||
9 | Library Act shall be deemed sufficient to comply with this | ||||||
10 | Section.
| ||||||
11 | (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02; | ||||||
12 | 92-789, eff. 8-6-02; 93-632, eff. 2-1-04.)
|