Bill Text: IL HB3558 | 2021-2022 | 102nd General Assembly | Introduced
Bill Title: Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission, upon consultation with the Workers' Compensation Medical Fee Advisory Board, shall promulgate an evidence-based drug formulary. Requires prescriptions in workers' compensation cases to be limited to the drugs on the formulary. Effective immediately.
Spectrum: Partisan Bill (Republican 3-0)
Status: (Introduced - Dead) 2022-02-18 - Rule 19(a) / Re-referred to Rules Committee [HB3558 Detail]
Download: Illinois-2021-HB3558-Introduced.html
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1 | AN ACT concerning employment.
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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 Workers' Compensation Act is amended by | |||||||||||||||||||
5 | changing Section 8.2 as follows:
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6 | (820 ILCS 305/8.2)
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7 | Sec. 8.2. Fee schedule.
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8 | (a) Except as provided for in subsection (c), for | |||||||||||||||||||
9 | procedures, treatments, or services covered under this Act and | |||||||||||||||||||
10 | rendered or to be rendered on and after February 1, 2006, the | |||||||||||||||||||
11 | maximum allowable payment shall be 90% of the 80th percentile | |||||||||||||||||||
12 | of charges and fees as determined by the Commission utilizing | |||||||||||||||||||
13 | information provided by employers' and insurers' national | |||||||||||||||||||
14 | databases, with a minimum of 12,000,000 Illinois line item | |||||||||||||||||||
15 | charges and fees comprised of health care provider and | |||||||||||||||||||
16 | hospital charges and fees as of August 1, 2004 but not earlier | |||||||||||||||||||
17 | than August 1, 2002. These charges and fees are provider | |||||||||||||||||||
18 | billed amounts and shall not include discounted charges. The | |||||||||||||||||||
19 | 80th percentile is the point on an ordered data set from low to | |||||||||||||||||||
20 | high such that 80% of the cases are below or equal to that | |||||||||||||||||||
21 | point and at most 20% are above or equal to that point. The | |||||||||||||||||||
22 | Commission shall adjust these historical charges and fees as | |||||||||||||||||||
23 | of August 1, 2004 by the Consumer Price Index-U for the period |
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1 | August 1, 2004 through September 30, 2005. The Commission | ||||||
2 | shall establish fee schedules for procedures, treatments, or | ||||||
3 | services for hospital inpatient, hospital outpatient, | ||||||
4 | emergency room and trauma, ambulatory surgical treatment | ||||||
5 | centers, and professional services. These charges and fees | ||||||
6 | shall be designated by geozip or any smaller geographic unit. | ||||||
7 | The data shall in no way identify or tend to identify any | ||||||
8 | patient, employer, or health care provider. As used in this | ||||||
9 | Section, "geozip" means a three-digit zip code based on data | ||||||
10 | similarities, geographical similarities, and frequencies. A | ||||||
11 | geozip does not cross state boundaries. As used in this | ||||||
12 | Section, "three-digit zip code" means a geographic area in | ||||||
13 | which all zip codes have the same first 3 digits. If a geozip | ||||||
14 | does not have the necessary number of charges and fees to | ||||||
15 | calculate a valid percentile for a specific procedure, | ||||||
16 | treatment, or service, the Commission may combine data from | ||||||
17 | the geozip with up to 4 other geozips that are demographically | ||||||
18 | and economically similar and exhibit similarities in data and | ||||||
19 | frequencies until the Commission reaches 9 charges or fees for | ||||||
20 | that specific procedure, treatment, or service. In cases where | ||||||
21 | the compiled data contains less than 9 charges or fees for a | ||||||
22 | procedure, treatment, or service, reimbursement shall occur at | ||||||
23 | 76% of charges and fees as determined by the Commission in a | ||||||
24 | manner consistent with the provisions of this paragraph. | ||||||
25 | Providers of out-of-state procedures, treatments, services, | ||||||
26 | products, or supplies shall be reimbursed at the lesser of |
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1 | that state's fee schedule amount or the fee schedule amount | ||||||
2 | for the region in which the employee resides. If no fee | ||||||
3 | schedule exists in that state, the provider shall be | ||||||
4 | reimbursed at the lesser of the actual charge or the fee | ||||||
5 | schedule amount for the region in which the employee resides. | ||||||
6 | Not later than September 30 in 2006 and each year thereafter, | ||||||
7 | the Commission shall automatically increase or decrease the | ||||||
8 | maximum allowable payment for a procedure, treatment, or | ||||||
9 | service established and in effect on January 1 of that year by | ||||||
10 | the percentage change in the Consumer Price Index-U for the 12 | ||||||
11 | month period ending August 31 of that year. The increase or | ||||||
12 | decrease shall become effective on January 1 of the following | ||||||
13 | year. As used in this Section, "Consumer Price Index-U" means | ||||||
14 | the index published by the Bureau of Labor Statistics of the | ||||||
15 | U.S. Department of Labor, that measures the average change in | ||||||
16 | prices of all goods and services purchased by all urban | ||||||
17 | consumers, U.S. city average, all items, 1982-84=100. | ||||||
18 | (a-1) Notwithstanding the provisions of subsection (a) and | ||||||
19 | unless otherwise indicated, the following provisions shall | ||||||
20 | apply to the medical fee schedule starting on September 1, | ||||||
21 | 2011: | ||||||
22 | (1) The Commission shall establish and maintain fee | ||||||
23 | schedules for procedures, treatments, products, services, | ||||||
24 | or supplies for hospital inpatient, hospital outpatient, | ||||||
25 | emergency room, ambulatory surgical treatment centers, | ||||||
26 | accredited ambulatory surgical treatment facilities, |
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1 | prescriptions filled and dispensed outside of a licensed | ||||||
2 | pharmacy, dental services, and professional services. This | ||||||
3 | fee schedule shall be based on the fee schedule amounts | ||||||
4 | already established by the Commission pursuant to | ||||||
5 | subsection (a) of this Section. However, starting on | ||||||
6 | January 1, 2012, these fee schedule amounts shall be | ||||||
7 | grouped into geographic regions in the following manner: | ||||||
8 | (A) Four regions for non-hospital fee schedule | ||||||
9 | amounts shall be utilized: | ||||||
10 | (i) Cook County; | ||||||
11 | (ii) DuPage, Kane, Lake, and Will Counties; | ||||||
12 | (iii) Bond, Calhoun, Clinton, Jersey, | ||||||
13 | Macoupin, Madison, Monroe, Montgomery, Randolph, | ||||||
14 | St. Clair, and Washington Counties; and | ||||||
15 | (iv) All other counties of the State. | ||||||
16 | (B) Fourteen regions for hospital fee schedule | ||||||
17 | amounts shall be utilized: | ||||||
18 | (i) Cook, DuPage, Will, Kane, McHenry, DeKalb, | ||||||
19 | Kendall, and Grundy Counties; | ||||||
20 | (ii) Kankakee County; | ||||||
21 | (iii) Madison, St. Clair, Macoupin, Clinton, | ||||||
22 | Monroe, Jersey, Bond, and Calhoun Counties; | ||||||
23 | (iv) Winnebago and Boone Counties; | ||||||
24 | (v) Peoria, Tazewell, Woodford, Marshall, and | ||||||
25 | Stark Counties; | ||||||
26 | (vi) Champaign, Piatt, and Ford Counties; |
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1 | (vii) Rock Island, Henry, and Mercer Counties; | ||||||
2 | (viii) Sangamon and Menard Counties; | ||||||
3 | (ix) McLean County; | ||||||
4 | (x) Lake County; | ||||||
5 | (xi) Macon County; | ||||||
6 | (xii) Vermilion County; | ||||||
7 | (xiii) Alexander County; and | ||||||
8 | (xiv) All other counties of the State. | ||||||
9 | (2) If a geozip, as defined in subsection (a) of this | ||||||
10 | Section, overlaps into one or more of the regions set | ||||||
11 | forth in this Section, then the Commission shall average | ||||||
12 | or repeat the charges and fees in a geozip in order to | ||||||
13 | designate charges and fees for each region. | ||||||
14 | (3) In cases where the compiled data contains less | ||||||
15 | than 9 charges or fees for a procedure, treatment, | ||||||
16 | product, supply, or service or where the fee schedule | ||||||
17 | amount cannot be determined by the non-discounted charge | ||||||
18 | data, non-Medicare relative values and conversion factors | ||||||
19 | derived from established fee schedule amounts, coding | ||||||
20 | crosswalks, or other data as determined by the Commission, | ||||||
21 | reimbursement shall occur at 76% of charges and fees until | ||||||
22 | September 1, 2011 and 53.2% of charges and fees thereafter | ||||||
23 | as determined by the Commission in a manner consistent | ||||||
24 | with the provisions of this paragraph. | ||||||
25 | (4) To establish additional fee schedule amounts, the | ||||||
26 | Commission shall utilize provider non-discounted charge |
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1 | data, non-Medicare relative values and conversion factors | ||||||
2 | derived from established fee schedule amounts, and coding | ||||||
3 | crosswalks. The Commission may establish additional fee | ||||||
4 | schedule amounts based on either the charge or cost of the | ||||||
5 | procedure, treatment, product, supply, or service. | ||||||
6 | (5) Implants shall be reimbursed at 25% above the net | ||||||
7 | manufacturer's invoice price less rebates, plus actual | ||||||
8 | reasonable and customary shipping charges whether or not | ||||||
9 | the implant charge is submitted by a provider in | ||||||
10 | conjunction with a bill for all other services associated | ||||||
11 | with the implant, submitted by a provider on a separate | ||||||
12 | claim form, submitted by a distributor, or submitted by | ||||||
13 | the manufacturer of the implant. "Implants" include the | ||||||
14 | following codes or any substantially similar updated code | ||||||
15 | as determined by the Commission: 0274 | ||||||
16 | (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens | ||||||
17 | implant); 0278 (implants); 0540 and 0545 (ambulance); 0624 | ||||||
18 | (investigational devices); and 0636 (drugs requiring | ||||||
19 | detailed coding). Non-implantable devices or supplies | ||||||
20 | within these codes shall be reimbursed at 65% of actual | ||||||
21 | charge, which is the provider's normal rates under its | ||||||
22 | standard chargemaster. A standard chargemaster is the | ||||||
23 | provider's list of charges for procedures, treatments, | ||||||
24 | products, supplies, or services used to bill payers in a | ||||||
25 | consistent manner. | ||||||
26 | (6) The Commission shall automatically update all |
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1 | codes and associated rules with the version of the codes | ||||||
2 | and rules valid on January 1 of that year. | ||||||
3 | (a-2) For procedures, treatments, services, or supplies | ||||||
4 | covered under this Act and rendered or to be rendered on or | ||||||
5 | after September 1, 2011, the maximum allowable payment shall | ||||||
6 | be 70% of the fee schedule amounts, which shall be adjusted | ||||||
7 | yearly by the Consumer Price Index-U, as described in | ||||||
8 | subsection (a) of this Section. | ||||||
9 | (a-3) Prescriptions filled and dispensed outside of a | ||||||
10 | licensed pharmacy shall be subject to a fee schedule that | ||||||
11 | shall not exceed the Average Wholesale Price (AWP) plus a | ||||||
12 | dispensing fee of $4.18. AWP or its equivalent as registered | ||||||
13 | by the National Drug Code shall be set forth for that drug on | ||||||
14 | that date as published in Medi-Span Medispan . | ||||||
15 | (a-4) By September 1, 2022, the Commission, in | ||||||
16 | consultation with the Workers' Compensation Medical Fee | ||||||
17 | Advisory Board, shall promulgate by rule an evidence-based | ||||||
18 | drug formulary and any rules necessary for its administration. | ||||||
19 | Prescriptions prescribed for workers' compensation cases shall | ||||||
20 | be limited to the prescription drugs and doses on the closed | ||||||
21 | formulary. | ||||||
22 | A request for a prescription that is not on the closed | ||||||
23 | formulary shall be reviewed under Section 8.7. | ||||||
24 | (b) Notwithstanding the provisions of subsection (a), if
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25 | the Commission finds that there is a significant limitation on
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26 | access to quality health care in either a specific field of
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1 | health care services or a specific geographic limitation on
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2 | access to health care, it may change the Consumer Price | ||||||
3 | Index-U
increase or decrease for that specific field or | ||||||
4 | specific
geographic limitation on access to health care to | ||||||
5 | address that
limitation. | ||||||
6 | (c) The Commission shall establish by rule a process to | ||||||
7 | review those medical cases or outliers that involve | ||||||
8 | extra-ordinary treatment to determine whether to make an | ||||||
9 | additional adjustment to the maximum payment within a fee | ||||||
10 | schedule for a procedure, treatment, or service. | ||||||
11 | (d) When a patient notifies a provider that the treatment, | ||||||
12 | procedure, or service being sought is for a work-related | ||||||
13 | illness or injury and furnishes the provider the name and | ||||||
14 | address of the responsible employer, the provider shall bill | ||||||
15 | the employer or its designee directly. The employer or its | ||||||
16 | designee shall make payment for treatment in accordance with | ||||||
17 | the provisions of this Section directly to the provider, | ||||||
18 | except that, if a provider has designated a third-party | ||||||
19 | billing entity to bill on its behalf, payment shall be made | ||||||
20 | directly to the billing entity. Providers shall submit bills | ||||||
21 | and records in accordance with the provisions of this Section. | ||||||
22 | (1) All payments to providers for treatment provided | ||||||
23 | pursuant to this Act shall be made within 30 days of | ||||||
24 | receipt of the bills as long as the bill contains | ||||||
25 | substantially all the required data elements necessary to | ||||||
26 | adjudicate the bill. |
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1 | (2) If the bill does not contain substantially all the | ||||||
2 | required data elements necessary to adjudicate the bill, | ||||||
3 | or the claim is denied for any other reason, in whole or in | ||||||
4 | part, the employer or insurer shall provide written | ||||||
5 | notification to the provider in the form of an explanation | ||||||
6 | of benefits explaining the basis for the denial and | ||||||
7 | describing any additional necessary data elements within | ||||||
8 | 30 days of receipt of the bill. The Commission, with | ||||||
9 | assistance from the Medical Fee Advisory Board, shall | ||||||
10 | adopt rules detailing the requirements for the explanation | ||||||
11 | of benefits required under this subsection. | ||||||
12 | (3) In the case (i) of nonpayment to a provider within | ||||||
13 | 30 days of receipt of the bill which contained | ||||||
14 | substantially all of the required data elements necessary | ||||||
15 | to adjudicate the bill, (ii) of nonpayment to a provider | ||||||
16 | of a portion of such a bill, or (iii) where the provider | ||||||
17 | has not been issued an explanation of benefits for a bill, | ||||||
18 | the bill, or portion of the bill up to the lesser of the | ||||||
19 | actual charge or the payment level set by the Commission | ||||||
20 | in the fee schedule established in this Section, shall | ||||||
21 | incur interest at a rate of 1% per month payable by the | ||||||
22 | employer to the provider. Any required interest payments | ||||||
23 | shall be made by the employer or its insurer to the | ||||||
24 | provider within 30 days after payment of the bill. | ||||||
25 | (4) If the employer or its insurer fails to pay | ||||||
26 | interest within 30 days after payment of the bill as |
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1 | required pursuant to paragraph (3), the provider may bring | ||||||
2 | an action in circuit court for the sole purpose of seeking | ||||||
3 | payment of interest pursuant to paragraph (3) against the | ||||||
4 | employer or its insurer responsible for insuring the | ||||||
5 | employer's liability pursuant to item (3) of subsection | ||||||
6 | (a) of Section 4. The circuit court's jurisdiction shall | ||||||
7 | be limited to enforcing payment of interest pursuant to | ||||||
8 | paragraph (3). Interest under paragraph (3) is only | ||||||
9 | payable to the provider. An employee is not responsible | ||||||
10 | for the payment of interest under this Section. The right | ||||||
11 | to interest under paragraph (3) shall not delay, diminish, | ||||||
12 | restrict, or alter in any way the benefits to which the | ||||||
13 | employee or his or her dependents are entitled under this | ||||||
14 | Act. | ||||||
15 | The changes made to this subsection (d) by this amendatory | ||||||
16 | Act of the 100th General Assembly apply to procedures, | ||||||
17 | treatments, and services rendered on and after the effective | ||||||
18 | date of this amendatory Act of the 100th General Assembly. | ||||||
19 | (e) Except as provided in subsections (e-5), (e-10), and | ||||||
20 | (e-15), a provider shall not hold an employee liable for costs | ||||||
21 | related to a non-disputed procedure, treatment, or service | ||||||
22 | rendered in connection with a compensable injury. The | ||||||
23 | provisions of subsections (e-5), (e-10), (e-15), and (e-20) | ||||||
24 | shall not apply if an employee provides information to the | ||||||
25 | provider regarding participation in a group health plan. If | ||||||
26 | the employee participates in a group health plan, the provider |
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1 | may submit a claim for services to the group health plan. If | ||||||
2 | the claim for service is covered by the group health plan, the | ||||||
3 | employee's responsibility shall be limited to applicable | ||||||
4 | deductibles, co-payments, or co-insurance. Except as provided | ||||||
5 | under subsections (e-5), (e-10), (e-15), and (e-20), a | ||||||
6 | provider shall not bill or otherwise attempt to recover from | ||||||
7 | the employee the difference between the provider's charge and | ||||||
8 | the amount paid by the employer or the insurer on a compensable | ||||||
9 | injury, or for medical services or treatment determined by the | ||||||
10 | Commission to be excessive or unnecessary. | ||||||
11 | (e-5) If an employer notifies a provider that the employer | ||||||
12 | does not consider the illness or injury to be compensable | ||||||
13 | under this Act, the provider may seek payment of the | ||||||
14 | provider's actual charges from the employee for any procedure, | ||||||
15 | treatment, or service rendered. Once an employee informs the | ||||||
16 | provider that there is an application filed with the | ||||||
17 | Commission to resolve a dispute over payment of such charges, | ||||||
18 | the provider shall cease any and all efforts to collect | ||||||
19 | payment for the services that are the subject of the dispute. | ||||||
20 | Any statute of limitations or statute of repose applicable to | ||||||
21 | the provider's efforts to collect payment from the employee | ||||||
22 | shall be tolled from the date that the employee files the | ||||||
23 | application with the Commission until the date that the | ||||||
24 | provider is permitted to resume collection efforts under the | ||||||
25 | provisions of this Section. | ||||||
26 | (e-10) If an employer notifies a provider that the |
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1 | employer will pay only a portion of a bill for any procedure, | ||||||
2 | treatment, or service rendered in connection with a | ||||||
3 | compensable illness or disease, the provider may seek payment | ||||||
4 | from the employee for the remainder of the amount of the bill | ||||||
5 | up to the lesser of the actual charge, negotiated rate, if | ||||||
6 | applicable, or the payment level set by the Commission in the | ||||||
7 | fee schedule established in this Section. Once an employee | ||||||
8 | informs the provider that there is an application filed with | ||||||
9 | the Commission to resolve a dispute over payment of such | ||||||
10 | charges, the provider shall cease any and all efforts to | ||||||
11 | collect payment for the services that are the subject of the | ||||||
12 | dispute. Any statute of limitations or statute of repose | ||||||
13 | applicable to the provider's efforts to collect payment from | ||||||
14 | the employee shall be tolled from the date that the employee | ||||||
15 | files the application with the Commission until the date that | ||||||
16 | the provider is permitted to resume collection efforts under | ||||||
17 | the provisions of this Section. | ||||||
18 | (e-15) When there is a dispute over the compensability of | ||||||
19 | or amount of payment for a procedure, treatment, or service, | ||||||
20 | and a case is pending or proceeding before an Arbitrator or the | ||||||
21 | Commission, the provider may mail the employee reminders that | ||||||
22 | the employee will be responsible for payment of any procedure, | ||||||
23 | treatment or service rendered by the provider. The reminders | ||||||
24 | must state that they are not bills, to the extent practicable | ||||||
25 | include itemized information, and state that the employee need | ||||||
26 | not pay until such time as the provider is permitted to resume |
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1 | collection efforts under this Section. The reminders shall not | ||||||
2 | be provided to any credit rating agency. The reminders may | ||||||
3 | request that the employee furnish the provider with | ||||||
4 | information about the proceeding under this Act, such as the | ||||||
5 | file number, names of parties, and status of the case. If an | ||||||
6 | employee fails to respond to such request for information or | ||||||
7 | fails to furnish the information requested within 90 days of | ||||||
8 | the date of the reminder, the provider is entitled to resume | ||||||
9 | any and all efforts to collect payment from the employee for | ||||||
10 | the services rendered to the employee and the employee shall | ||||||
11 | be responsible for payment of any outstanding bills for a | ||||||
12 | procedure, treatment, or service rendered by a provider. | ||||||
13 | (e-20) Upon a final award or judgment by an Arbitrator or | ||||||
14 | the Commission, or a settlement agreed to by the employer and | ||||||
15 | the employee, a provider may resume any and all efforts to | ||||||
16 | collect payment from the employee for the services rendered to | ||||||
17 | the employee and the employee shall be responsible for payment | ||||||
18 | of any outstanding bills for a procedure, treatment, or | ||||||
19 | service rendered by a provider as well as the interest awarded | ||||||
20 | under subsection (d) of this Section. In the case of a | ||||||
21 | procedure, treatment, or service deemed compensable, the | ||||||
22 | provider shall not require a payment rate, excluding the | ||||||
23 | interest provisions under subsection (d), greater than the | ||||||
24 | lesser of the actual charge or the payment level set by the | ||||||
25 | Commission in the fee schedule established in this Section. | ||||||
26 | Payment for services deemed not covered or not compensable |
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1 | under this Act is the responsibility of the employee unless a | ||||||
2 | provider and employee have agreed otherwise in writing. | ||||||
3 | Services not covered or not compensable under this Act are not | ||||||
4 | subject to the fee schedule in this Section. | ||||||
5 | (f) Nothing in this Act shall prohibit an employer or
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6 | insurer from contracting with a health care provider or group
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7 | of health care providers for reimbursement levels for benefits | ||||||
8 | under this Act different
from those provided in this Section. | ||||||
9 | (g) On or before January 1, 2010 the Commission shall | ||||||
10 | provide to the Governor and General Assembly a report | ||||||
11 | regarding the implementation of the medical fee schedule and | ||||||
12 | the index used for annual adjustment to that schedule as | ||||||
13 | described in this Section.
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14 | (Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff. | ||||||
15 | 1-11-19.)
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16 | Section 99. Effective date. This Act takes effect upon | ||||||
17 | becoming law.
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