94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB0732

 

Introduced 2/1/2005, by Rep. Naomi D. Jakobsson

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.7 new
215 ILCS 105/8   from Ch. 73, par. 1308
215 ILCS 125/5-3   from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10   from Ch. 32, par. 604
305 ILCS 5/5-5   from Ch. 23, par. 5-5

    Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, the School Code, Illinois Insurance Code, the Comprehensive Health Insurance Plan Act, the Health Maintenance Organization Act, the Voluntary Health Services Plans Act, and the Public Aid Code. Provides coverage for services rendered by a licensed athletic trainer in accordance with the Illinois Athletic Trainers Practice Act if those services are ordered by a physician licensed to practice medicine in all of its branches.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB0732 LRB094 05496 LJB 35543 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The State Employees Group Insurance Act of 1971
5 is amended by changing Section 6.11 as follows:
 
6     (5 ILCS 375/6.11)
7     Sec. 6.11. Required health benefits; Illinois Insurance
8 Code requirements. The program of health benefits shall provide
9 the post-mastectomy care benefits required to be covered by a
10 policy of accident and health insurance under Section 356t of
11 the Illinois Insurance Code. The program of health benefits
12 shall provide the coverage required under Sections 356u, 356w,
13 356x, 356z.2, 356z.4, and 356z.6, and 356z.7 of the Illinois
14 Insurance Code. The program of health benefits must comply with
15 Section 155.37 of the Illinois Insurance Code.
16 (Source: P.A. 92-440, eff. 8-17-01; 92-764, eff. 1-1-03;
17 93-102, eff. 1-1-04; 93-853, eff. 1-1-05.)
 
18     Section 10. The Counties Code is amended by changing
19 Section 5-1069.3 as follows:
 
20     (55 ILCS 5/5-1069.3)
21     Sec. 5-1069.3. Required health benefits. If a county,
22 including a home rule county, is a self-insurer for purposes of
23 providing health insurance coverage for its employees, the
24 coverage shall include coverage for the post-mastectomy care
25 benefits required to be covered by a policy of accident and
26 health insurance under Section 356t and the coverage required
27 under Sections 356u, 356w, 356x, and 356z.6, and 356z.7 of the
28 Illinois Insurance Code. The requirement that health benefits
29 be covered as provided in this Section is an exclusive power
30 and function of the State and is a denial and limitation under

 

 

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1 Article VII, Section 6, subsection (h) of the Illinois
2 Constitution. A home rule county to which this Section applies
3 must comply with every provision of this Section.
4 (Source: P.A. 93-853, eff. 1-1-05.)
 
5     Section 15. The Illinois Municipal Code is amended by
6 changing Section 10-4-2.3 as follows:
 
7     (65 ILCS 5/10-4-2.3)
8     Sec. 10-4-2.3. Required health benefits. If a
9 municipality, including a home rule municipality, is a
10 self-insurer for purposes of providing health insurance
11 coverage for its employees, the coverage shall include coverage
12 for the post-mastectomy care benefits required to be covered by
13 a policy of accident and health insurance under Section 356t
14 and the coverage required under Sections 356u, 356w, 356x, and
15 356z.6, and 356z.7 of the Illinois Insurance Code. The
16 requirement that health benefits be covered as provided in this
17 is an exclusive power and function of the State and is a denial
18 and limitation under Article VII, Section 6, subsection (h) of
19 the Illinois Constitution. A home rule municipality to which
20 this Section applies must comply with every provision of this
21 Section.
22 (Source: P.A. 93-853, eff. 1-1-05.)
 
23     Section 20. The School Code is amended by changing Section
24 10-22.3f as follows:
 
25     (105 ILCS 5/10-22.3f)
26     Sec. 10-22.3f. Required health benefits. Insurance
27 protection and benefits for employees shall provide the
28 post-mastectomy care benefits required to be covered by a
29 policy of accident and health insurance under Section 356t and
30 the coverage required under Sections 356u, 356w, 356x, and
31 356z.6, and 356z.7 of the Illinois Insurance Code.
32 (Source: P.A. 93-853, eff. 1-1-05.)
 

 

 

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1     Section 25. The Illinois Insurance Code is amended by
2 adding Section 356z.7 as follows:
 
3     (215 ILCS 5/356z.7 new)
4     Sec. 356z.7. Athletic Trainers. A group or individual
5 policy of accident and health insurance or managed care plan
6 amended, delivered, issued, or renewed after the effective date
7 of this amendatory Act of the 94th General Assembly must
8 provide coverage for services rendered by a licensed athletic
9 trainer in accordance with the Illinois Athletic Trainers
10 Practice Act if those services are ordered by a physician
11 licensed to practice medicine in all of its branches.
 
12     Section 30. The Comprehensive Health Insurance Plan Act is
13 amended by changing Section 8 as follows:
 
14     (215 ILCS 105/8)  (from Ch. 73, par. 1308)
15     Sec. 8. Minimum benefits.
16     a. Availability. The Plan shall offer in an annually
17 renewable policy major medical expense coverage to every
18 eligible person who is not eligible for Medicare. Major medical
19 expense coverage offered by the Plan shall pay an eligible
20 person's covered expenses, subject to limit on the deductible
21 and coinsurance payments authorized under paragraph (4) of
22 subsection d of this Section, up to a lifetime benefit limit of
23 $1,000,000 per covered individual. The maximum limit under this
24 subsection shall not be altered by the Board, and no actuarial
25 equivalent benefit may be substituted by the Board. Any person
26 who otherwise would qualify for coverage under the Plan, but is
27 excluded because he or she is eligible for Medicare, shall be
28 eligible for any separate Medicare supplement policy or
29 policies which the Board may offer.
30     b. Outline of benefits. Covered expenses shall be limited
31 to the usual and customary charge, including negotiated fees,
32 in the locality for the following services and articles when

 

 

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1 prescribed by a physician and determined by the Plan to be
2 medically necessary for the following areas of services,
3 subject to such separate deductibles, co-payments, exclusions,
4 and other limitations on benefits as the Board shall establish
5 and approve, and the other provisions of this Section:
6         (1) Hospital services, except that any services
7     provided by a hospital that is located more than 75 miles
8     outside the State of Illinois shall be covered only for a
9     maximum of 45 days in any calendar year. With respect to
10     covered expenses incurred during any calendar year ending
11     on or after December 31, 1999, inpatient hospitalization of
12     an eligible person for the treatment of mental illness at a
13     hospital located within the State of Illinois shall be
14     subject to the same terms and conditions as for any other
15     illness.
16         (2) Professional services for the diagnosis or
17     treatment of injuries, illnesses or conditions, other than
18     dental and mental and nervous disorders as described in
19     paragraph (17), which are rendered by a physician, or by
20     other licensed professionals at the physician's direction.
21     This includes reconstruction of the breast on which a
22     mastectomy was performed; surgery and reconstruction of
23     the other breast to produce a symmetrical appearance; and
24     prostheses and treatment of physical complications at all
25     stages of the mastectomy, including lymphedemas.
26         (2.5) Professional services provided by a physician to
27     children under the age of 16 years for physical
28     examinations and age appropriate immunizations ordered by
29     a physician licensed to practice medicine in all its
30     branches.
31         (3) (Blank).
32         (4) Outpatient prescription drugs that by law require a
33     prescription written by a physician licensed to practice
34     medicine in all its branches subject to such separate
35     deductible, copayment, and other limitations or
36     restrictions as the Board shall approve, including the use

 

 

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1     of a prescription drug card or any other program, or both.
2         (5) Skilled nursing services of a licensed skilled
3     nursing facility for not more than 120 days during a policy
4     year.
5         (6) Services of a home health agency in accord with a
6     home health care plan, up to a maximum of 270 visits per
7     year.
8         (7) Services of a licensed hospice for not more than
9     180 days during a policy year.
10         (8) Use of radium or other radioactive materials.
11         (9) Oxygen.
12         (10) Anesthetics.
13         (11) Orthoses and prostheses other than dental.
14         (12) Rental or purchase in accordance with Board
15     policies or procedures of durable medical equipment, other
16     than eyeglasses or hearing aids, for which there is no
17     personal use in the absence of the condition for which it
18     is prescribed.
19         (13) Diagnostic x-rays and laboratory tests.
20         (14) Oral surgery (i) for excision of partially or
21     completely unerupted impacted teeth when not performed in
22     connection with the routine extraction or repair of teeth;
23     (ii) for excision of tumors or cysts of the jaws, cheeks,
24     lips, tongue, and roof and floor of the mouth; (iii)
25     required for correction of cleft lip and palate and other
26     craniofacial and maxillofacial birth defects; or (iv) for
27     treatment of injuries to natural teeth or a fractured jaw
28     due to an accident.
29         (15) Physical, speech, and functional occupational
30     therapy as medically necessary and provided by appropriate
31     licensed professionals.
32         (16) Emergency and other medically necessary
33     transportation provided by a licensed ambulance service to
34     the nearest health care facility qualified to treat a
35     covered illness, injury, or condition, subject to the
36     provisions of the Emergency Medical Systems (EMS) Act.

 

 

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1         (17) Outpatient services for diagnosis and treatment
2     of mental and nervous disorders provided that a covered
3     person shall be required to make a copayment not to exceed
4     50% and that the Plan's payment shall not exceed such
5     amounts as are established by the Board.
6         (18) Human organ or tissue transplants specified by the
7     Board that are performed at a hospital designated by the
8     Board as a participating transplant center for that
9     specific organ or tissue transplant.
10         (19) Naprapathic services, as appropriate, provided by
11     a licensed naprapathic practitioner.
12         (20) Services rendered by a licensed athletic trainer
13     in accordance with the Illinois Athletic Trainers Practice
14     Act if those services are ordered by a physician licensed
15     to practice medicine in all of its branches.
16     c. Exclusions. Covered expenses of the Plan shall not
17 include the following:
18         (1) Any charge for treatment for cosmetic purposes
19     other than for reconstructive surgery when the service is
20     incidental to or follows surgery resulting from injury,
21     sickness or other diseases of the involved part or surgery
22     for the repair or treatment of a congenital bodily defect
23     to restore normal bodily functions.
24         (2) Any charge for care that is primarily for rest,
25     custodial, educational, or domiciliary purposes.
26         (3) Any charge for services in a private room to the
27     extent it is in excess of the institution's charge for its
28     most common semiprivate room, unless a private room is
29     prescribed as medically necessary by a physician.
30         (4) That part of any charge for room and board or for
31     services rendered or articles prescribed by a physician,
32     dentist, or other health care personnel that exceeds the
33     reasonable and customary charge in the locality or for any
34     services or supplies not medically necessary for the
35     diagnosed injury or illness.
36         (5) Any charge for services or articles the provision

 

 

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1     of which is not within the scope of licensure of the
2     institution or individual providing the services or
3     articles.
4         (6) Any expense incurred prior to the effective date of
5     coverage by the Plan for the person on whose behalf the
6     expense is incurred.
7         (7) Dental care, dental surgery, dental treatment, any
8     other dental procedure involving the teeth or
9     periodontium, or any dental appliances, including crowns,
10     bridges, implants, or partial or complete dentures, except
11     as specifically provided in paragraph (14) of subsection b
12     of this Section.
13         (8) Eyeglasses, contact lenses, hearing aids or their
14     fitting.
15         (9) Illness or injury due to acts of war.
16         (10) Services of blood donors and any fee for failure
17     to replace the first 3 pints of blood provided to a covered
18     person each policy year.
19         (11) Personal supplies or services provided by a
20     hospital or nursing home, or any other nonmedical or
21     nonprescribed supply or service.
22         (12) Routine maternity charges for a pregnancy, except
23     where added as optional coverage with payment of an
24     additional premium for pregnancy resulting from conception
25     occurring after the effective date of the optional
26     coverage.
27         (13) (Blank).
28         (14) Any expense or charge for services, drugs, or
29     supplies that are: (i) not provided in accord with
30     generally accepted standards of current medical practice;
31     (ii) for procedures, treatments, equipment, transplants,
32     or implants, any of which are investigational,
33     experimental, or for research purposes; (iii)
34     investigative and not proven safe and effective; or (iv)
35     for, or resulting from, a gender transformation operation.
36         (15) Any expense or charge for routine physical

 

 

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1     examinations or tests except as provided in item (2.5) of
2     subsection b of this Section.
3         (16) Any expense for which a charge is not made in the
4     absence of insurance or for which there is no legal
5     obligation on the part of the patient to pay.
6         (17) Any expense incurred for benefits provided under
7     the laws of the United States and this State, including
8     Medicare, Medicaid, and other medical assistance, maternal
9     and child health services and any other program that is
10     administered or funded by the Department of Human Services,
11     Department of Public Aid, or Department of Public Health,
12     military service-connected disability payments, medical
13     services provided for members of the armed forces and their
14     dependents or employees of the armed forces of the United
15     States, and medical services financed on behalf of all
16     citizens by the United States.
17         (18) Any expense or charge for in vitro fertilization,
18     artificial insemination, or any other artificial means
19     used to cause pregnancy.
20         (19) Any expense or charge for oral contraceptives used
21     for birth control or any other temporary birth control
22     measures.
23         (20) Any expense or charge for sterilization or
24     sterilization reversals.
25         (21) Any expense or charge for weight loss programs,
26     exercise equipment, or treatment of obesity, except when
27     certified by a physician as morbid obesity (at least 2
28     times normal body weight).
29         (22) Any expense or charge for acupuncture treatment
30     unless used as an anesthetic agent for a covered surgery.
31         (23) Any expense or charge for or related to organ or
32     tissue transplants other than those performed at a hospital
33     with a Board approved organ transplant program that has
34     been designated by the Board as a preferred or exclusive
35     provider organization for that specific organ or tissue
36     transplant.

 

 

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1         (24) Any expense or charge for procedures, treatments,
2     equipment, or services that are provided in special
3     settings for research purposes or in a controlled
4     environment, are being studied for safety, efficiency, and
5     effectiveness, and are awaiting endorsement by the
6     appropriate national medical speciality college for
7     general use within the medical community.
8     d. Deductibles and coinsurance.
9     The Plan coverage defined in Section 6 shall provide for a
10 choice of deductibles per individual as authorized by the
11 Board. If 2 individual members of the same family household,
12 who are both covered persons under the Plan, satisfy the same
13 applicable deductibles, no other member of that family who is
14 also a covered person under the Plan shall be required to meet
15 any deductibles for the balance of that calendar year. The
16 deductibles must be applied first to the authorized amount of
17 covered expenses incurred by the covered person. A mandatory
18 coinsurance requirement shall be imposed at the rate authorized
19 by the Board in excess of the mandatory deductible, the
20 coinsurance in the aggregate not to exceed such amounts as are
21 authorized by the Board per annum. At its discretion the Board
22 may, however, offer catastrophic coverages or other policies
23 that provide for larger deductibles with or without coinsurance
24 requirements. The deductibles and coinsurance factors may be
25 adjusted annually according to the Medical Component of the
26 Consumer Price Index.
27     e. Scope of coverage.
28         (1) In approving any of the benefit plans to be offered
29     by the Plan, the Board shall establish such benefit levels,
30     deductibles, coinsurance factors, exclusions, and
31     limitations as it may deem appropriate and that it believes
32     to be generally reflective of and commensurate with health
33     insurance coverage that is provided in the individual
34     market in this State.
35         (2) The benefit plans approved by the Board may also
36     provide for and employ various cost containment measures

 

 

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1     and other requirements including, but not limited to,
2     preadmission certification, prior approval, second
3     surgical opinions, concurrent utilization review programs,
4     individual case management, preferred provider
5     organizations, health maintenance organizations, and other
6     cost effective arrangements for paying for covered
7     expenses.
8     f. Preexisting conditions.
9         (1) Except for federally eligible individuals
10     qualifying for Plan coverage under Section 15 of this Act
11     or eligible persons who qualify for the waiver authorized
12     in paragraph (3) of this subsection, plan coverage shall
13     exclude charges or expenses incurred during the first 6
14     months following the effective date of coverage as to any
15     condition for which medical advice, care or treatment was
16     recommended or received during the 6 month period
17     immediately preceding the effective date of coverage.
18         (2) (Blank).
19         (3) Waiver: The preexisting condition exclusions as
20     set forth in paragraph (1) of this subsection shall be
21     waived to the extent to which the eligible person (a) has
22     satisfied similar exclusions under any prior individual
23     health insurance policy that was involuntarily terminated
24     because of the insolvency of the issuer of the policy and
25     (b) has applied for Plan coverage within 90 days following
26     the involuntary termination of that individual health
27     insurance coverage.
28     g. Other sources primary; nonduplication of benefits.
29         (1) The Plan shall be the last payor of benefits
30     whenever any other benefit or source of third party payment
31     is available. Subject to the provisions of subsection e of
32     Section 7, benefits otherwise payable under Plan coverage
33     shall be reduced by all amounts paid or payable by Medicare
34     or any other government program or through any health
35     insurance coverage or group health plan, whether by
36     insurance, reimbursement, or otherwise, or through any

 

 

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1     third party liability, settlement, judgment, or award,
2     regardless of the date of the settlement, judgment, or
3     award, whether the settlement, judgment, or award is in the
4     form of a contract, agreement, or trust on behalf of a
5     minor or otherwise and whether the settlement, judgment, or
6     award is payable to the covered person, his or her
7     dependent, estate, personal representative, or guardian in
8     a lump sum or over time, and by all hospital or medical
9     expense benefits paid or payable under any worker's
10     compensation coverage, automobile medical payment, or
11     liability insurance, whether provided on the basis of fault
12     or nonfault, and by any hospital or medical benefits paid
13     or payable under or provided pursuant to any State or
14     federal law or program.
15         (2) The Plan shall have a cause of action against any
16     covered person or any other person or entity for the
17     recovery of any amount paid to the extent the amount was
18     for treatment, services, or supplies not covered in this
19     Section or in excess of benefits as set forth in this
20     Section.
21         (3) Whenever benefits are due from the Plan because of
22     sickness or an injury to a covered person resulting from a
23     third party's wrongful act or negligence and the covered
24     person has recovered or may recover damages from a third
25     party or its insurer, the Plan shall have the right to
26     reduce benefits or to refuse to pay benefits that otherwise
27     may be payable by the amount of damages that the covered
28     person has recovered or may recover regardless of the date
29     of the sickness or injury or the date of any settlement,
30     judgment, or award resulting from that sickness or injury.
31         During the pendency of any action or claim that is
32     brought by or on behalf of a covered person against a third
33     party or its insurer, any benefits that would otherwise be
34     payable except for the provisions of this paragraph (3)
35     shall be paid if payment by or for the third party has not
36     yet been made and the covered person or, if incapable, that

 

 

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1     person's legal representative agrees in writing to pay back
2     promptly the benefits paid as a result of the sickness or
3     injury to the extent of any future payments made by or for
4     the third party for the sickness or injury. This agreement
5     is to apply whether or not liability for the payments is
6     established or admitted by the third party or whether those
7     payments are itemized.
8         Any amounts due the plan to repay benefits may be
9     deducted from other benefits payable by the Plan after
10     payments by or for the third party are made.
11         (4) Benefits due from the Plan may be reduced or
12     refused as an offset against any amount otherwise
13     recoverable under this Section.
14     h. Right of subrogation; recoveries.
15         (1) Whenever the Plan has paid benefits because of
16     sickness or an injury to any covered person resulting from
17     a third party's wrongful act or negligence, or for which an
18     insurer is liable in accordance with the provisions of any
19     policy of insurance, and the covered person has recovered
20     or may recover damages from a third party that is liable
21     for the damages, the Plan shall have the right to recover
22     the benefits it paid from any amounts that the covered
23     person has received or may receive regardless of the date
24     of the sickness or injury or the date of any settlement,
25     judgment, or award resulting from that sickness or injury.
26     The Plan shall be subrogated to any right of recovery the
27     covered person may have under the terms of any private or
28     public health care coverage or liability coverage,
29     including coverage under the Workers' Compensation Act or
30     the Workers' Occupational Diseases Act, without the
31     necessity of assignment of claim or other authorization to
32     secure the right of recovery. To enforce its subrogation
33     right, the Plan may (i) intervene or join in an action or
34     proceeding brought by the covered person or his personal
35     representative, including his guardian, conservator,
36     estate, dependents, or survivors, against any third party

 

 

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1     or the third party's insurer that may be liable or (ii)
2     institute and prosecute legal proceedings against any
3     third party or the third party's insurer that may be liable
4     for the sickness or injury in an appropriate court either
5     in the name of the Plan or in the name of the covered
6     person or his personal representative, including his
7     guardian, conservator, estate, dependents, or survivors.
8         (2) If any action or claim is brought by or on behalf
9     of a covered person against a third party or the third
10     party's insurer, the covered person or his personal
11     representative, including his guardian, conservator,
12     estate, dependents, or survivors, shall notify the Plan by
13     personal service or registered mail of the action or claim
14     and of the name of the court in which the action or claim
15     is brought, filing proof thereof in the action or claim.
16     The Plan may, at any time thereafter, join in the action or
17     claim upon its motion so that all orders of court after
18     hearing and judgment shall be made for its protection. No
19     release or settlement of a claim for damages and no
20     satisfaction of judgment in the action shall be valid
21     without the written consent of the Plan to the extent of
22     its interest in the settlement or judgment and of the
23     covered person or his personal representative.
24         (3) In the event that the covered person or his
25     personal representative fails to institute a proceeding
26     against any appropriate third party before the fifth month
27     before the action would be barred, the Plan may, in its own
28     name or in the name of the covered person or personal
29     representative, commence a proceeding against any
30     appropriate third party for the recovery of damages on
31     account of any sickness, injury, or death to the covered
32     person. The covered person shall cooperate in doing what is
33     reasonably necessary to assist the Plan in any recovery and
34     shall not take any action that would prejudice the Plan's
35     right to recovery. The Plan shall pay to the covered person
36     or his personal representative all sums collected from any

 

 

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1     third party by judgment or otherwise in excess of amounts
2     paid in benefits under the Plan and amounts paid or to be
3     paid as costs, attorneys fees, and reasonable expenses
4     incurred by the Plan in making the collection or enforcing
5     the judgment.
6         (4) In the event that a covered person or his personal
7     representative, including his guardian, conservator,
8     estate, dependents, or survivors, recovers damages from a
9     third party for sickness or injury caused to the covered
10     person, the covered person or the personal representative
11     shall pay to the Plan from the damages recovered the amount
12     of benefits paid or to be paid on behalf of the covered
13     person.
14         (5) When the action or claim is brought by the covered
15     person alone and the covered person incurs a personal
16     liability to pay attorney's fees and costs of litigation,
17     the Plan's claim for reimbursement of the benefits provided
18     to the covered person shall be the full amount of benefits
19     paid to or on behalf of the covered person under this Act
20     less a pro rata share that represents the Plan's reasonable
21     share of attorney's fees paid by the covered person and
22     that portion of the cost of litigation expenses determined
23     by multiplying by the ratio of the full amount of the
24     expenditures to the full amount of the judgement, award, or
25     settlement.
26         (6) In the event of judgment or award in a suit or
27     claim against a third party or insurer, the court shall
28     first order paid from any judgement or award the reasonable
29     litigation expenses incurred in preparation and
30     prosecution of the action or claim, together with
31     reasonable attorney's fees. After payment of those
32     expenses and attorney's fees, the court shall apply out of
33     the balance of the judgment or award an amount sufficient
34     to reimburse the Plan the full amount of benefits paid on
35     behalf of the covered person under this Act, provided the
36     court may reduce and apportion the Plan's portion of the

 

 

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1     judgement proportionate to the recovery of the covered
2     person. The burden of producing evidence sufficient to
3     support the exercise by the court of its discretion to
4     reduce the amount of a proven charge sought to be enforced
5     against the recovery shall rest with the party seeking the
6     reduction. The court may consider the nature and extent of
7     the injury, economic and non-economic loss, settlement
8     offers, comparative negligence as it applies to the case at
9     hand, hospital costs, physician costs, and all other
10     appropriate costs. The Plan shall pay its pro rata share of
11     the attorney fees based on the Plan's recovery as it
12     compares to the total judgment. Any reimbursement rights of
13     the Plan shall take priority over all other liens and
14     charges existing under the laws of this State with the
15     exception of any attorney liens filed under the Attorneys
16     Lien Act.
17         (7) The Plan may compromise or settle and release any
18     claim for benefits provided under this Act or waive any
19     claims for benefits, in whole or in part, for the
20     convenience of the Plan or if the Plan determines that
21     collection would result in undue hardship upon the covered
22     person.
23 (Source: P.A. 91-639, eff. 8-20-99; 91-735, eff. 6-2-00; 92-2,
24 eff. 5-1-01; 92-630, eff. 7-11-02.)
 
25     Section 35. The Health Maintenance Organization Act is
26 amended by changing Section 5-3 as follows:
 
27     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
28     Sec. 5-3. Insurance Code provisions.
29     (a) Health Maintenance Organizations shall be subject to
30 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
31 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
32 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
33 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01, 367.2,
34 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, 401, 401.1, 402,

 

 

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1 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c)
2 of subsection (2) of Section 367, and Articles IIA, VIII 1/2,
3 XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the Illinois
4 Insurance Code.
5     (b) For purposes of the Illinois Insurance Code, except for
6 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
7 Maintenance Organizations in the following categories are
8 deemed to be "domestic companies":
9         (1) a corporation authorized under the Dental Service
10     Plan Act or the Voluntary Health Services Plans Act;
11         (2) a corporation organized under the laws of this
12     State; or
13         (3) a corporation organized under the laws of another
14     state, 30% or more of the enrollees of which are residents
15     of this State, except a corporation subject to
16     substantially the same requirements in its state of
17     organization as is a "domestic company" under Article VIII
18     1/2 of the Illinois Insurance Code.
19     (c) In considering the merger, consolidation, or other
20 acquisition of control of a Health Maintenance Organization
21 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22         (1) the Director shall give primary consideration to
23     the continuation of benefits to enrollees and the financial
24     conditions of the acquired Health Maintenance Organization
25     after the merger, consolidation, or other acquisition of
26     control takes effect;
27         (2)(i) the criteria specified in subsection (1)(b) of
28     Section 131.8 of the Illinois Insurance Code shall not
29     apply and (ii) the Director, in making his determination
30     with respect to the merger, consolidation, or other
31     acquisition of control, need not take into account the
32     effect on competition of the merger, consolidation, or
33     other acquisition of control;
34         (3) the Director shall have the power to require the
35     following information:
36             (A) certification by an independent actuary of the

 

 

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1         adequacy of the reserves of the Health Maintenance
2         Organization sought to be acquired;
3             (B) pro forma financial statements reflecting the
4         combined balance sheets of the acquiring company and
5         the Health Maintenance Organization sought to be
6         acquired as of the end of the preceding year and as of
7         a date 90 days prior to the acquisition, as well as pro
8         forma financial statements reflecting projected
9         combined operation for a period of 2 years;
10             (C) a pro forma business plan detailing an
11         acquiring party's plans with respect to the operation
12         of the Health Maintenance Organization sought to be
13         acquired for a period of not less than 3 years; and
14             (D) such other information as the Director shall
15         require.
16     (d) The provisions of Article VIII 1/2 of the Illinois
17 Insurance Code and this Section 5-3 shall apply to the sale by
18 any health maintenance organization of greater than 10% of its
19 enrollee population (including without limitation the health
20 maintenance organization's right, title, and interest in and to
21 its health care certificates).
22     (e) In considering any management contract or service
23 agreement subject to Section 141.1 of the Illinois Insurance
24 Code, the Director (i) shall, in addition to the criteria
25 specified in Section 141.2 of the Illinois Insurance Code, take
26 into account the effect of the management contract or service
27 agreement on the continuation of benefits to enrollees and the
28 financial condition of the health maintenance organization to
29 be managed or serviced, and (ii) need not take into account the
30 effect of the management contract or service agreement on
31 competition.
32     (f) Except for small employer groups as defined in the
33 Small Employer Rating, Renewability and Portability Health
34 Insurance Act and except for medicare supplement policies as
35 defined in Section 363 of the Illinois Insurance Code, a Health
36 Maintenance Organization may by contract agree with a group or

 

 

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1 other enrollment unit to effect refunds or charge additional
2 premiums under the following terms and conditions:
3         (i) the amount of, and other terms and conditions with
4     respect to, the refund or additional premium are set forth
5     in the group or enrollment unit contract agreed in advance
6     of the period for which a refund is to be paid or
7     additional premium is to be charged (which period shall not
8     be less than one year); and
9         (ii) the amount of the refund or additional premium
10     shall not exceed 20% of the Health Maintenance
11     Organization's profitable or unprofitable experience with
12     respect to the group or other enrollment unit for the
13     period (and, for purposes of a refund or additional
14     premium, the profitable or unprofitable experience shall
15     be calculated taking into account a pro rata share of the
16     Health Maintenance Organization's administrative and
17     marketing expenses, but shall not include any refund to be
18     made or additional premium to be paid pursuant to this
19     subsection (f)). The Health Maintenance Organization and
20     the group or enrollment unit may agree that the profitable
21     or unprofitable experience may be calculated taking into
22     account the refund period and the immediately preceding 2
23     plan years.
24     The Health Maintenance Organization shall include a
25 statement in the evidence of coverage issued to each enrollee
26 describing the possibility of a refund or additional premium,
27 and upon request of any group or enrollment unit, provide to
28 the group or enrollment unit a description of the method used
29 to calculate (1) the Health Maintenance Organization's
30 profitable experience with respect to the group or enrollment
31 unit and the resulting refund to the group or enrollment unit
32 or (2) the Health Maintenance Organization's unprofitable
33 experience with respect to the group or enrollment unit and the
34 resulting additional premium to be paid by the group or
35 enrollment unit.
36     In no event shall the Illinois Health Maintenance

 

 

HB0732 - 19 - LRB094 05496 LJB 35543 b

1 Organization Guaranty Association be liable to pay any
2 contractual obligation of an insolvent organization to pay any
3 refund authorized under this Section.
4 (Source: P.A. 92-764, eff. 1-1-03; 93-102, eff. 1-1-04; 93-261,
5 eff. 1-1-04; 93-477, eff. 8-8-03; 93-529, eff. 8-14-03; 93-853,
6 eff. 1-1-05; 93-1000, eff. 1-1-05; revised 10-14-04.)
 
7     Section 40. The Voluntary Health Services Plans Act is
8 amended by changing Section 10 as follows:
 
9     (215 ILCS 165/10)  (from Ch. 32, par. 604)
10     Sec. 10. Application of Insurance Code provisions. Health
11 services plan corporations and all persons interested therein
12 or dealing therewith shall be subject to the provisions of
13 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
14 149, 155.37, 354, 355.2, 356r, 356t, 356u, 356v, 356w, 356x,
15 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.7, 364.01,
16 367.2, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
17 and paragraphs (7) and (15) of Section 367 of the Illinois
18 Insurance Code.
19 (Source: P.A. 92-130, eff. 7-20-01; 92-440, eff. 8-17-01;
20 92-651, eff. 7-11-02; 92-764, eff. 1-1-03; 93-102, eff. 1-1-04;
21 93-529, eff. 8-14-03; 93-853, eff. 1-1-05; 93-1000, eff.
22 1-1-05; revised 10-14-04.)
 
23     Section 45. The Illinois Public Aid Code is amended by
24 changing Section 5-5 as follows:
 
25     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
26     Sec. 5-5. Medical services. The Illinois Department, by
27 rule, shall determine the quantity and quality of and the rate
28 of reimbursement for the medical assistance for which payment
29 will be authorized, and the medical services to be provided,
30 which may include all or part of the following: (1) inpatient
31 hospital services; (2) outpatient hospital services; (3) other
32 laboratory and X-ray services; (4) skilled nursing home

 

 

HB0732 - 20 - LRB094 05496 LJB 35543 b

1 services; (5) physicians' services whether furnished in the
2 office, the patient's home, a hospital, a skilled nursing home,
3 or elsewhere; (6) medical care, or any other type of remedial
4 care furnished by licensed practitioners; (7) home health care
5 services; (8) private duty nursing service; (9) clinic
6 services; (10) dental services, including prevention and
7 treatment of periodontal disease and dental caries disease for
8 pregnant women; (11) physical therapy and related services;
9 (12) prescribed drugs, dentures, and prosthetic devices; and
10 eyeglasses prescribed by a physician skilled in the diseases of
11 the eye, or by an optometrist, whichever the person may select;
12 (13) other diagnostic, screening, preventive, and
13 rehabilitative services; (14) transportation and such other
14 expenses as may be necessary; (15) medical treatment of sexual
15 assault survivors, as defined in Section 1a of the Sexual
16 Assault Survivors Emergency Treatment Act, for injuries
17 sustained as a result of the sexual assault, including
18 examinations and laboratory tests to discover evidence which
19 may be used in criminal proceedings arising from the sexual
20 assault; (16) the diagnosis and treatment of sickle cell
21 anemia; and (17) any other medical care, and any other type of
22 remedial care recognized under the laws of this State, but not
23 including abortions, or induced miscarriages or premature
24 births, unless, in the opinion of a physician, such procedures
25 are necessary for the preservation of the life of the woman
26 seeking such treatment, or except an induced premature birth
27 intended to produce a live viable child and such procedure is
28 necessary for the health of the mother or her unborn child. The
29 Illinois Department, by rule, shall prohibit any physician from
30 providing medical assistance to anyone eligible therefor under
31 this Code where such physician has been found guilty of
32 performing an abortion procedure in a wilful and wanton manner
33 upon a woman who was not pregnant at the time such abortion
34 procedure was performed. The term "any other type of remedial
35 care" shall include nursing care and nursing home service for
36 persons who rely on treatment by spiritual means alone through

 

 

HB0732 - 21 - LRB094 05496 LJB 35543 b

1 prayer for healing.
2     Notwithstanding any other provision of this Section, a
3 comprehensive tobacco use cessation program that includes
4 purchasing prescription drugs or prescription medical devices
5 approved by the Food and Drug administration shall be covered
6 under the medical assistance program under this Article for
7 persons who are otherwise eligible for assistance under this
8 Article.
9     For persons eligible for assistance under this Article, the
10 Illinois Department shall require coverage for services
11 rendered by a licensed athletic trainer in accordance with the
12 Illinois Athletic Trainers Practice Act if those services are
13 ordered by a physician licensed to practice medicine in all of
14 its branches.
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.
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
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
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.
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.
35     The Illinois Department shall authorize the provision of,
36 and shall authorize payment for, screening by low-dose

 

 

HB0732 - 22 - LRB094 05496 LJB 35543 b

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
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.
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
20 licensed by the Department of Human Services or to a licensed
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.
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
32 that may be needed by addicted women in addition to treatment
33 for addiction.
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

 

 

HB0732 - 23 - LRB094 05496 LJB 35543 b

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.
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.
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.
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.
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
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:

 

 

HB0732 - 24 - LRB094 05496 LJB 35543 b

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.
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.
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.
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.
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.
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

 

 

HB0732 - 25 - LRB094 05496 LJB 35543 b

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
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
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
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.
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

 

 

HB0732 - 26 - LRB094 05496 LJB 35543 b

1 such medical services.
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

 

 

HB0732 - 27 - LRB094 05496 LJB 35543 b

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     The Department shall execute, relative to the nursing home
6 prescreening project, written inter-agency agreements with the
7 Department of Human Services and the Department on Aging, to
8 effect the following: (i) intake procedures and common
9 eligibility criteria for those persons who are receiving
10 non-institutional services; and (ii) the establishment and
11 development of non-institutional services in areas of the State
12 where they are not currently available or are undeveloped.
13     The Illinois Department shall develop and operate, in
14 cooperation with other State Departments and agencies and in
15 compliance with applicable federal laws and regulations,
16 appropriate and effective systems of health care evaluation and
17 programs for monitoring of utilization of health care services
18 and facilities, as it affects persons eligible for medical
19 assistance under this Code.
20     The Illinois Department shall report annually to the
21 General Assembly, no later than the second Friday in April of
22 1979 and each year thereafter, in regard to:
23         (a) actual statistics and trends in utilization of
24     medical services by public aid recipients;
25         (b) actual statistics and trends in the provision of
26     the various medical services by medical vendors;
27         (c) current rate structures and proposed changes in
28     those rate structures for the various medical vendors; and
29         (d) efforts at utilization review and control by the
30     Illinois Department.
31     The period covered by each report shall be the 3 years
32 ending on the June 30 prior to the report. The report shall
33 include suggested legislation for consideration by the General
34 Assembly. The filing of one copy of the report with the
35 Speaker, one copy with the Minority Leader and one copy with
36 the Clerk of the House of Representatives, one copy with the

 

 

HB0732 - 28 - LRB094 05496 LJB 35543 b

1 President, one copy with the Minority Leader and one copy with
2 the Secretary of the Senate, one copy with the Legislative
3 Research Unit, and such additional copies with the State
4 Government Report Distribution Center for the General Assembly
5 as is required under paragraph (t) of Section 7 of the State
6 Library Act shall be deemed sufficient to comply with this
7 Section.
8 (Source: P.A. 92-16, eff. 6-28-01; 92-651, eff. 7-11-02;
9 92-789, eff. 8-6-02; 93-632, eff. 2-1-04; 93-841, eff. 7-30-04;
10 93-981, eff. 8-23-04; revised 10-22-04.)