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1 | AN ACT concerning regulation.
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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 Comprehensive Health Insurance Plan Act is | ||||||
5 | amended by changing Section 2 as follows: | ||||||
6 | (215 ILCS 105/2) (from Ch. 73, par. 1302)
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7 | Sec. 2. Definitions. As used in this Act, unless the | ||||||
8 | context otherwise
requires:
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9 | "Plan administrator" means the insurer or third party
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10 | administrator designated under Section 5 of this Act.
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11 | "Benefits plan" means the coverage to be offered by the | ||||||
12 | Plan to
eligible persons and federally eligible individuals | ||||||
13 | pursuant to this Act.
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14 | "Board" means the Illinois Comprehensive Health Insurance | ||||||
15 | Board.
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16 | "Church plan" has the same meaning given that term in the | ||||||
17 | federal Health
Insurance Portability and Accountability Act of | ||||||
18 | 1996.
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19 | "Continuation coverage" means continuation of coverage | ||||||
20 | under a group health
plan or other health insurance coverage | ||||||
21 | for former employees or dependents of
former employees that | ||||||
22 | would otherwise have terminated under the terms of that
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23 | coverage pursuant to any continuation provisions under federal |
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1 | or State law,
including the Consolidated Omnibus Budget | ||||||
2 | Reconciliation Act of 1985 (COBRA),
as amended, Sections 367.2, | ||||||
3 | 367e, and 367e.1 of the Illinois Insurance Code, or
any
other | ||||||
4 | similar requirement in another State.
| ||||||
5 | "Covered person" means a person who is and continues to | ||||||
6 | remain eligible for
Plan coverage and is covered under one of | ||||||
7 | the benefit plans offered by the
Plan.
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8 | "Creditable coverage" means, with respect to a federally | ||||||
9 | eligible
individual, coverage of the individual under any of | ||||||
10 | the following:
| ||||||
11 | (A) A group health plan.
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12 | (B) Health insurance coverage (including group health | ||||||
13 | insurance coverage).
| ||||||
14 | (C) Medicare.
| ||||||
15 | (D) Medical assistance.
| ||||||
16 | (E) Chapter 55 of title 10, United States Code.
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17 | (F) A medical care program of the Indian Health Service | ||||||
18 | or of a tribal
organization.
| ||||||
19 | (G) A state health benefits risk pool.
| ||||||
20 | (H) A health plan offered under Chapter 89 of title 5, | ||||||
21 | United States Code.
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22 | (I) A public health plan (as defined in regulations | ||||||
23 | consistent with
Section
104 of the Health Care Portability | ||||||
24 | and Accountability Act of 1996 that may be
promulgated by | ||||||
25 | the Secretary of the U.S. Department of Health and Human
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26 | Services).
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| |||||||
1 | (J) A health benefit plan under Section 5(e) of the | ||||||
2 | Peace Corps Act (22
U.S.C. 2504(e)).
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3 | (K) Any other qualifying coverage required by the | ||||||
4 | federal Health Insurance
Portability and Accountability | ||||||
5 | Act of 1996, as it may be amended, or
regulations under | ||||||
6 | that
Act.
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7 | "Creditable coverage" does not include coverage consisting | ||||||
8 | solely of coverage
of excepted benefits, as defined in Section | ||||||
9 | 2791(c) of title XXVII of
the
Public Health Service Act (42 | ||||||
10 | U.S.C. 300 gg-91), nor does it include any
period
of coverage | ||||||
11 | under any of items (A) through (K) that occurred before a break | ||||||
12 | of
more than 90 days or, if the individual has
been certified | ||||||
13 | as eligible pursuant to the federal Trade Act
of 2002, a
break | ||||||
14 | of more than 63 days during all of which the individual was not | ||||||
15 | covered
under any of items (A) through (K) above.
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16 | Any period that an individual is in a waiting period for
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17 | any coverage under a group health plan (or for group health | ||||||
18 | insurance
coverage) or is in an affiliation period under the | ||||||
19 | terms of health insurance
coverage offered by a health | ||||||
20 | maintenance organization shall not be taken into
account in | ||||||
21 | determining if there has been a break of more than 90
days in | ||||||
22 | any
creditable coverage.
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23 | "Department" means the Illinois Department of Insurance.
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24 | "Dependent" means an Illinois resident: who is a spouse; or | ||||||
25 | who is claimed
as a dependent by the principal insured for | ||||||
26 | purposes of filing a federal income
tax return and resides in |
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1 | the principal insured's household, and is a resident
unmarried | ||||||
2 | child under the age of 19 years; or who is an unmarried child | ||||||
3 | who
also is a full-time student under the age of 23 years and | ||||||
4 | who is financially
dependent upon the principal insured; or who | ||||||
5 | is a child of any age and who is
disabled and financially | ||||||
6 | dependent upon the
principal insured.
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7 | "Direct Illinois premiums" means, for Illinois business, | ||||||
8 | an insurer's direct
premium income for the kinds of business | ||||||
9 | described in clause (b) of Class 1 or
clause (a) of Class 2 of | ||||||
10 | Section 4 of the Illinois Insurance Code, and direct
premium | ||||||
11 | income of a health maintenance organization or a voluntary | ||||||
12 | health
services plan, except it shall not include credit health | ||||||
13 | insurance as defined
in Article IX 1/2 of the Illinois | ||||||
14 | Insurance Code.
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15 | "Director" means the Director of the Illinois Department of | ||||||
16 | Insurance.
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17 | "Effective date of medical assistance" means the date that | ||||||
18 | eligibility for medical assistance for a person is approved by | ||||||
19 | the Department of Human Services, except when the Department of | ||||||
20 | Human Services determines eligibility retroactively. In such | ||||||
21 | circumstances, the effective date of the medical assistance is | ||||||
22 | the date the Department of Human Services determines the person | ||||||
23 | to be eligible for medical assistance. | ||||||
24 | "Eligible person" means a resident of this State who | ||||||
25 | qualifies
for Plan coverage under Section 7 of this Act.
| ||||||
26 | "Employee" means a resident of this State who is employed |
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1 | by an employer
or has entered into
the employment of or works | ||||||
2 | under contract or service of an employer
including the | ||||||
3 | officers, managers and employees of subsidiary or affiliated
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4 | corporations and the individual proprietors, partners and | ||||||
5 | employees of
affiliated individuals and firms when the business | ||||||
6 | of the subsidiary or
affiliated corporations, firms or | ||||||
7 | individuals is controlled by a common
employer through stock | ||||||
8 | ownership, contract, or otherwise.
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9 | "Employer" means any individual, partnership, association, | ||||||
10 | corporation,
business trust, or any person or group of persons | ||||||
11 | acting directly or indirectly
in the interest of an employer in | ||||||
12 | relation to an employee, for which one or
more
persons is | ||||||
13 | gainfully employed.
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14 | "Family" coverage means the coverage provided by the Plan | ||||||
15 | for the
covered person and his or her eligible dependents who | ||||||
16 | also are
covered persons.
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17 | "Federally eligible individual" means an individual | ||||||
18 | resident of this State:
| ||||||
19 | (1)(A) for whom, as of the date on which the individual | ||||||
20 | seeks Plan
coverage
under Section 15 of this Act, the | ||||||
21 | aggregate of the periods of creditable
coverage is 18 or | ||||||
22 | more months or, if the individual has been
certified as
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23 | eligible pursuant to the federal Trade Act of 2002,
3 or | ||||||
24 | more
months, and (B) whose most recent prior creditable
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25 | coverage was under group health insurance coverage offered | ||||||
26 | by a health
insurance issuer, a group health plan, a |
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1 | governmental plan, or a church plan
(or
health insurance | ||||||
2 | coverage offered in connection with any such plans) or any
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3 | other type of creditable coverage that may be required by | ||||||
4 | the federal Health
Insurance Portability
and | ||||||
5 | Accountability Act of 1996, as it may be amended, or the | ||||||
6 | regulations
under that Act;
| ||||||
7 | (2) who
is not eligible for coverage under
(A) a group | ||||||
8 | health plan
(other than an individual who has been | ||||||
9 | certified as eligible
pursuant to the federal Trade Act of | ||||||
10 | 2002), (B)
part
A or part B of Medicare due to age
(other | ||||||
11 | than an individual who has been certified as eligible
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12 | pursuant to the federal Trade Act of 2002), or (C) medical | ||||||
13 | assistance, and
does not
have other
health insurance | ||||||
14 | coverage (other than an individual who has been certified | ||||||
15 | as
eligible pursuant to the federal Trade Act of 2002);
| ||||||
16 | (3) with respect to whom (other than an individual who | ||||||
17 | has been
certified as eligible pursuant to the federal | ||||||
18 | Trade Act of 2002) the most
recent coverage within the | ||||||
19 | coverage
period
described in paragraph (1)(A) of this | ||||||
20 | definition was not terminated
based upon a factor relating | ||||||
21 | to nonpayment of premiums or fraud;
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22 | (4) if the individual (other than an individual who has
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23 | been certified
as eligible pursuant to the federal Trade | ||||||
24 | Act
of 2002)
had been offered the option of continuation
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25 | coverage
under a COBRA continuation provision or under a | ||||||
26 | similar State program, who
elected such coverage; and
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1 | (5) who, if the individual elected such continuation | ||||||
2 | coverage, has
exhausted
such continuation coverage under | ||||||
3 | such provision or program.
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4 | However, an individual who has been certified as
eligible
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5 | pursuant to the
federal Trade Act of 2002
shall not be required | ||||||
6 | to elect
continuation
coverage under a COBRA continuation | ||||||
7 | provision or under a similar state
program.
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8 | "Group health insurance coverage" means, in connection | ||||||
9 | with a group health
plan, health insurance coverage offered in | ||||||
10 | connection with that plan.
| ||||||
11 | "Group health plan" has the same meaning given that term in | ||||||
12 | the federal
Health
Insurance Portability and Accountability | ||||||
13 | Act of 1996.
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14 | "Governmental plan" has the same meaning given that term in | ||||||
15 | the federal
Health
Insurance Portability and Accountability | ||||||
16 | Act of 1996.
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17 | "Health insurance coverage" means benefits consisting of | ||||||
18 | medical care
(provided directly, through insurance or | ||||||
19 | reimbursement, or otherwise and
including items and services | ||||||
20 | paid for as medical care) under any hospital and
medical | ||||||
21 | expense-incurred policy,
certificate, or
contract provided by | ||||||
22 | an insurer, non-profit health care service plan
contract, | ||||||
23 | health maintenance organization or other subscriber contract, | ||||||
24 | or
any other health care plan or arrangement that pays for or | ||||||
25 | furnishes
medical or health care services whether by
insurance | ||||||
26 | or otherwise. Health insurance coverage shall not include short
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1 | term,
accident only,
disability income, hospital confinement | ||||||
2 | or fixed indemnity, dental only,
vision only, limited benefit, | ||||||
3 | or credit
insurance, coverage issued as a supplement to | ||||||
4 | liability insurance,
insurance arising out of a workers' | ||||||
5 | compensation or similar law, automobile
medical-payment | ||||||
6 | insurance, or insurance under which benefits are payable
with | ||||||
7 | or without regard to fault and which is statutorily required to | ||||||
8 | be
contained in any liability insurance policy or equivalent | ||||||
9 | self-insurance.
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10 | "Health insurance issuer" means an insurance company, | ||||||
11 | insurance service,
or insurance organization (including a | ||||||
12 | health maintenance organization and a
voluntary health | ||||||
13 | services plan) that is authorized to transact health
insurance
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14 | business in this State. Such term does not include a group | ||||||
15 | health plan.
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16 | "Health Maintenance Organization" means an organization as
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17 | defined in the Health Maintenance Organization Act.
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18 | "Hospice" means a program as defined in and licensed under | ||||||
19 | the
Hospice Program Licensing Act.
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20 | "Hospital" means a duly licensed institution as defined in | ||||||
21 | the
Hospital Licensing Act,
an institution that meets all | ||||||
22 | comparable conditions and requirements in
effect in the state | ||||||
23 | in which it is located, or the University of Illinois
Hospital | ||||||
24 | as defined in the University of Illinois Hospital Act.
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25 | "Individual health insurance coverage" means health | ||||||
26 | insurance coverage
offered to individuals in the individual |
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1 | market, but does not include
short-term, limited-duration | ||||||
2 | insurance.
| ||||||
3 | "Insured" means any individual resident of this State who | ||||||
4 | is
eligible to receive benefits from any insurer (including | ||||||
5 | health insurance
coverage offered in connection with a group | ||||||
6 | health plan) or health
insurance issuer as
defined in this | ||||||
7 | Section.
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8 | "Insurer" means any insurance company authorized to | ||||||
9 | transact health
insurance business in this State and any | ||||||
10 | corporation that provides medical
services and is organized | ||||||
11 | under the Voluntary Health Services Plans Act or
the Health | ||||||
12 | Maintenance Organization
Act.
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13 | "Medical assistance" means the State medical assistance or | ||||||
14 | medical
assistance no grant (MANG) programs provided under
| ||||||
15 | Title XIX of the Social Security Act and
Articles V (Medical | ||||||
16 | Assistance) and VI (General Assistance) of the Illinois
Public | ||||||
17 | Aid Code (or any successor program) or under any
similar | ||||||
18 | program of health care benefits in a state other than Illinois.
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19 | "Medically necessary" means that a service, drug, or supply | ||||||
20 | is
necessary and appropriate for the diagnosis or treatment of | ||||||
21 | an illness or
injury in accord with generally accepted | ||||||
22 | standards of medical practice at
the time the service, drug, or | ||||||
23 | supply is provided. When specifically
applied to a confinement | ||||||
24 | it further means that the diagnosis or treatment
of the covered | ||||||
25 | person's medical symptoms or condition cannot be
safely
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26 | provided to that person as an outpatient. A service, drug, or |
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1 | supply shall
not be medically necessary if it: (i) is | ||||||
2 | investigational, experimental, or
for research purposes; or | ||||||
3 | (ii) is provided solely for the convenience of
the patient, the | ||||||
4 | patient's family, physician, hospital, or any other
provider; | ||||||
5 | or (iii) exceeds in scope, duration, or intensity that level of
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6 | care that is needed to provide safe, adequate, and appropriate | ||||||
7 | diagnosis or
treatment; or (iv) could have been omitted without | ||||||
8 | adversely affecting the
covered person's condition or the | ||||||
9 | quality of medical care; or
(v) involves
the use of a medical | ||||||
10 | device, drug, or substance not formally approved by
the United | ||||||
11 | States Food and Drug Administration.
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12 | "Medical care" means the ordinary and usual professional | ||||||
13 | services rendered
by a physician or other specified provider | ||||||
14 | during a professional visit for
treatment of an illness or | ||||||
15 | injury.
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16 | "Medicare" means coverage under both Part A and Part B of | ||||||
17 | Title XVIII of
the Social Security
Act, 42 U.S.C. Sec. 1395, et | ||||||
18 | seq.
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19 | "Minimum premium plan" means an arrangement whereby a | ||||||
20 | specified
amount of health care claims is self-funded, but the | ||||||
21 | insurance company
assumes the risk that claims will exceed that | ||||||
22 | amount.
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23 | "Participating transplant center" means a hospital | ||||||
24 | designated by the
Board as a preferred or exclusive provider of | ||||||
25 | services for one or more
specified human organ or tissue | ||||||
26 | transplants for which the hospital has
signed an agreement with |
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1 | the Board to accept a transplant payment allowance
for all | ||||||
2 | expenses related to the transplant during a transplant benefit | ||||||
3 | period.
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4 | "Physician" means a person licensed to practice medicine | ||||||
5 | pursuant to
the Medical Practice Act of 1987.
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6 | "Plan" means the Comprehensive Health Insurance Plan
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7 | established by this Act.
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8 | "Plan of operation" means the plan of operation of the
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9 | Plan, including articles, bylaws and operating rules, adopted | ||||||
10 | by the board
pursuant to this Act.
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11 | "Provider" means any hospital, skilled nursing facility, | ||||||
12 | hospice, home
health agency, physician, registered pharmacist | ||||||
13 | acting within the scope of that
registration, or any other | ||||||
14 | person or entity licensed in Illinois to furnish
medical care.
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15 | "Qualified high risk pool" has the same meaning given that | ||||||
16 | term in the
federal Health
Insurance Portability and | ||||||
17 | Accountability Act of 1996.
| ||||||
18 | "Resident" means a person who is and continues to be | ||||||
19 | legally domiciled
and physically residing on a permanent and | ||||||
20 | full-time basis in a
place of permanent habitation
in this | ||||||
21 | State
that remains that person's principal residence and from | ||||||
22 | which that person is
absent only for temporary or transitory | ||||||
23 | purpose.
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24 | "Skilled nursing facility" means a facility or that portion | ||||||
25 | of a facility
that is licensed by the Illinois Department of | ||||||
26 | Public Health under the
Nursing Home Care Act or a comparable |
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1 | licensing authority in another state
to provide skilled nursing | ||||||
2 | care.
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3 | "Stop-loss coverage" means an arrangement whereby an | ||||||
4 | insurer
insures against the risk that any one claim will exceed | ||||||
5 | a specific dollar
amount or that the entire loss of a | ||||||
6 | self-insurance plan will exceed
a specific amount.
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7 | "Third party administrator" means an administrator as | ||||||
8 | defined in
Section 511.101 of the Illinois Insurance Code who | ||||||
9 | is licensed under
Article XXXI 1/4 of that Code.
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10 | (Source: P.A. 92-153, eff. 7-25-01; 93-33, eff. 6-23-03; 93-34, | ||||||
11 | eff. 6-23-03; 93-477, eff. 8-8-03; 93-622, eff. 12-18-03.)
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12 | Section 99. Effective date. This Act takes effect upon | ||||||
13 | becoming law.
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