Bill Amendment: IL HB3479 | 2017-2018 | 100th General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: MEDICAID-MCCN-PHARMACY RATES
Status: 2019-01-08 - Session Sine Die [HB3479 Detail]
Download: Illinois-2017-HB3479-Senate_Amendment_005.html
Bill Title: MEDICAID-MCCN-PHARMACY RATES
Status: 2019-01-08 - Session Sine Die [HB3479 Detail]
Download: Illinois-2017-HB3479-Senate_Amendment_005.html
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| 1 | AMENDMENT TO HOUSE BILL 3479
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| 2 | AMENDMENT NO. ______. Amend House Bill 3479 by replacing | ||||||
| 3 | everything after the enacting clause with the following:
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| 4 | "Section 1. Short title. This Act may be cited as the | ||||||
| 5 | Pharmacy Benefits Manager Licensing Act.
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| 6 | Section 5. Definitions. As used in this Act: | ||||||
| 7 | "Average reimbursement" means a statistical methodology | ||||||
| 8 | selected by the Department through any rules adopted pursuant | ||||||
| 9 | to this Section that shall include, at a minimum, the median | ||||||
| 10 | and mean. | ||||||
| 11 | "Department" means the Department of Insurance. | ||||||
| 12 | "Director" means the Director of Insurance. | ||||||
| 13 | "Person beneficially interested", with respect to an | ||||||
| 14 | applicant for a pharmacy benefits manager license, means: | ||||||
| 15 | (1) if the applicant is a partnership or other | ||||||
| 16 | unincorporated association, each partner or member; | ||||||
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| 1 | (2) if the applicant is a corporation, each of its | ||||||
| 2 | officers, directors, and stockholders, except that a | ||||||
| 3 | natural person shall not be deemed to be beneficially | ||||||
| 4 | interested in a nonprofit corporation; or | ||||||
| 5 | (3) if the applicant is a limited liability company, | ||||||
| 6 | each officer, manager, or member. | ||||||
| 7 | "Pharmacist" has the meaning given to the term in the | ||||||
| 8 | Pharmacy Practice Act. | ||||||
| 9 | "Pharmacy" has the meaning given to the term in the | ||||||
| 10 | Pharmacy Practice Act. | ||||||
| 11 | "Pharmacy benefits manager" means a person, business, or | ||||||
| 12 | other entity that, pursuant to a contract or under an | ||||||
| 13 | employment relationship with a plan sponsor, insurer, or other | ||||||
| 14 | third-party payer, either directly or through an intermediary, | ||||||
| 15 | manages the prescription drug coverage provided by the plan | ||||||
| 16 | sponsor, insurer, or other third-party payer, including, but | ||||||
| 17 | not limited to, the processing and payment of claims for | ||||||
| 18 | prescription drugs, the performance of drug utilization | ||||||
| 19 | review, the processing of drug prior authorization requests, | ||||||
| 20 | the adjudication of appeals or grievances related to | ||||||
| 21 | prescription drug coverage, contracting with network | ||||||
| 22 | pharmacies, and controlling the cost of covered prescription | ||||||
| 23 | drugs. | ||||||
| 24 | "Pharmacy provider" means a pharmacy or pharmacist. | ||||||
| 25 | "Proprietary information" means information on pricing, | ||||||
| 26 | costs, revenue, taxes, market share, negotiating strategies, | ||||||
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| 1 | customers, and personnel that is held by a pharmacy benefits | ||||||
| 2 | manager and used for its business purposes.
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| 3 | Section 10. Pharmacy benefits manager licensing | ||||||
| 4 | requirements. | ||||||
| 5 | (a) A pharmacy benefits manager shall be licensed by the | ||||||
| 6 | Department before conducting business in this State. | ||||||
| 7 | (b) A pharmacy benefits manager license under this Section | ||||||
| 8 | is not transferable. | ||||||
| 9 | (c) The Department shall develop, by rule, application | ||||||
| 10 | forms for pharmacy benefits manager licensure. The application | ||||||
| 11 | form for the pharmacy benefits manager license shall require | ||||||
| 12 | the pharmacy benefits manager to submit all of the following | ||||||
| 13 | information to the Department: | ||||||
| 14 | (1) the name of the pharmacy benefits manager; | ||||||
| 15 | (2) the address and contact telephone number for the | ||||||
| 16 | pharmacy benefits manager; | ||||||
| 17 | (3) the name and address of the pharmacy benefits | ||||||
| 18 | manager's agent for service of process in this State; | ||||||
| 19 | (4) the name and address of each person beneficially | ||||||
| 20 | interested in the pharmacy benefits manager; and | ||||||
| 21 | (5) the name and address of each person with management | ||||||
| 22 | or control over the pharmacy benefits manager. | ||||||
| 23 | (d) If the applicant is a partnership or other | ||||||
| 24 | unincorporated association, a limited liability company, or a | ||||||
| 25 | corporation and the number of partners, members, or | ||||||
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| 1 | stockholders, as the case may be, exceeds 5, the application | ||||||
| 2 | shall so state and shall further state the name, address, usual | ||||||
| 3 | occupation, and professional qualifications of each of the 5 | ||||||
| 4 | partners, members, or stockholders who own the 5 largest | ||||||
| 5 | interests in the applicant entity. Upon request by the | ||||||
| 6 | Department, the applicant shall furnish the Department with the | ||||||
| 7 | name, address, usual occupation, and professional | ||||||
| 8 | qualifications of partners, members, or stockholders not named | ||||||
| 9 | in the application or shall refer the Department to an | ||||||
| 10 | appropriate source of that information. | ||||||
| 11 | (e) The application shall contain a statement to the effect | ||||||
| 12 | that the applicant has not been convicted of a felony and has | ||||||
| 13 | not violated any of the provisions of this Act. If the | ||||||
| 14 | applicant cannot make this statement, the application shall | ||||||
| 15 | contain a statement of the violation, if any, or reasons that | ||||||
| 16 | prevent the applicant from being able to comply with the | ||||||
| 17 | requirements with respect to the statement. | ||||||
| 18 | (f) Within 30 days after a change in any of the information | ||||||
| 19 | disclosed to the Department on an application for licensure, | ||||||
| 20 | the pharmacy benefits manager shall notify the Department of | ||||||
| 21 | that change in writing. | ||||||
| 22 | (g) The Department may, by rule, set a fee for the license | ||||||
| 23 | issued under this Act. The fee shall not exceed the actual | ||||||
| 24 | costs incurred by the Department in carrying out its duties | ||||||
| 25 | under this Act.
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| 1 | Section 15. Discipline; grounds. | ||||||
| 2 | (a) The Director may refuse to issue, restore, or remove or | ||||||
| 3 | may revoke, suspend, or place on probation a pharmacy benefits | ||||||
| 4 | manager's license under any of the following circumstances: | ||||||
| 5 | (1) The pharmacy benefits manager has engaged in | ||||||
| 6 | fraudulent activity that constitutes a violation of State | ||||||
| 7 | or federal law. | ||||||
| 8 | (2) The Department has received consumer complaints | ||||||
| 9 | that justify an action under this Section in order to | ||||||
| 10 | protect the safety and interests of consumers. | ||||||
| 11 | (3) The pharmacy benefits manager fails to pay an | ||||||
| 12 | application fee for the license. | ||||||
| 13 | (4) The pharmacy benefits manager fails to comply with | ||||||
| 14 | a requirement set forth in Section 20 or 25. | ||||||
| 15 | (b) The Department shall, by rule, develop procedures that | ||||||
| 16 | provide a pharmacy benefits manager subject to discipline under | ||||||
| 17 | subsection (a) with reasonable notice of, and an opportunity to | ||||||
| 18 | respond to, the Department before taking that action.
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| 19 | Section 20. Transparency requirements. | ||||||
| 20 | (a) A pharmacy benefits manager contracting with a managed | ||||||
| 21 | care organization to administer benefits provided under the | ||||||
| 22 | State Employees Group Insurance Act of 1971 or the Illinois | ||||||
| 23 | Public Aid Code shall provide the following information to the | ||||||
| 24 | Department no later than March 31, 2019 and for each year | ||||||
| 25 | thereafter for the previous calendar year that the pharmacy | ||||||
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| 1 | benefits manager is contracted with a managed care organization | ||||||
| 2 | to administer benefits: | ||||||
| 3 | (1) the total amount paid to the pharmacy benefits | ||||||
| 4 | manager by a managed care organization to administer | ||||||
| 5 | benefits for each contract under which the pharmacy | ||||||
| 6 | benefits manager is contracted to administer benefits | ||||||
| 7 | under the State Employees Group Insurance Act of 1971 or | ||||||
| 8 | the Illinois Public Aid Code; | ||||||
| 9 | (2) the total amount paid in reimbursements to | ||||||
| 10 | pharmacies licensed in Illinois for each contract under | ||||||
| 11 | which the pharmacy benefits manager is contracted to | ||||||
| 12 | administer benefits under the State Employees Group | ||||||
| 13 | Insurance Act of 1971 or the Illinois Public Aid Code; | ||||||
| 14 | (3) the average reimbursement per contract by drug | ||||||
| 15 | ingredient cost, dispensing fee, and any other fee paid by | ||||||
| 16 | a pharmacy benefits manager to licensed pharmacies with | ||||||
| 17 | which the pharmacy benefits manager shares common | ||||||
| 18 | ownership, management, or control; or that are owned, | ||||||
| 19 | managed, or collected by any of the pharmacy benefits | ||||||
| 20 | manager's management companies, parent companies, | ||||||
| 21 | subsidiary companies, jointly held companies, or companies | ||||||
| 22 | otherwise affiliated by a common owner, manager, or holding | ||||||
| 23 | company; or that share any common members on the board of | ||||||
| 24 | directors; or that share managers in common; | ||||||
| 25 | (4) the average reimbursement per contract by drug | ||||||
| 26 | ingredient cost, dispensing fee, and any other fee, paid by | ||||||
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| 1 | a pharmacy benefits manager to pharmacies licensed in | ||||||
| 2 | Illinois other than those subject to paragraph (3); | ||||||
| 3 | (5) any direct or indirect fees, charges, or any kind | ||||||
| 4 | of assessments imposed by the pharmacy benefits manager on | ||||||
| 5 | pharmacies licensed in Illinois with which the pharmacy | ||||||
| 6 | benefits manager shares common ownership, management, or | ||||||
| 7 | control; or that are owned, managed, or controlled by any | ||||||
| 8 | of the pharmacy benefits manager's management companies, | ||||||
| 9 | parent companies, subsidiary companies, jointly held | ||||||
| 10 | companies, or companies otherwise affiliated by a common | ||||||
| 11 | owner, manager, or holding company; or that share any | ||||||
| 12 | common members on the board of directors; or that share | ||||||
| 13 | managers in common; | ||||||
| 14 | (6) any direct or indirect fees, charges, or any kind | ||||||
| 15 | of assessments imposed by the pharmacy benefits manager on | ||||||
| 16 | pharmacies licensed in Illinois other than those subject to | ||||||
| 17 | paragraph (5); and | ||||||
| 18 | (7) all common ownership, management, common members | ||||||
| 19 | of a board of directors, shared managers, or control of a | ||||||
| 20 | pharmacy benefits manager, or any of the pharmacy benefits | ||||||
| 21 | manager's management companies, parent companies, | ||||||
| 22 | subsidiary companies, jointly held companies, or companies | ||||||
| 23 | otherwise affiliated by a common owner, manager, or holding | ||||||
| 24 | company with any managed care organization contracted to | ||||||
| 25 | administer Medicaid benefits, any entity that contracts on | ||||||
| 26 | behalf of a pharmacy, or any pharmacy services | ||||||
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| 1 | administration organization, or any common ownership, | ||||||
| 2 | management, common members of a board of directors, shared | ||||||
| 3 | managers, or control of a pharmacy services administration | ||||||
| 4 | organization that is contracted with a pharmacy benefits | ||||||
| 5 | manager, with any drug wholesaler or distributors or any of | ||||||
| 6 | the pharmacy services administration organization, | ||||||
| 7 | management companies, parent companies, subsidiary | ||||||
| 8 | companies, jointly held companies, or companies otherwise | ||||||
| 9 | affiliated by a common owner, common members of a board of | ||||||
| 10 | directors, manager, or holding company. | ||||||
| 11 | (b) All information provided by a pharmacy benefits manager | ||||||
| 12 | pursuant to this Section shall reflect data for the most recent | ||||||
| 13 | full calendar year and shall be divided by quarter. This | ||||||
| 14 | information shall be managed by the Department and shall be | ||||||
| 15 | exempt from the Freedom of Information Act. The Department | ||||||
| 16 | shall submit a report to the General Assembly annually and | ||||||
| 17 | publish the report on its website on the information provided | ||||||
| 18 | in this Section provided the information is presented in the | ||||||
| 19 | aggregate. The report to the General Assembly shall be filed | ||||||
| 20 | with the Clerk of the House of Representatives and the | ||||||
| 21 | Secretary of the Senate in electronic form only, in the manner | ||||||
| 22 | that the Clerk and the Secretary shall direct. | ||||||
| 23 | (c) Contract information between a pharmacy benefits | ||||||
| 24 | manager and a pharmacy provider shall be exempt from the | ||||||
| 25 | Freedom of Information Act.
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| 1 | Section 25. Duties to pharmacy providers. | ||||||
| 2 | (a) A pharmacy benefits manager shall not include in a | ||||||
| 3 | contract with a pharmacy provider any of the following | ||||||
| 4 | provisions: | ||||||
| 5 | (1) a provision that prohibits the pharmacy provider | ||||||
| 6 | from informing a patient of a more affordable alternative | ||||||
| 7 | to a prescribed medication if a more affordable alternative | ||||||
| 8 | is available; | ||||||
| 9 | (2) a provision prohibiting a pharmacy provider from | ||||||
| 10 | disclosing any contract information to the Department or | ||||||
| 11 | any other government agency or an elected official; or | ||||||
| 12 | (3) a provision requiring the pharmacy provider to | ||||||
| 13 | participate in a managed care organization's provider | ||||||
| 14 | network to administer benefits under the State Employees | ||||||
| 15 | Group Insurance Act of 1971 or the Illinois Public Aid Code | ||||||
| 16 | as a condition of participation in a national pharmacy | ||||||
| 17 | provider contract. | ||||||
| 18 | (b) A pharmacy benefits manager shall be subject to the | ||||||
| 19 | following requirements regarding reimbursement appeals: | ||||||
| 20 | (1) A pharmacy provider may appeal a reimbursement to a | ||||||
| 21 | pharmacy benefits manager within 60 days after the date of | ||||||
| 22 | service and the pharmacy benefits manager shall respond no | ||||||
| 23 | later than 7 days after the appeal is filed with the | ||||||
| 24 | pharmacy benefits manager. If the pharmacy benefits | ||||||
| 25 | manager fails to respond within 7 days after the appeal is | ||||||
| 26 | filed with the pharmacy benefits manager, the appeal is to | ||||||
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| 1 | be ruled in favor of the pharmacy provider. | ||||||
| 2 | (2) A pharmacy provider may appeal the remuneration | ||||||
| 3 | rate to the managed care organization within 60 days after | ||||||
| 4 | the date of service, and the managed care organization | ||||||
| 5 | shall respond no later than 7 days after the appeal is | ||||||
| 6 | filed with the managed care organization. If the managed | ||||||
| 7 | care organization fails to respond within 7 days after the | ||||||
| 8 | appeal is filed with the managed care organization, the | ||||||
| 9 | appeal is to be ruled in favor of the pharmacy provider. | ||||||
| 10 | (c) A pharmacy benefits manager that performs pharmacy | ||||||
| 11 | audits or contracts with an auditing entity for the purpose of | ||||||
| 12 | administering pharmacy audits shall not engage in conduct | ||||||
| 13 | prohibited under Section 30. An auditing entity's conduct under | ||||||
| 14 | Section 30 shall be attributed to the contracting pharmacy | ||||||
| 15 | benefits manager for purposes of Section 15. | ||||||
| 16 | (d) The Department shall, by rule, develop procedures that | ||||||
| 17 | provide a pharmacy provider the opportunity to file a complaint | ||||||
| 18 | of violations of this Section and receive a resolution.
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| 19 | Section 30. Audits. | ||||||
| 20 | (a) As used in this Section: | ||||||
| 21 | "Auditing entity" means a person or company contracted to | ||||||
| 22 | perform a pharmacy audit. | ||||||
| 23 | "Business day" means any day of the week excluding | ||||||
| 24 | Saturday, Sunday, and any legal holiday, as defined in Section | ||||||
| 25 | 17 of the Promissory Note and Bank Holiday Act. | ||||||
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| 1 | "Covered entity" has the meaning given to it under 45 CFR | ||||||
| 2 | 160.103. | ||||||
| 3 | "Covered individual" means a member, participant, | ||||||
| 4 | enrollee, or beneficiary of a covered entity, including a | ||||||
| 5 | dependent or other person covered through the policy or | ||||||
| 6 | contract of a covered individual. | ||||||
| 7 | "Extrapolation" means the practice of inferring a | ||||||
| 8 | frequency of dollar amount of overpayments, underpayments, | ||||||
| 9 | nonvalid claims, or other errors on any portion of claims | ||||||
| 10 | submitted, based on the frequency of dollar amount of | ||||||
| 11 | overpayments, underpayments, nonvalid claims, or other errors | ||||||
| 12 | actually measured in a sample of claims. | ||||||
| 13 | "Misfill" means a prescription that was not dispensed, | ||||||
| 14 | dispensing of an incorrect dose, amount, or type of medication, | ||||||
| 15 | dispensing a prescription drug to the wrong person, a | ||||||
| 16 | prescription in which the prescriber denied the authorization | ||||||
| 17 | request, or a prescription in which an additional dispensing | ||||||
| 18 | fee was charged. | ||||||
| 19 | "Pharmacy audit" means an audit conducted of any records of | ||||||
| 20 | a pharmacy for prescriptions or non-proprietary drugs | ||||||
| 21 | dispensed by a pharmacy to a covered individual. | ||||||
| 22 | "Pharmacy record" means any record stored electronically | ||||||
| 23 | or as a hard copy by a pharmacy that relates to the provision | ||||||
| 24 | of a prescription or pharmacy services or other component of | ||||||
| 25 | pharmacist care that is included in the practice of pharmacy. | ||||||
| 26 | (b) When conducting a pharmacy audit on behalf of a | ||||||
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| 1 | pharmacy benefits manager, an auditing entity shall: | ||||||
| 2 | (1) not conduct an on-site audit of a pharmacy at any | ||||||
| 3 | time during the first 3 business days of a month; | ||||||
| 4 | (2) notify the pharmacy or its contracting agent no | ||||||
| 5 | later than 15 days before the date of initial on-site | ||||||
| 6 | audit; the notification to the pharmacy or its contracting | ||||||
| 7 | agent shall be in writing delivered either: | ||||||
| 8 | (A) by mail or common carrier, return receipt | ||||||
| 9 | requested; or | ||||||
| 10 | (B) electronically with electronic receipt | ||||||
| 11 | confirmation, addressed to the supervising pharmacist | ||||||
| 12 | of record and pharmacy corporate office, if | ||||||
| 13 | applicable, at least 15 days before the date of an | ||||||
| 14 | initial on-site audit; | ||||||
| 15 | (3) limit the audit period to 24 months after the date | ||||||
| 16 | a claim is submitted to or adjudicated by the pharmacy | ||||||
| 17 | benefits manager; | ||||||
| 18 | (4) include in the written advance notice of an on-site | ||||||
| 19 | audit the list of specific prescription numbers to be | ||||||
| 20 | included in the audit that may or may not include the final | ||||||
| 21 | 2 digits of the prescription numbers; | ||||||
| 22 | (5) use the written and verifiable records of a | ||||||
| 23 | hospital, physician, or other authorized practitioner that | ||||||
| 24 | are transmitted by any means of communication to validate | ||||||
| 25 | the pharmacy records in accordance with State and federal | ||||||
| 26 | law; | ||||||
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| 1 | (6) limit the number of prescriptions audited to no | ||||||
| 2 | more than 100 randomly selected in a 12-month period, | ||||||
| 3 | except in cases of fraud; | ||||||
| 4 | (7) provide the pharmacy or its contracting agent with | ||||||
| 5 | a copy of the preliminary audit report within 45 days after | ||||||
| 6 | the conclusion of the audit; | ||||||
| 7 | (8) be allowed to conduct a follow-up audit on-site if | ||||||
| 8 | a remote or desk audit reveals the necessity for a review | ||||||
| 9 | of additional claims; | ||||||
| 10 | (9) in the case of invoice audits, accept as validation | ||||||
| 11 | invoices from any wholesaler registered with the | ||||||
| 12 | Department of Financial and Professional Regulation from | ||||||
| 13 | which the pharmacy has purchased prescription drugs or, in | ||||||
| 14 | the case of durable medical equipment or sickroom supplies, | ||||||
| 15 | invoices from an authorized distributor other than a | ||||||
| 16 | wholesaler; | ||||||
| 17 | (10) provide the pharmacy or its contracting agent with | ||||||
| 18 | the ability to provide documentation to address a | ||||||
| 19 | discrepancy or audit finding; the documentation must be | ||||||
| 20 | received by the pharmacy benefits manager no later than the | ||||||
| 21 | 45th day after the preliminary audit report was provided to | ||||||
| 22 | the pharmacy or its contracting agent; the pharmacy | ||||||
| 23 | benefits manager shall consider a reasonable request from | ||||||
| 24 | the pharmacy for an extension of time to submit | ||||||
| 25 | documentation to address or correct any findings in the | ||||||
| 26 | report; | ||||||
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| 1 | (11) provide the pharmacy or its contracting agent with | ||||||
| 2 | the final audit report no later than 60 days after the | ||||||
| 3 | preliminary audit report was provided to the pharmacy or | ||||||
| 4 | its contracting agent unless an extension was granted | ||||||
| 5 | pursuant to paragraph (10), in which case the final audit | ||||||
| 6 | report is due 30 days after the expiration of the | ||||||
| 7 | extension; and | ||||||
| 8 | (12) conduct the audit in consultation with a | ||||||
| 9 | pharmacist if the audit involves clinical or professional | ||||||
| 10 | judgment. | ||||||
| 11 | (c) Except as otherwise provided by federal or State law, | ||||||
| 12 | an auditing entity conducting a pharmacy audit may have access | ||||||
| 13 | to a pharmacy's previous audit report only if the report was | ||||||
| 14 | prepared by that auditing entity. | ||||||
| 15 | (d) Information collected during a pharmacy audit shall be | ||||||
| 16 | confidential by law, except that the auditing entity conducting | ||||||
| 17 | the pharmacy audit may share the information with the covered | ||||||
| 18 | entity for which a pharmacy audit is being conducted and with | ||||||
| 19 | any regulatory agencies and law enforcement agencies as | ||||||
| 20 | required by law. | ||||||
| 21 | (e) A pharmacy may not be subject to a charge-back or | ||||||
| 22 | recoupment for a clerical or recordkeeping error in a required | ||||||
| 23 | document or record, including a typographical error or computer | ||||||
| 24 | error, unless the error resulted in overpayment to the | ||||||
| 25 | pharmacy. | ||||||
| 26 | (f) A pharmacy shall have the right to file a written | ||||||
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| 1 | appeal of a preliminary and final pharmacy audit report in | ||||||
| 2 | accordance with the procedures established by the entity | ||||||
| 3 | conducting the pharmacy audit. | ||||||
| 4 | (g) An auditing entity conducing a pharmacy audit may not | ||||||
| 5 | charge-back, recoup, or collect penalties from a pharmacy until | ||||||
| 6 | the time period to file an appeal of the final pharmacy audit | ||||||
| 7 | report has passed or the appeals process has been exhausted, | ||||||
| 8 | whichever is later, unless the identified discrepancy is | ||||||
| 9 | expected to exceed $25,000, in which case the auditing entity | ||||||
| 10 | may withhold future payments in excess of that amount until the | ||||||
| 11 | final resolution of the audit. | ||||||
| 12 | (h) No interest shall accrue for any party during the audit | ||||||
| 13 | period, beginning with the notice of the pharmacy audit and | ||||||
| 14 | ending with the conclusion of the appeals process. | ||||||
| 15 | (i) The auditing entity may not compensate the employee or | ||||||
| 16 | contractor conducting the audit based on a percentage of the | ||||||
| 17 | amount claimed or recouped pursuant to the audit. | ||||||
| 18 | (j) The auditing entity may not use extrapolation to | ||||||
| 19 | calculate penalties or amounts to be charged back or recouped | ||||||
| 20 | unless otherwise required by federal law or regulation. Any | ||||||
| 21 | amount to be charged back or recouped due to overpayment may | ||||||
| 22 | not exceed the amount the pharmacy was overpaid. | ||||||
| 23 | (k) The auditing entity may not include dispensing fees in | ||||||
| 24 | the calculation of overpayments unless a prescription is | ||||||
| 25 | considered a misfill. | ||||||
| 26 | (l) An auditing entity shall conduct a pharmacy audit under | ||||||
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| 1 | the same standards and parameters as conducted for other | ||||||
| 2 | similarly situated pharmacies audited by the auditing entity. | ||||||
| 3 | (m) Any claim that was retroactively denied for a clerical | ||||||
| 4 | error, typographical error, scrivener's error, or computer | ||||||
| 5 | error shall be paid if the prescription was properly and | ||||||
| 6 | correctly dispensed, unless a pattern of such errors exists, | ||||||
| 7 | fraudulent billing is alleged, or the error results in actual | ||||||
| 8 | financial loss to the entity. A clerical error is an error that | ||||||
| 9 | does not result in actual financial harm to the covered entity | ||||||
| 10 | or consumer and does not include the dispensing of an incorrect | ||||||
| 11 | dose, amount or type of medication, or dispensing a | ||||||
| 12 | prescription drug to the wrong person. | ||||||
| 13 | (n) This Section does not apply to: | ||||||
| 14 | (1) audits in which suspected fraudulent activity or | ||||||
| 15 | other intentional or willful misrepresentation is | ||||||
| 16 | evidenced by a physical review, review of claims data or | ||||||
| 17 | statements, or other investigative methods; or | ||||||
| 18 | (2) concurrent reviews or desk audits that occur within | ||||||
| 19 | 3 business days after transmission of a claim and where no | ||||||
| 20 | charge-back or recoupment is demanded.
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| 21 | Section 35. Rulemaking. No later than 90 days after the | ||||||
| 22 | effective date of this Act, the Department shall adopt rules | ||||||
| 23 | necessary to implement the provisions of this Act.
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| 24 | Section 90. The Freedom of Information Act is amended by | ||||||
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| 1 | changing Section 7 as follows:
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| 2 | (5 ILCS 140/7) (from Ch. 116, par. 207) | ||||||
| 3 | Sec. 7. Exemptions.
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| 4 | (1) When a request is made to inspect or copy a public | ||||||
| 5 | record that contains information that is exempt from disclosure | ||||||
| 6 | under this Section, but also contains information that is not | ||||||
| 7 | exempt from disclosure, the public body may elect to redact the | ||||||
| 8 | information that is exempt. The public body shall make the | ||||||
| 9 | remaining information available for inspection and copying. | ||||||
| 10 | Subject to this requirement, the following shall be exempt from | ||||||
| 11 | inspection and copying:
| ||||||
| 12 | (a) Information specifically prohibited from | ||||||
| 13 | disclosure by federal or
State law or rules and regulations | ||||||
| 14 | implementing federal or State law.
| ||||||
| 15 | (b) Private information, unless disclosure is required | ||||||
| 16 | by another provision of this Act, a State or federal law or | ||||||
| 17 | a court order. | ||||||
| 18 | (b-5) Files, documents, and other data or databases | ||||||
| 19 | maintained by one or more law enforcement agencies and | ||||||
| 20 | specifically designed to provide information to one or more | ||||||
| 21 | law enforcement agencies regarding the physical or mental | ||||||
| 22 | status of one or more individual subjects. | ||||||
| 23 | (c) Personal information contained within public | ||||||
| 24 | records, the disclosure of which would constitute a clearly
| ||||||
| 25 | unwarranted invasion of personal privacy, unless the | ||||||
| |||||||
| |||||||
| 1 | disclosure is
consented to in writing by the individual | ||||||
| 2 | subjects of the information. "Unwarranted invasion of | ||||||
| 3 | personal privacy" means the disclosure of information that | ||||||
| 4 | is highly personal or objectionable to a reasonable person | ||||||
| 5 | and in which the subject's right to privacy outweighs any | ||||||
| 6 | legitimate public interest in obtaining the information. | ||||||
| 7 | The
disclosure of information that bears on the public | ||||||
| 8 | duties of public
employees and officials shall not be | ||||||
| 9 | considered an invasion of personal
privacy.
| ||||||
| 10 | (d) Records in the possession of any public body | ||||||
| 11 | created in the course of administrative enforcement
| ||||||
| 12 | proceedings, and any law enforcement or correctional | ||||||
| 13 | agency for
law enforcement purposes,
but only to the extent | ||||||
| 14 | that disclosure would:
| ||||||
| 15 | (i) interfere with pending or actually and | ||||||
| 16 | reasonably contemplated
law enforcement proceedings | ||||||
| 17 | conducted by any law enforcement or correctional
| ||||||
| 18 | agency that is the recipient of the request;
| ||||||
| 19 | (ii) interfere with active administrative | ||||||
| 20 | enforcement proceedings
conducted by the public body | ||||||
| 21 | that is the recipient of the request;
| ||||||
| 22 | (iii) create a substantial likelihood that a | ||||||
| 23 | person will be deprived of a fair trial or an impartial | ||||||
| 24 | hearing;
| ||||||
| 25 | (iv) unavoidably disclose the identity of a | ||||||
| 26 | confidential source, confidential information | ||||||
| |||||||
| |||||||
| 1 | furnished only by the confidential source, or persons | ||||||
| 2 | who file complaints with or provide information to | ||||||
| 3 | administrative, investigative, law enforcement, or | ||||||
| 4 | penal agencies; except that the identities of | ||||||
| 5 | witnesses to traffic accidents, traffic accident | ||||||
| 6 | reports, and rescue reports shall be provided by | ||||||
| 7 | agencies of local government, except when disclosure | ||||||
| 8 | would interfere with an active criminal investigation | ||||||
| 9 | conducted by the agency that is the recipient of the | ||||||
| 10 | request;
| ||||||
| 11 | (v) disclose unique or specialized investigative | ||||||
| 12 | techniques other than
those generally used and known or | ||||||
| 13 | disclose internal documents of
correctional agencies | ||||||
| 14 | related to detection, observation or investigation of
| ||||||
| 15 | incidents of crime or misconduct, and disclosure would | ||||||
| 16 | result in demonstrable harm to the agency or public | ||||||
| 17 | body that is the recipient of the request;
| ||||||
| 18 | (vi) endanger the life or physical safety of law | ||||||
| 19 | enforcement personnel
or any other person; or
| ||||||
| 20 | (vii) obstruct an ongoing criminal investigation | ||||||
| 21 | by the agency that is the recipient of the request.
| ||||||
| 22 | (d-5) A law enforcement record created for law | ||||||
| 23 | enforcement purposes and contained in a shared electronic | ||||||
| 24 | record management system if the law enforcement agency that | ||||||
| 25 | is the recipient of the request did not create the record, | ||||||
| 26 | did not participate in or have a role in any of the events | ||||||
| |||||||
| |||||||
| 1 | which are the subject of the record, and only has access to | ||||||
| 2 | the record through the shared electronic record management | ||||||
| 3 | system. | ||||||
| 4 | (e) Records that relate to or affect the security of | ||||||
| 5 | correctional
institutions and detention facilities.
| ||||||
| 6 | (e-5) Records requested by persons committed to the | ||||||
| 7 | Department of Corrections or a county jail if those | ||||||
| 8 | materials are available in the library of the correctional | ||||||
| 9 | facility or jail where the inmate is confined. | ||||||
| 10 | (e-6) Records requested by persons committed to the | ||||||
| 11 | Department of Corrections or a county jail if those | ||||||
| 12 | materials include records from staff members' personnel | ||||||
| 13 | files, staff rosters, or other staffing assignment | ||||||
| 14 | information. | ||||||
| 15 | (e-7) Records requested by persons committed to the | ||||||
| 16 | Department of Corrections if those materials are available | ||||||
| 17 | through an administrative request to the Department of | ||||||
| 18 | Corrections. | ||||||
| 19 | (e-8) Records requested by a person committed to the | ||||||
| 20 | Department of Corrections or a county jail, the disclosure | ||||||
| 21 | of which would result in the risk of harm to any person or | ||||||
| 22 | the risk of an escape from a jail or correctional | ||||||
| 23 | institution or facility. | ||||||
| 24 | (e-9) Records requested by a person in a county jail or | ||||||
| 25 | committed to the Department of Corrections containing | ||||||
| 26 | personal information pertaining to the person's victim or | ||||||
| |||||||
| |||||||
| 1 | the victim's family, including, but not limited to, a | ||||||
| 2 | victim's home address, home telephone number, work or | ||||||
| 3 | school address, work telephone number, social security | ||||||
| 4 | number, or any other identifying information, except as may | ||||||
| 5 | be relevant to a requester's current or potential case or | ||||||
| 6 | claim. | ||||||
| 7 | (e-10) Law enforcement records of other persons | ||||||
| 8 | requested by a person committed to the Department of | ||||||
| 9 | Corrections or a county jail, including, but not limited | ||||||
| 10 | to, arrest and booking records, mug shots, and crime scene | ||||||
| 11 | photographs, except as these records may be relevant to the | ||||||
| 12 | requester's current or potential case or claim. | ||||||
| 13 | (f) Preliminary drafts, notes, recommendations, | ||||||
| 14 | memoranda and other
records in which opinions are | ||||||
| 15 | expressed, or policies or actions are
formulated, except | ||||||
| 16 | that a specific record or relevant portion of a
record | ||||||
| 17 | shall not be exempt when the record is publicly cited
and | ||||||
| 18 | identified by the head of the public body. The exemption | ||||||
| 19 | provided in
this paragraph (f) extends to all those records | ||||||
| 20 | of officers and agencies
of the General Assembly that | ||||||
| 21 | pertain to the preparation of legislative
documents.
| ||||||
| 22 | (g) Trade secrets and commercial or financial | ||||||
| 23 | information obtained from
a person or business where the | ||||||
| 24 | trade secrets or commercial or financial information are | ||||||
| 25 | furnished under a claim that they are
proprietary, | ||||||
| 26 | privileged or confidential, and that disclosure of the | ||||||
| |||||||
| |||||||
| 1 | trade
secrets or commercial or financial information would | ||||||
| 2 | cause competitive harm to the person or business, and only | ||||||
| 3 | insofar as the claim directly applies to the records | ||||||
| 4 | requested. | ||||||
| 5 | The information included under this exemption includes | ||||||
| 6 | all trade secrets and commercial or financial information | ||||||
| 7 | obtained by a public body, including a public pension fund, | ||||||
| 8 | from a private equity fund or a privately held company | ||||||
| 9 | within the investment portfolio of a private equity fund as | ||||||
| 10 | a result of either investing or evaluating a potential | ||||||
| 11 | investment of public funds in a private equity fund. The | ||||||
| 12 | exemption contained in this item does not apply to the | ||||||
| 13 | aggregate financial performance information of a private | ||||||
| 14 | equity fund, nor to the identity of the fund's managers or | ||||||
| 15 | general partners. The exemption contained in this item does | ||||||
| 16 | not apply to the identity of a privately held company | ||||||
| 17 | within the investment portfolio of a private equity fund, | ||||||
| 18 | unless the disclosure of the identity of a privately held | ||||||
| 19 | company may cause competitive harm. | ||||||
| 20 | Nothing contained in this
paragraph (g) shall be | ||||||
| 21 | construed to prevent a person or business from
consenting | ||||||
| 22 | to disclosure.
| ||||||
| 23 | (h) Proposals and bids for any contract, grant, or | ||||||
| 24 | agreement, including
information which if it were | ||||||
| 25 | disclosed would frustrate procurement or give
an advantage | ||||||
| 26 | to any person proposing to enter into a contractor | ||||||
| |||||||
| |||||||
| 1 | agreement
with the body, until an award or final selection | ||||||
| 2 | is made. Information
prepared by or for the body in | ||||||
| 3 | preparation of a bid solicitation shall be
exempt until an | ||||||
| 4 | award or final selection is made.
| ||||||
| 5 | (i) Valuable formulae,
computer geographic systems,
| ||||||
| 6 | designs, drawings and research data obtained or
produced by | ||||||
| 7 | any public body when disclosure could reasonably be | ||||||
| 8 | expected to
produce private gain or public loss.
The | ||||||
| 9 | exemption for "computer geographic systems" provided in | ||||||
| 10 | this paragraph
(i) does not extend to requests made by news | ||||||
| 11 | media as defined in Section 2 of
this Act when the | ||||||
| 12 | requested information is not otherwise exempt and the only
| ||||||
| 13 | purpose of the request is to access and disseminate | ||||||
| 14 | information regarding the
health, safety, welfare, or | ||||||
| 15 | legal rights of the general public.
| ||||||
| 16 | (j) The following information pertaining to | ||||||
| 17 | educational matters: | ||||||
| 18 | (i) test questions, scoring keys and other | ||||||
| 19 | examination data used to
administer an academic | ||||||
| 20 | examination;
| ||||||
| 21 | (ii) information received by a primary or | ||||||
| 22 | secondary school, college, or university under its | ||||||
| 23 | procedures for the evaluation of faculty members by | ||||||
| 24 | their academic peers; | ||||||
| 25 | (iii) information concerning a school or | ||||||
| 26 | university's adjudication of student disciplinary | ||||||
| |||||||
| |||||||
| 1 | cases, but only to the extent that disclosure would | ||||||
| 2 | unavoidably reveal the identity of the student; and | ||||||
| 3 | (iv) course materials or research materials used | ||||||
| 4 | by faculty members. | ||||||
| 5 | (k) Architects' plans, engineers' technical | ||||||
| 6 | submissions, and
other
construction related technical | ||||||
| 7 | documents for
projects not constructed or developed in | ||||||
| 8 | whole or in part with public funds
and the same for | ||||||
| 9 | projects constructed or developed with public funds, | ||||||
| 10 | including but not limited to power generating and | ||||||
| 11 | distribution stations and other transmission and | ||||||
| 12 | distribution facilities, water treatment facilities, | ||||||
| 13 | airport facilities, sport stadiums, convention centers, | ||||||
| 14 | and all government owned, operated, or occupied buildings, | ||||||
| 15 | but
only to the extent
that disclosure would compromise | ||||||
| 16 | security.
| ||||||
| 17 | (l) Minutes of meetings of public bodies closed to the
| ||||||
| 18 | public as provided in the Open Meetings Act until the | ||||||
| 19 | public body
makes the minutes available to the public under | ||||||
| 20 | Section 2.06 of the Open
Meetings Act.
| ||||||
| 21 | (m) Communications between a public body and an | ||||||
| 22 | attorney or auditor
representing the public body that would | ||||||
| 23 | not be subject to discovery in
litigation, and materials | ||||||
| 24 | prepared or compiled by or for a public body in
| ||||||
| 25 | anticipation of a criminal, civil or administrative | ||||||
| 26 | proceeding upon the
request of an attorney advising the | ||||||
| |||||||
| |||||||
| 1 | public body, and materials prepared or
compiled with | ||||||
| 2 | respect to internal audits of public bodies.
| ||||||
| 3 | (n) Records relating to a public body's adjudication of | ||||||
| 4 | employee grievances or disciplinary cases; however, this | ||||||
| 5 | exemption shall not extend to the final outcome of cases in | ||||||
| 6 | which discipline is imposed.
| ||||||
| 7 | (o) Administrative or technical information associated | ||||||
| 8 | with automated
data processing operations, including but | ||||||
| 9 | not limited to software,
operating protocols, computer | ||||||
| 10 | program abstracts, file layouts, source
listings, object | ||||||
| 11 | modules, load modules, user guides, documentation
| ||||||
| 12 | pertaining to all logical and physical design of | ||||||
| 13 | computerized systems,
employee manuals, and any other | ||||||
| 14 | information that, if disclosed, would
jeopardize the | ||||||
| 15 | security of the system or its data or the security of
| ||||||
| 16 | materials exempt under this Section.
| ||||||
| 17 | (p) Records relating to collective negotiating matters
| ||||||
| 18 | between public bodies and their employees or | ||||||
| 19 | representatives, except that
any final contract or | ||||||
| 20 | agreement shall be subject to inspection and copying.
| ||||||
| 21 | (q) Test questions, scoring keys, and other | ||||||
| 22 | examination data used to determine the qualifications of an | ||||||
| 23 | applicant for a license or employment.
| ||||||
| 24 | (r) The records, documents, and information relating | ||||||
| 25 | to real estate
purchase negotiations until those | ||||||
| 26 | negotiations have been completed or
otherwise terminated. | ||||||
| |||||||
| |||||||
| 1 | With regard to a parcel involved in a pending or
actually | ||||||
| 2 | and reasonably contemplated eminent domain proceeding | ||||||
| 3 | under the Eminent Domain Act, records, documents and
| ||||||
| 4 | information relating to that parcel shall be exempt except | ||||||
| 5 | as may be
allowed under discovery rules adopted by the | ||||||
| 6 | Illinois Supreme Court. The
records, documents and | ||||||
| 7 | information relating to a real estate sale shall be
exempt | ||||||
| 8 | until a sale is consummated.
| ||||||
| 9 | (s) Any and all proprietary information and records | ||||||
| 10 | related to the
operation of an intergovernmental risk | ||||||
| 11 | management association or
self-insurance pool or jointly | ||||||
| 12 | self-administered health and accident
cooperative or pool.
| ||||||
| 13 | Insurance or self insurance (including any | ||||||
| 14 | intergovernmental risk management association or self | ||||||
| 15 | insurance pool) claims, loss or risk management | ||||||
| 16 | information, records, data, advice or communications.
| ||||||
| 17 | (t) Information contained in or related to | ||||||
| 18 | examination, operating, or
condition reports prepared by, | ||||||
| 19 | on behalf of, or for the use of a public
body responsible | ||||||
| 20 | for the regulation or supervision of financial
| ||||||
| 21 | institutions or insurance companies, unless disclosure is | ||||||
| 22 | otherwise
required by State law.
| ||||||
| 23 | (u) Information that would disclose
or might lead to | ||||||
| 24 | the disclosure of
secret or confidential information, | ||||||
| 25 | codes, algorithms, programs, or private
keys intended to be | ||||||
| 26 | used to create electronic or digital signatures under the
| ||||||
| |||||||
| |||||||
| 1 | Electronic Commerce Security Act.
| ||||||
| 2 | (v) Vulnerability assessments, security measures, and | ||||||
| 3 | response policies
or plans that are designed to identify, | ||||||
| 4 | prevent, or respond to potential
attacks upon a community's | ||||||
| 5 | population or systems, facilities, or installations,
the | ||||||
| 6 | destruction or contamination of which would constitute a | ||||||
| 7 | clear and present
danger to the health or safety of the | ||||||
| 8 | community, but only to the extent that
disclosure could | ||||||
| 9 | reasonably be expected to jeopardize the effectiveness of | ||||||
| 10 | the
measures or the safety of the personnel who implement | ||||||
| 11 | them or the public.
Information exempt under this item may | ||||||
| 12 | include such things as details
pertaining to the | ||||||
| 13 | mobilization or deployment of personnel or equipment, to | ||||||
| 14 | the
operation of communication systems or protocols, or to | ||||||
| 15 | tactical operations.
| ||||||
| 16 | (w) (Blank). | ||||||
| 17 | (x) Maps and other records regarding the location or | ||||||
| 18 | security of generation, transmission, distribution, | ||||||
| 19 | storage, gathering,
treatment, or switching facilities | ||||||
| 20 | owned by a utility, by a power generator, or by the | ||||||
| 21 | Illinois Power Agency.
| ||||||
| 22 | (y) Information contained in or related to proposals, | ||||||
| 23 | bids, or negotiations related to electric power | ||||||
| 24 | procurement under Section 1-75 of the Illinois Power Agency | ||||||
| 25 | Act and Section 16-111.5 of the Public Utilities Act that | ||||||
| 26 | is determined to be confidential and proprietary by the | ||||||
| |||||||
| |||||||
| 1 | Illinois Power Agency or by the Illinois Commerce | ||||||
| 2 | Commission.
| ||||||
| 3 | (z) Information about students exempted from | ||||||
| 4 | disclosure under Sections 10-20.38 or 34-18.29 of the | ||||||
| 5 | School Code, and information about undergraduate students | ||||||
| 6 | enrolled at an institution of higher education exempted | ||||||
| 7 | from disclosure under Section 25 of the Illinois Credit | ||||||
| 8 | Card Marketing Act of 2009. | ||||||
| 9 | (aa) Information the disclosure of which is
exempted | ||||||
| 10 | under the Viatical Settlements Act of 2009.
| ||||||
| 11 | (bb) Records and information provided to a mortality | ||||||
| 12 | review team and records maintained by a mortality review | ||||||
| 13 | team appointed under the Department of Juvenile Justice | ||||||
| 14 | Mortality Review Team Act. | ||||||
| 15 | (cc) Information regarding interments, entombments, or | ||||||
| 16 | inurnments of human remains that are submitted to the | ||||||
| 17 | Cemetery Oversight Database under the Cemetery Care Act or | ||||||
| 18 | the Cemetery Oversight Act, whichever is applicable. | ||||||
| 19 | (dd) Correspondence and records (i) that may not be | ||||||
| 20 | disclosed under Section 11-9 of the Illinois Public Aid | ||||||
| 21 | Code or (ii) that pertain to appeals under Section 11-8 of | ||||||
| 22 | the Illinois Public Aid Code. | ||||||
| 23 | (ee) The names, addresses, or other personal | ||||||
| 24 | information of persons who are minors and are also | ||||||
| 25 | participants and registrants in programs of park | ||||||
| 26 | districts, forest preserve districts, conservation | ||||||
| |||||||
| |||||||
| 1 | districts, recreation agencies, and special recreation | ||||||
| 2 | associations. | ||||||
| 3 | (ff) The names, addresses, or other personal | ||||||
| 4 | information of participants and registrants in programs of | ||||||
| 5 | park districts, forest preserve districts, conservation | ||||||
| 6 | districts, recreation agencies, and special recreation | ||||||
| 7 | associations where such programs are targeted primarily to | ||||||
| 8 | minors. | ||||||
| 9 | (gg) Confidential information described in Section | ||||||
| 10 | 1-100 of the Illinois Independent Tax Tribunal Act of 2012. | ||||||
| 11 | (hh) The report submitted to the State Board of | ||||||
| 12 | Education by the School Security and Standards Task Force | ||||||
| 13 | under item (8) of subsection (d) of Section 2-3.160 of the | ||||||
| 14 | School Code and any information contained in that report. | ||||||
| 15 | (ii) Records requested by persons committed to or | ||||||
| 16 | detained by the Department of Human Services under the | ||||||
| 17 | Sexually Violent Persons Commitment Act or committed to the | ||||||
| 18 | Department of Corrections under the Sexually Dangerous | ||||||
| 19 | Persons Act if those materials: (i) are available in the | ||||||
| 20 | library of the facility where the individual is confined; | ||||||
| 21 | (ii) include records from staff members' personnel files, | ||||||
| 22 | staff rosters, or other staffing assignment information; | ||||||
| 23 | or (iii) are available through an administrative request to | ||||||
| 24 | the Department of Human Services or the Department of | ||||||
| 25 | Corrections. | ||||||
| 26 | (jj) Confidential information described in Section | ||||||
| |||||||
| |||||||
| 1 | 5-535 of the Civil Administrative Code of Illinois. | ||||||
| 2 | (kk) Information described in Section 20 of the | ||||||
| 3 | Pharmacy Benefits Manager Licensing Act. | ||||||
| 4 | (1.5) Any information exempt from disclosure under the | ||||||
| 5 | Judicial Privacy Act shall be redacted from public records | ||||||
| 6 | prior to disclosure under this Act. | ||||||
| 7 | (2) A public record that is not in the possession of a | ||||||
| 8 | public body but is in the possession of a party with whom the | ||||||
| 9 | agency has contracted to perform a governmental function on | ||||||
| 10 | behalf of the public body, and that directly relates to the | ||||||
| 11 | governmental function and is not otherwise exempt under this | ||||||
| 12 | Act, shall be considered a public record of the public body, | ||||||
| 13 | for purposes of this Act. | ||||||
| 14 | (3) This Section does not authorize withholding of | ||||||
| 15 | information or limit the
availability of records to the public, | ||||||
| 16 | except as stated in this Section or
otherwise provided in this | ||||||
| 17 | Act.
| ||||||
| 18 | (Source: P.A. 99-298, eff. 8-6-15; 99-346, eff. 1-1-16; 99-642, | ||||||
| 19 | eff. 7-28-16; 100-26, eff. 8-4-17; 100-201, eff. 8-18-17.)
| ||||||
| 20 | Section 99. Effective date. This Act takes effect January | ||||||
| 21 | 1, 2019.".
| ||||||
