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Rep. Mary E. Flowers
Filed: 3/4/2008
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09500HB4223ham002 |
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LRB095 15305 AMC 47284 a |
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| AMENDMENT TO HOUSE BILL 4223
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| AMENDMENT NO. ______. Amend House Bill 4223, on page 4, |
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| line 17, by deleting " or "; and |
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| on page 4, line 20, after " health ", by inserting " , or (iii) |
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| nonrenewal or termination of a policy or plan "; and |
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| on page 15, immediately below line 8, by inserting the |
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| following:
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| "Section 37. The Managed Care Reform and Patient Rights Act |
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| is amended by changing Section 45 as follows:
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| (215 ILCS 134/45)
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| Sec. 45. Health care services appeals,
complaints, and
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| external independent reviews.
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| (a) A health care plan shall establish and maintain an |
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| appeals procedure as
outlined in this Act. Compliance with this |
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LRB095 15305 AMC 47284 a |
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| Act's appeals procedures shall
satisfy a health care plan's |
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| obligation to provide appeal procedures under any
other State |
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| law or rules.
All appeals of a health care plan's |
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| administrative determinations and
complaints regarding its |
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| administrative decisions shall be handled as required
under |
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| Section 50.
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| (b) When an appeal concerns a decision or action by a |
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| health care plan,
its
employees, or its subcontractors that |
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| relates to (i) health care services,
including, but not limited |
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| to, procedures or
treatments,
for an enrollee with an ongoing |
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| course of treatment ordered
by a health care provider,
the |
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| denial of which could significantly
increase the risk to an
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| enrollee's health,
or (ii) a treatment referral, service,
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| procedure, or other health care service,
the denial of which |
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| could significantly
increase the risk to an
enrollee's health , |
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| or (iii) nonrenewal or termination of a plan ,
the health care |
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| plan must allow for the filing of an appeal
either orally or in |
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| writing. Upon submission of the appeal, a health care plan
must |
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| notify the party filing the appeal, as soon as possible, but in |
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| no event
more than 24 hours after the submission of the appeal, |
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| of all information
that the plan requires to evaluate the |
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| appeal.
The health care plan shall render a decision on the |
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| appeal within
24 hours after receipt of the required |
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| information. The health care plan shall
notify the party filing |
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| the
appeal and the enrollee, enrollee's primary care physician, |
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| and any health care
provider who recommended the health care |
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LRB095 15305 AMC 47284 a |
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| service involved in the appeal of its
decision orally
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| followed-up by a written notice of the determination.
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| (c) For all appeals related to health care services |
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| including, but not
limited to, procedures or treatments for an |
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| enrollee and not covered by
subsection (b) above, the health |
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| care
plan shall establish a procedure for the filing of such |
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| appeals. Upon
submission of an appeal under this subsection, a |
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| health care plan must notify
the party filing an appeal, within |
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| 3 business days, of all information that the
plan requires to |
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| evaluate the appeal.
The health care plan shall render a |
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| decision on the appeal within 15 business
days after receipt of |
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| the required information. The health care plan shall
notify the |
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| party filing the appeal,
the enrollee, the enrollee's primary |
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| care physician, and any health care
provider
who recommended |
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| the health care service involved in the appeal orally of its
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| decision followed-up by a written notice of the determination.
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| (d) An appeal under subsection (b) or (c) may be filed by |
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| the
enrollee, the enrollee's designee or guardian, the |
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| enrollee's primary care
physician, or the enrollee's health |
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| care provider. A health care plan shall
designate a clinical |
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| peer to review
appeals, because these appeals pertain to |
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| medical or clinical matters
and such an appeal must be reviewed |
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| by an appropriate
health care professional. No one reviewing an |
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| appeal may have had any
involvement
in the initial |
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| determination that is the subject of the appeal. The written
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| notice of determination required under subsections (b) and (c) |
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LRB095 15305 AMC 47284 a |
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| shall
include (i) clear and detailed reasons for the |
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| determination, (ii)
the medical or
clinical criteria for the |
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| determination, which shall be based upon sound
clinical |
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| evidence and reviewed on a periodic basis, and (iii) in the |
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| case of an
adverse determination, the
procedures for requesting |
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| an external independent review under subsection (f).
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| (e) If an appeal filed under subsection (b) or (c) is |
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| denied for a reason
including, but not limited to, the
service, |
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| procedure, or treatment is not viewed as medically necessary,
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| denial of specific tests or procedures, denial of referral
to |
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| specialist physicians or denial of hospitalization requests or |
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| length of
stay requests, any involved party may request an |
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| external independent review
under subsection (f) of the adverse |
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| determination.
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| (f) External independent review.
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| (1) The party seeking an external independent review |
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| shall so notify the
health care plan.
The health care plan |
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| shall seek to resolve all
external independent
reviews in |
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| the most expeditious manner and shall make a determination |
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| and
provide notice of the determination no more
than 24 |
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| hours after the receipt of all necessary information when a |
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| delay would
significantly increase
the risk to an |
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| enrollee's health or when extended health care services for |
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| an
enrollee undergoing a
course of treatment prescribed by |
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| a health care provider are at issue.
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| (2) Within 30 days after the enrollee receives written |
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LRB095 15305 AMC 47284 a |
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| notice of an
adverse
determination,
if the enrollee decides |
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| to initiate an external independent review, the
enrollee |
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| shall send to the health
care plan a written request for an |
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| external independent review, including any
information or
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| documentation to support the enrollee's request for the |
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| covered service or
claim for a covered
service.
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| (3) Within 30 days after the health care plan receives |
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| a request for an
external
independent review from an |
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| enrollee, the health care plan shall:
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| (A) provide a mechanism for joint selection of an |
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| external independent
reviewer by the enrollee, the |
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| enrollee's physician or other health care
provider,
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| and the health care plan; and
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| (B) forward to the independent reviewer all |
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| medical records and
supporting
documentation |
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| pertaining to the case, a summary description of the |
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| applicable
issues including a
statement of the health |
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| care plan's decision, the criteria used, and the
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| medical and clinical reasons
for that decision.
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| (4) Within 5 days after receipt of all necessary |
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| information, the
independent
reviewer
shall evaluate and |
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| analyze the case and render a decision that is based on
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| whether or not the health
care service or claim for the |
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| health care service is medically appropriate. The
decision |
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| by the
independent reviewer is final. If the external |
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| independent reviewer determines
the health care
service to |
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09500HB4223ham002 |
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LRB095 15305 AMC 47284 a |
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| be medically
appropriate, the health
care plan shall pay |
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| for the health care service.
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| (5) The health care plan shall be solely responsible |
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| for paying the fees
of the external
independent reviewer |
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| who is selected to perform the review.
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| (6) An external independent reviewer who acts in good |
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| faith shall have
immunity
from any civil or criminal |
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| liability or professional discipline as a result of
acts or |
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| omissions with
respect to any external independent review, |
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| unless the acts or omissions
constitute wilful and wanton
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| misconduct. For purposes of any proceeding, the good faith |
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| of the person
participating shall be
presumed.
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| (7) Future contractual or employment action by the |
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| health care plan
regarding the
patient's physician or other |
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| health care provider shall not be based solely on
the |
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| physician's or other
health care provider's participation |
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| in this procedure.
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| (8) For the purposes of this Section, an external |
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| independent reviewer
shall:
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| (A) be a clinical peer;
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| (B) have no direct financial interest in |
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| connection with the case; and
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| (C) have not been informed of the specific identity |
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| of the enrollee.
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| (g) Nothing in this Section shall be construed to require a |
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| health care
plan to pay for a health care service not covered |
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LRB095 15305 AMC 47284 a |
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| under the enrollee's
certificate of coverage or policy.
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| (h) Notwithstanding any other rulemaking authority that |
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| may exist, neither the Governor nor any agency or agency head |
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| under the jurisdiction of the Governor has any authority to |
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| make or promulgate rules to implement or enforce the provisions |
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| of this amendatory Act of the 95th General Assembly. If, |
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| however, the Governor believes that rules are necessary to |
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| implement or enforce the provisions of this amendatory Act of |
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| the 95th General Assembly, the Governor may suggest rules to |
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| the General Assembly by filing them with the Clerk of the House |
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| and the Secretary of the Senate and by requesting that the |
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| General Assembly authorize such rulemaking by law, enact those |
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| suggested rules into law, or take any other appropriate action |
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| in the General Assembly's discretion. Nothing contained in this |
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| amendatory Act of the 95th General Assembly shall be |
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| interpreted to grant rulemaking authority under any other |
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| Illinois statute where such authority is not otherwise |
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| explicitly given. For the purposes of this amendatory Act of |
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| the 95th General Assembly, "rules" is given the meaning |
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| contained in Section 1-70 of the Illinois Administrative |
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| Procedure Act, and "agency" and "agency head" are given the |
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| meanings contained in Sections 1-20 and 1-25 of the Illinois |
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| Administrative Procedure Act to the extent that such |
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| definitions apply to agencies or agency heads under the |
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| jurisdiction of the Governor. |
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| (Source: P.A. 91-617, eff. 1-1-00.)".
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