Sen. James A. DeLeo
Filed: 7/10/2008
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1 | AMENDMENT TO HOUSE BILL 415
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2 | AMENDMENT NO. ______. Amend House Bill 415 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by changing Section 6.11 as follows:
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6 | (5 ILCS 375/6.11)
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7 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
8 | Code
requirements. The program of health
benefits shall provide | ||||||
9 | the post-mastectomy care benefits required to be covered
by a | ||||||
10 | policy of accident and health insurance under Section 356t of | ||||||
11 | the Illinois
Insurance Code. The program of health benefits | ||||||
12 | shall provide the coverage
required under Sections 356g.5,
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13 | 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, 356z.10, | ||||||
14 | and 356z.11
356z.9 of the
Illinois Insurance Code.
The program | ||||||
15 | of health benefits must comply with Section 155.37 of the
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16 | Illinois Insurance Code.
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1 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
2 | 95-520, eff. 8-28-07; revised 12-4-07.)
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3 | Section 10. The Counties Code is amended by changing | ||||||
4 | Section 5-1069.3 as follows: | ||||||
5 | (55 ILCS 5/5-1069.3)
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6 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
7 | including a home
rule
county, is a self-insurer for purposes of | ||||||
8 | providing health insurance coverage
for its employees, the | ||||||
9 | coverage shall include coverage for the post-mastectomy
care | ||||||
10 | benefits required to be covered by a policy of accident and | ||||||
11 | health
insurance under Section 356t and the coverage required | ||||||
12 | under Sections 356g.5, 356u,
356w, 356x, 356z.6, and 356z.9, | ||||||
13 | 356z.10, and
356z.11 356z.9 of
the Illinois Insurance Code. The | ||||||
14 | requirement that health benefits be covered
as provided in this | ||||||
15 | Section is an
exclusive power and function of the State and is | ||||||
16 | a denial and limitation under
Article VII, Section 6, | ||||||
17 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
18 | to which this Section applies must comply with every provision | ||||||
19 | of
this Section.
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20 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
21 | 95-520, eff. 8-28-07; revised 12-4-07.)
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22 | Section 15. The Illinois Municipal Code is amended by | ||||||
23 | changing Section 10-4-2.3 as follows: |
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1 | (65 ILCS 5/10-4-2.3)
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2 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
3 | municipality, including a
home rule municipality, is a | ||||||
4 | self-insurer for purposes of providing health
insurance | ||||||
5 | coverage for its employees, the coverage shall include coverage | ||||||
6 | for
the post-mastectomy care benefits required to be covered by | ||||||
7 | a policy of
accident and health insurance under Section 356t | ||||||
8 | and the coverage required
under Sections 356g.5, 356u, 356w, | ||||||
9 | 356x, 356z.6, and 356z.9, 356z.10, and 356z.11
356z.9 of the | ||||||
10 | Illinois
Insurance
Code. The requirement that health
benefits | ||||||
11 | be covered as provided in this is an exclusive power and | ||||||
12 | function of
the State and is a denial and limitation under | ||||||
13 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
14 | Constitution. A home rule municipality to which
this Section | ||||||
15 | applies must comply with every provision of this Section.
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16 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
17 | 95-520, eff. 8-28-07; revised 12-4-07.)
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18 | Section 20. The School Code is amended by changing Section | ||||||
19 | 10-22.3f as follows: | ||||||
20 | (105 ILCS 5/10-22.3f)
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21 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
22 | protection and
benefits
for employees shall provide the | ||||||
23 | post-mastectomy care benefits required to be
covered by a |
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1 | policy of accident and health insurance under Section 356t and | ||||||
2 | the
coverage required under Sections 356g.5, 356u, 356w, 356x,
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3 | 356z.6, and 356z.9 , and 356z.11 of
the
Illinois Insurance Code.
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4 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
5 | revised 12-4-07.)
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6 | Section 25. The Illinois Insurance Code is amended by | ||||||
7 | adding Section 356z.11 as follows: | ||||||
8 | (215 ILCS 5/356z.11 new)
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9 | Sec. 356z.11. Autism spectrum disorders. | ||||||
10 | (a) A group or individual policy of accident and health | ||||||
11 | insurance or managed care plan amended, delivered, issued, or | ||||||
12 | renewed after the effective date of this amendatory Act of the | ||||||
13 | 95th General Assembly must provide individuals under 21 years | ||||||
14 | of age coverage for the diagnosis of autism spectrum disorders | ||||||
15 | and for the treatment of autism spectrum disorders to the | ||||||
16 | extent that the diagnosis and treatment of autism spectrum | ||||||
17 | disorders are not already covered by the policy of accident and | ||||||
18 | health insurance or managed care plan. | ||||||
19 | (b) Coverage provided under this Section shall be subject | ||||||
20 | to a maximum benefit of $36,000 per year, but shall not be | ||||||
21 | subject to any limits on the number of visits to a service | ||||||
22 | provider. After December 30, 2009, the Director of the Division | ||||||
23 | of Insurance shall, on an annual basis, adjust the maximum | ||||||
24 | benefit for inflation using the Medical Care Component of the |
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1 | United States Department of Labor Consumer Price Index for All | ||||||
2 | Urban Consumers. Payments made by an insurer on behalf of a | ||||||
3 | covered individual for any care, treatment, intervention, | ||||||
4 | service, or item, the provision of which was for the treatment | ||||||
5 | of a health condition not diagnosed as an autism spectrum | ||||||
6 | disorder, shall not be applied toward any maximum benefit | ||||||
7 | established under this subsection. | ||||||
8 | (c) Coverage under this Section shall be subject to | ||||||
9 | co-payment, deductible, and coinsurance provisions of a policy | ||||||
10 | of accident and health insurance or managed care plan to the | ||||||
11 | extent that other medical services covered by the policy of | ||||||
12 | accident and health insurance or managed care plan are subject | ||||||
13 | to these provisions. | ||||||
14 | (d) This Section shall not be construed as limiting | ||||||
15 | benefits that are otherwise available to an individual under a | ||||||
16 | policy of accident and health insurance or managed care plan | ||||||
17 | and benefits provided under this Section may not be subject to | ||||||
18 | dollar limits, deductibles, copayments, or coinsurance | ||||||
19 | provisions that are less favorable to the insured than the | ||||||
20 | dollar limits, deductibles, or coinsurance provisions that | ||||||
21 | apply to physical illness generally. | ||||||
22 | (e) An insurer may not deny or refuse to provide otherwise | ||||||
23 | covered services, or refuse to renew, refuse to reissue, or | ||||||
24 | otherwise terminate or restrict coverage under an individual | ||||||
25 | contract to provide services to an individual because the | ||||||
26 | individual or their dependent is diagnosed with an autism |
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1 | spectrum disorder or due to the individual utilizing benefits | ||||||
2 | in this Section. | ||||||
3 | (f) Upon request of the reimbursing insurer, a provider of | ||||||
4 | treatment for autism spectrum disorders shall furnish medical | ||||||
5 | records, clinical notes, or other necessary data that | ||||||
6 | substantiate that initial or continued medical treatment is | ||||||
7 | medically necessary and is resulting in improved clinical | ||||||
8 | status. When treatment is anticipated to require continued | ||||||
9 | services to achieve demonstrable progress, the insurer may | ||||||
10 | request a treatment plan consisting of diagnosis, proposed | ||||||
11 | treatment by type, frequency, anticipated duration of | ||||||
12 | treatment, the anticipated outcomes stated as goals, and the | ||||||
13 | frequency by which the treatment plan will be updated. | ||||||
14 | (g) When making a determination of medical necessity for a | ||||||
15 | treatment modality for autism spectrum disorders, an insurer | ||||||
16 | must make the determination in a manner that is consistent with | ||||||
17 | the manner used to make that determination with respect to | ||||||
18 | other diseases or illnesses covered under the policy, including | ||||||
19 | an appeals process. During the appeals process, any challenge | ||||||
20 | to medical necessity must be viewed as reasonable only if the | ||||||
21 | review includes a physician with expertise in the most current | ||||||
22 | and effective treatment modalities for autism spectrum | ||||||
23 | disorders. | ||||||
24 | (h) Coverage for medically necessary early intervention | ||||||
25 | services must be delivered by certified early intervention | ||||||
26 | specialists, as defined in the early intervention operational |
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1 | standards by the Department of Human Services and in accordance | ||||||
2 | with applicable certification requirements. | ||||||
3 | (i) As used in this Section: | ||||||
4 | "Autism spectrum disorders" means pervasive developmental | ||||||
5 | disorders as defined in the most recent edition of the | ||||||
6 | Diagnostic and Statistical Manual of Mental Disorders, | ||||||
7 | including autism, Asperger's disorder, and pervasive | ||||||
8 | developmental disorder not otherwise specified. | ||||||
9 | "Diagnosis of autism spectrum disorders" means a diagnosis | ||||||
10 | of an individual with an autism spectrum disorder by (A) a | ||||||
11 | physician licensed to practice medicine in all its branches or | ||||||
12 | (B) a licensed clinical psychologist with expertise in | ||||||
13 | diagnosing autism spectrum disorders. | ||||||
14 | "Medically necessary" means any care, treatment, | ||||||
15 | intervention, service or item which will or is reasonably | ||||||
16 | expected to do any of the following: (i) prevent the onset of | ||||||
17 | an illness, condition, injury, disease or disability; (ii) | ||||||
18 | reduce or ameliorate the physical, mental or developmental | ||||||
19 | effects of an illness, condition, injury, disease or | ||||||
20 | disability; or (iii) assist to achieve or maintain maximum | ||||||
21 | functional activity in performing daily activities. | ||||||
22 | "Treatment for autism spectrum disorders" shall include | ||||||
23 | the following care prescribed, provided, or ordered for an | ||||||
24 | individual diagnosed with an autism spectrum disorder by (A) a | ||||||
25 | physician licensed to practice medicine in all its branches or | ||||||
26 | (B) a certified, registered, or licensed health care |
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1 | professional with expertise in treating effects of autism | ||||||
2 | spectrum disorders when the care is determined to be medically | ||||||
3 | necessary and ordered by a physician licensed to practice | ||||||
4 | medicine in all its branches: | ||||||
5 | (1) Psychiatric care, including diagnostic services. | ||||||
6 | (2) Psychological assessments and treatments. | ||||||
7 | (3) Rehabilitative treatments. | ||||||
8 | (4) Therapeutic care, including behavioral speech, | ||||||
9 | occupational, and physical therapies that provide | ||||||
10 | treatment in the following areas: (i) self care and | ||||||
11 | feeding, (ii) pragmatic, receptive, and expressive | ||||||
12 | language, (iii) cognitive functioning, (iv) applied | ||||||
13 | behavior analysis, intervention, and modification, (v) | ||||||
14 | motor planning, and (vi) sensory processing.
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15 | Section 30. The Health Maintenance Organization Act is | ||||||
16 | amended by changing Section 5-3 as follows:
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17 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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18 | Sec. 5-3. Insurance Code provisions.
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19 | (a) Health Maintenance Organizations
shall be subject to | ||||||
20 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
21 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
22 | 154.6,
154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x, | ||||||
23 | 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10
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24 | 356z.9 , 356z.11, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, |
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1 | 368c, 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
2 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
3 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
4 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
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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":
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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
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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
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17 | organization as is a "domestic company" under Article VIII | ||||||
18 | 1/2 of the
Illinois Insurance Code.
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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,
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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;
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1 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
2 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
3 | apply and (ii) the Director, in making
his determination | ||||||
4 | with respect to the merger, consolidation, or other
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5 | acquisition of control, need not take into account the | ||||||
6 | effect on
competition of the merger, consolidation, or | ||||||
7 | other acquisition of control;
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8 | (3) the Director shall have the power to require the | ||||||
9 | following
information:
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10 | (A) certification by an independent actuary of the | ||||||
11 | adequacy
of the reserves of the Health Maintenance | ||||||
12 | Organization sought to be acquired;
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13 | (B) pro forma financial statements reflecting the | ||||||
14 | combined balance
sheets of the acquiring company and | ||||||
15 | the Health Maintenance Organization sought
to be | ||||||
16 | acquired as of the end of the preceding year and as of | ||||||
17 | a date 90 days
prior to the acquisition, as well as pro | ||||||
18 | forma financial statements
reflecting projected | ||||||
19 | combined operation for a period of 2 years;
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20 | (C) a pro forma business plan detailing an | ||||||
21 | acquiring party's plans with
respect to the operation | ||||||
22 | of the Health Maintenance Organization sought to
be | ||||||
23 | acquired for a period of not less than 3 years; and
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24 | (D) such other information as the Director shall | ||||||
25 | require.
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26 | (d) The provisions of Article VIII 1/2 of the Illinois |
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1 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
2 | any health maintenance
organization of greater than 10% of its
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3 | enrollee population (including without limitation the health | ||||||
4 | maintenance
organization's right, title, and interest in and to | ||||||
5 | its health care
certificates).
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6 | (e) In considering any management contract or service | ||||||
7 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
8 | Code, the Director (i) shall, in
addition to the criteria | ||||||
9 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
10 | into account the effect of the management contract or
service | ||||||
11 | agreement on the continuation of benefits to enrollees and the
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12 | financial condition of the health maintenance organization to | ||||||
13 | be managed or
serviced, and (ii) need not take into account the | ||||||
14 | effect of the management
contract or service agreement on | ||||||
15 | competition.
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16 | (f) Except for small employer groups as defined in the | ||||||
17 | Small Employer
Rating, Renewability and Portability Health | ||||||
18 | Insurance Act and except for
medicare supplement policies as | ||||||
19 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
20 | Maintenance Organization may by contract agree with a
group or | ||||||
21 | other enrollment unit to effect refunds or charge additional | ||||||
22 | premiums
under the following terms and conditions:
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23 | (i) the amount of, and other terms and conditions with | ||||||
24 | respect to, the
refund or additional premium are set forth | ||||||
25 | in the group or enrollment unit
contract agreed in advance | ||||||
26 | of the period for which a refund is to be paid or
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1 | additional premium is to be charged (which period shall not | ||||||
2 | be less than one
year); and
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3 | (ii) the amount of the refund or additional premium | ||||||
4 | shall not exceed 20%
of the Health Maintenance | ||||||
5 | Organization's profitable or unprofitable experience
with | ||||||
6 | respect to the group or other enrollment unit for the | ||||||
7 | period (and, for
purposes of a refund or additional | ||||||
8 | premium, the profitable or unprofitable
experience shall | ||||||
9 | be calculated taking into account a pro rata share of the
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10 | Health Maintenance Organization's administrative and | ||||||
11 | marketing expenses, but
shall not include any refund to be | ||||||
12 | made or additional premium to be paid
pursuant to this | ||||||
13 | subsection (f)). The Health Maintenance Organization and | ||||||
14 | the
group or enrollment unit may agree that the profitable | ||||||
15 | or unprofitable
experience may be calculated taking into | ||||||
16 | account the refund period and the
immediately preceding 2 | ||||||
17 | plan years.
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18 | The Health Maintenance Organization shall include a | ||||||
19 | statement in the
evidence of coverage issued to each enrollee | ||||||
20 | describing the possibility of a
refund or additional premium, | ||||||
21 | and upon request of any group or enrollment unit,
provide to | ||||||
22 | the group or enrollment unit a description of the method used | ||||||
23 | to
calculate (1) the Health Maintenance Organization's | ||||||
24 | profitable experience with
respect to the group or enrollment | ||||||
25 | unit and the resulting refund to the group
or enrollment unit | ||||||
26 | or (2) the Health Maintenance Organization's unprofitable
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1 | experience with respect to the group or enrollment unit and the | ||||||
2 | resulting
additional premium to be paid by the group or | ||||||
3 | enrollment unit.
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4 | In no event shall the Illinois Health Maintenance | ||||||
5 | Organization
Guaranty Association be liable to pay any | ||||||
6 | contractual obligation of an
insolvent organization to pay any | ||||||
7 | refund authorized under this Section.
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8 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
9 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
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10 | Section 35. The Voluntary Health Services Plans Act is | ||||||
11 | amended by changing Section 10 as follows:
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12 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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13 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
14 | services
plan corporations and all persons interested therein | ||||||
15 | or dealing therewith
shall be subject to the provisions of | ||||||
16 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
17 | 149, 155.37, 354, 355.2, 356g.5, 356r, 356t, 356u, 356v,
356w, | ||||||
18 | 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, | ||||||
19 | 356z.9,
356z.10
356z.9 , 356z.11, 364.01, 367.2, 368a, 401, | ||||||
20 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
21 | and (15) of Section 367 of the Illinois
Insurance Code.
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22 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
23 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
24 | 8-28-07; revised 12-5-07.)
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1 | Section 99. Effective date. This Act takes effect upon | ||||||
2 | becoming law.".
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