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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for an enrollee with |
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certain mental disorders. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. AMENDMENTS TO SUBCHAPTER A, CHAPTER 1355, |
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INSURANCE CODE |
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SECTION 1.01. Subchapter A, Chapter 1355, Insurance Code, |
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as effective April 1, 2005, is amended to read as follows: |
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SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR |
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CERTAIN [SERIOUS] MENTAL DISORDERS [ILLNESSES] |
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Sec. 1355.001. DEFINITIONS. In this subchapter, "mental |
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disorder"[:
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[(1)"Serious mental illness"] means a disorder [the
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following psychiatric illnesses] as defined by the American |
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Psychiatric Association in the Diagnostic and Statistical Manual of |
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Mental Disorders, fourth edition, or in a subsequent edition of |
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that manual that the commissioner adopts to take the place of the |
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fourth edition or any subsequent edition for the purposes of this |
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subdivision, that results in an impairment of a person's |
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functioning in the person's community, employment, family, school, |
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or social group [(DSM):
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[(A) bipolar disorders (hypomanic, manic,
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depressive, and mixed);
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[(B)depression in childhood and adolescence;
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[(C) major depressive disorders (single episode
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or recurrent);
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[(D)obsessive-compulsive disorders;
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[(E)paranoid and other psychotic disorders;
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[(F)pervasive developmental disorders;
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[(G) schizo-affective disorders (bipolar or
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depressive); and
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[(H)schizophrenia]. |
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[(2) "Small employer" has the meaning assigned by
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Section 1501.002.] |
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Sec. 1355.002. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a [group] health benefit plan that |
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provides benefits for medical or surgical expenses incurred as a |
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result of a health condition, accident, or sickness, including an |
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individual, [:
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[(1)a] group, blanket, or franchise insurance policy |
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or [, group] insurance agreement, a group hospital service |
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contract, an individual or group evidence of coverage, or a similar |
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coverage document, that is offered by: |
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(1) [(A)] an insurance company; |
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(2) [(B)] a group hospital service corporation |
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operating under Chapter 842; |
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(3) [(C)] a fraternal benefit society operating under |
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Chapter 885; |
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(4) [(D)] a stipulated premium company operating |
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under Chapter 884; [or] |
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(5) [(E)] a health maintenance organization operating |
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under Chapter 843; |
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(6) a reciprocal exchange operating under Chapter 942; |
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(7) a Lloyd's plan operating under Chapter 941; |
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(8) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; or [and] |
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(9) [(2) to the extent permitted by the Employee
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Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
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seq.), a plan offered under:
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[(A)] a multiple employer welfare arrangement |
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that holds a certificate of authority under Chapter 846 [as defined
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by Section 3 of that Act; or
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[(B)another analogous benefit arrangement]. |
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(b) This subchapter applies to a small employer health |
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benefit plan written under Chapter 1501. |
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Sec. 1355.003. EXCEPTION. [(a)] This subchapter does not |
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apply to [coverage under]: |
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(1) a plan that provides coverage: |
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(A) only for benefits for a specified disease or |
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for another limited benefit, other than a plan that provides |
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benefits for mental health or similar services; |
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(B) only for accidental death or dismemberment; |
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(C) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(D) as a supplement to a liability insurance |
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policy; |
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(E) only for dental or vision care; |
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(F) only for hospital expenses; or |
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(G) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
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(3) a workers' compensation insurance policy; |
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(4) medical payment insurance coverage provided under |
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an automobile insurance policy; |
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(5) a credit insurance policy; or |
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(6) a long-term care insurance policy, including a |
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nursing home fixed indemnity policy, unless the commissioner |
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determines that the policy provides benefit coverage so |
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comprehensive that the policy is a health benefit plan as described |
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by Section 1355.002 [a blanket accident and health insurance
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policy, as described by Chapter 1251;
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[(2)a short-term travel policy;
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[(3)an accident-only policy;
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[(4) a limited or specified-disease policy that does
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not provide benefits for mental health care or similar services;
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[(5) except as provided by Subsection (b), a plan
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offered under Chapter 1551 or Chapter 1601;
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[(6) a plan offered in accordance with Section
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1355.151; or
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[(7) a Medicare supplement benefit plan, as defined by
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Section 1652.002]. |
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[(b) For the purposes of a plan described by Subsection
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(a)(5), "serious mental illness" has the meaning assigned by
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Section 1355.001.] |
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Sec. 1355.004. REQUIRED COVERAGE [FOR SERIOUS MENTAL
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ILLNESS]. [(a)] A [group] health benefit plan[:
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[(1)] must provide coverage for the diagnosis and |
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treatment of a mental disorder, under the same terms and conditions |
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as coverage provided for the diagnosis and treatment of physical |
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illness[, based on medical necessity, for not less than the
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following treatments of serious mental illness in each calendar
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year:
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[(A)45 days of inpatient treatment; and
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[(B) 60 visits for outpatient treatment,
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including group and individual outpatient treatment;
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[(2) may not include a lifetime limitation on the
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number of days of inpatient treatment or the number of visits for
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outpatient treatment covered under the plan; and
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[(3) must include the same amount limitations,
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deductibles, copayments, and coinsurance factors for serious
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mental illness as the plan includes for physical illness]. |
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[(b)A group health benefit plan issuer:
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[(1) may not count an outpatient visit for medication
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management against the number of outpatient visits required to be
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covered under Subsection (a)(1)(B); and
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[(2) must provide coverage for an outpatient visit
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described by Subsection (a)(1)(B) under the same terms as the
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coverage the issuer provides for an outpatient visit for the
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treatment of physical illness.] |
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Sec. 1355.005. COVERAGE OF INPATIENT STAYS AND OUTPATIENT |
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VISITS. A health benefit plan must cover inpatient stays and |
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outpatient visits under this subchapter under the same terms and |
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conditions as the plan covers inpatient stays and outpatient visits |
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for treatment of a physical illness. [MANAGED CARE PLAN
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AUTHORIZED. A group health benefit plan issuer may provide or
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offer coverage required by Section 1355.004 through a managed care
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plan.] |
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Sec. 1355.006. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS; |
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COINSURANCE. Coverage provided under this subchapter must be |
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subject to the same amount limits, deductibles, copayments, and |
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coinsurance factors as coverage for physical illness. [COVERAGE FOR
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CERTAIN CONDITIONS RELATED TO CONTROLLED SUBSTANCE OR MARIHUANA NOT
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REQUIRED. (a) In this section, "controlled substance" and
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"marihuana" have the meanings assigned by Section 481.002, Health
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and Safety Code.
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[(b) This subchapter does not require a group health benefit
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plan to provide coverage for the treatment of:
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[(1) addiction to a controlled substance or marihuana
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that is used in violation of law; or
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[(2) mental illness that results from the use of a
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controlled substance or marihuana in violation of law.] |
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Sec. 1355.007. RULES. The commissioner shall adopt rules |
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as necessary to implement this article. [SMALL EMPLOYER
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COVERAGE. An issuer of a group health benefit plan to a small
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employer must offer the coverage described by Section 1355.004 to
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the employer but is not required to provide the coverage if the
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employer rejects the coverage.] |
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ARTICLE 2. CONFORMING AMENDMENTS |
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SECTION 2.01. Section 1355.151, Insurance Code, as |
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effective April 1, 2005, is amended to read as follows: |
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Sec. 1355.151. PROHIBITION ON EXCLUSION OR LIMITATION OF |
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CERTAIN COVERAGES. (a) In this section, "mental disorder" |
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["serious mental illness"] has the meaning assigned by Section |
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1355.001. |
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(b) A political subdivision that provides group health |
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insurance coverage, health maintenance organization coverage, or |
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self-insured health care coverage to the political subdivision's |
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officers or employees may not contract for or provide coverage that |
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is less extensive for a mental disorder [serious mental illness] |
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than the coverage provided for any [other] physical illness. |
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SECTION 2.02. Section 1551.003, Insurance Code, is amended |
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by adding Subsection (10-a) to read as follows: |
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(10-a) "Mental disorder" has the meaning assigned by |
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Section 1355.001. |
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SECTION 2.03. Section 1551.205, Insurance Code, is amended |
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to read as follows: |
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Sec. 1551.205. LIMITATIONS. The board of trustees may not |
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contract for or provide a coverage plan that: |
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(1) excludes or limits coverage or services for |
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acquired immune deficiency syndrome, as defined by the Centers for |
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Disease Control and Prevention of the United States Public Health |
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Service, or human immunodeficiency virus infection; |
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(2) provides coverage for a mental disorder [serious
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mental illness] that is less extensive than the coverage provided |
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for any physical illness; or |
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(3) may provide coverage for prescription drugs to |
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assist in stopping smoking at a lower benefit level than is provided |
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for other prescription drugs. |
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SECTION 2.04. Section 1601.109, Insurance Code, is amended |
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to read as follows: |
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Sec. 1601.109. COVERAGE FOR AIDS, HIV, OR [SERIOUS] MENTAL |
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DISORDER [ILLNESS]. (a) In this section, "mental disorder" |
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["serious mental illness"] has the meaning assigned by Section |
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1355.001 [1, Article 3.51-14]. |
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(b) A system may not contract for or provide for group |
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insurance or HMO coverage or provide self-insured coverage, that: |
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(1) excludes or limits coverage or services for |
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acquired immune deficiency syndrome, as defined by the Centers for |
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Disease Control and Prevention of the United States Public Health |
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Service, or human immunodeficiency virus infection; or |
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(2) provides coverage for a mental disorder [serious
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mental illness] that is less extensive than the coverage provided |
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for any [other] physical illness. |
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SECTION 2.05. Section 3(b), Article 3.80, Insurance Code, |
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is amended to read as follows: |
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(b) For purposes of this article, "state-mandated health |
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benefits" does not include benefits that are mandated by federal |
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law or standard provisions or rights required under this code or |
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other laws of this state to be provided in an individual, blanket, |
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or group policy for accident and health insurance that are |
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unrelated to specific health illnesses, injuries, or conditions of |
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an insured, including provisions related to: |
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(1) continuation of coverage under: |
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(A) Subchapters F and G, Chapter 1251 [Section
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1(d)(3) and Section 3B, Article 3.51-6] of this code; |
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(B) Section 1201.059 of this code [2(C), Chapter
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397, Acts of the 54th Legislature, Regular Session, 1955 (Article
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3.70-2, Vernon's Texas Insurance Code)]; and |
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(C) Subchapter B, Chapter 1253 [Article 3.51-8] |
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of this code[; and
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[(D) Section 3C, Article 3.51-6 of this code, as
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added by Section 10, Chapter 1041, Acts of the 71st Legislature,
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Regular Session, 1989]; |
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(2) termination of coverage under Sections 1202.051 |
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and 1501.108 [Articles 3.70-1A, 26.23, and 26.86] of this code; |
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(3) preexisting conditions under Subchapter D, |
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Chapter 1201, and Sections 1501.102-1501.105 [Section 1(H),
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Chapter 397, Acts of the 54th Legislature, Regular Session, 1955
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(Article 3.70-1, Vernon's Texas Insurance Code), and Articles 26.49
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and 26.90] of this code; |
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(4) coverage of children, including newborn or adopted |
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children, under: |
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(A) Subchapter D, Chapter 1251 [Sections 1, 3D,
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and 3E, Article 3.51-6] of this code; |
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(B) Sections 1201.053, 1201.061, |
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1201.063-1201.065, and Subchapter A, Chapter 1367, of this code |
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[2(A), (E), (K), and (M), Chapter 397, Acts of the 54th Legislature,
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Regular Session, 1955 (Article 3.70-2, Vernon's Texas Insurance
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Code)]; |
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(C) Chapter 1504 [Subchapter J, Chapter 3] of |
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this code; |
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(D) Chapter 1503 [Article 21.24-2] of this code; |
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(E) Section 1501.157 [Article 26.21(n)] of this |
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code; |
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(F) Section 1501.158 [Article 26.21A] of this |
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code; and |
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(G) Sections 1501.607-1501.609 [Article 26.84] |
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of this code; |
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(5) services of practitioners under: |
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(A) Subchapters A, B, and C, Chapter 1451 |
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[Article 21.52] of this code; or |
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(B) Section 1301.052 [Article 3.70-3C] of this |
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code[, as added by Chapter 1260, Acts of the 75th Legislature,
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Regular Session, 1997; or
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[(C) Section 2(B), Chapter 397, Acts of the 54th
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Legislature, Regular Session, 1955 (Article 3.70-2, Vernon's Texas
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Insurance Code)]; |
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(6) supplies and services associated with the |
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treatment of diabetes under Subchapter B, Chapter 1358 [Article
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21.53G] of this code; |
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(7) coverage for a mental disorder [serious mental
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illness] under Subchapter A, Chapter 1355 [Article 3.51-14 of this
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code if the standard health benefit plan is issued to a large
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employer as defined by Article 26.02 of this code]; |
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(8) coverage for childhood immunizations and hearing |
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screening as required by: |
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(A) Subchapters B and C, Chapter 1367 [Article
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21.53F] of this code, other than Section 1367.053(c); and |
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(B) Chapter 1353 [as added by Chapter 683, Acts
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of the 75th Legislature, Regular Session, 1997, and Article 21.53K] |
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of this code; |
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(9) coverage for reconstructive surgery for certain |
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craniofacial abnormalities of children as required by Subchapter D, |
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Chapter 1367 [Article 21.53W] of this code; |
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(10) coverage for the dietary treatment of |
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phenylketonuria as required by Chapter 1359 [Article 3.79] of this |
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code; |
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(11) coverage for referral to a non-network physician |
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or provider when medically necessary covered services are not |
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available through network physicians or providers, as required by |
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Section 1271.055 [Article 20A.09(a)(3)(C)] of this code; and |
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(12) coverage for cancer screenings under the |
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following chapters [articles] of this code: |
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(A) Chapter 1356 [Article 3.70-2(H), as added by
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Chapter 1091, Acts of the 70th Legislature, Regular Session, 1987]; |
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(B) Chapter 1362 [Article 21.53F, as added by
|
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Chapter 1287, Acts of the 75th Legislature, Regular Session, 1997]; |
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and |
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(C) Chapter 1363 [Article 21.53S]. |
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SECTION 2.06. Subsection (d), Article 20A.09N, Insurance |
|
Code, is amended to read as follows: |
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(d) For purposes of this section, "state-mandated health |
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benefits" does not include coverage that is mandated by federal law |
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or standard provisions or rights required under the Insurance Code |
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or other law of this state to be provided in an evidence of coverage |
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that are unrelated to specific health illnesses, injuries, or |
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conditions of an insured, including provisions related to: |
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(1) continuation of coverage under Subchapter G, |
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Chapter 1251 [Section 3B, Article 3.51-6], Insurance Code; |
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(2) termination of coverage under Sections 1202.051 |
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and 1501.108 [Articles 3.70-1A, 26.23, and 26.86], Insurance Code; |
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(3) preexisting conditions under Subchapter D, |
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Chapter 1201, Insurance Code, and Sections 1501.102-1501.105, |
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[Section 1(H), Chapter 397, Acts of the 54th Legislature, Regular
|
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Session, 1955 (Article 3.70-1, Vernon's Texas Insurance Code), and
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Articles 26.49 and 26.90,] Insurance Code; |
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(4) coverage of children, including newborn or adopted |
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children, under: |
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(A) Chapter 1504 [Subchapter J, Chapter 3], |
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Insurance Code; |
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(B) Chapter 1503 [Article 21.24-2], Insurance |
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Code; |
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(C) Section 1501.157 [Article 26.21(n)], |
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Insurance Code; |
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(D) Section 1501.158 [Article 26.21A], Insurance |
|
Code; and |
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(E) Sections 1501.607-1501.609 [Article 26.84], |
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Insurance Code; |
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(5) services of providers under Section 843.304, |
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Insurance Code [of this code]; |
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(6) coverage for a mental disorder [serious mental
|
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health illness] under Subchapter A, Chapter 1355 [Article 3.51-14], |
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Insurance Code [, if the standard health benefit plan is issued to a
|
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large employer as defined in Article 26.02, Insurance Code]; and |
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(7) coverage for cancer screenings under the following |
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chapters [articles] of the Insurance Code [this code]: |
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(A) Chapter 1356, Insurance Code [Article
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3.70-2(H), as added by Chapter 1091, Acts of the 70th Legislature,
|
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Regular Session, 1987]; |
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(B) Chapter 1362, Insurance Code [Article
|
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21.53F, as added by Chapter 1287, Acts of the 75th Legislature,
|
|
Regular Session, 1997]; and |
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(C) Chapter 1363, Insurance Code [Article
|
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21.53S]. |
|
SECTION 2.07. Section 1551.003(12), Insurance Code, is |
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repealed. |
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ARTICLE 3. TRANSITION; EFFECTIVE DATE |
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SECTION 3.01. The change in law made by this Act applies |
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only to a health benefit plan delivered, issued for delivery, or |
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renewed on or after January 1, 2008. A health benefit plan |
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delivered, issued for delivery, or renewed before January 1, 2008, |
|
is governed by the law as it existed immediately before the |
|
effective date of this Act, and that law is continued in effect for |
|
that purpose. |
|
SECTION 3.02. To the extent of any conflict, this Act |
|
prevails over another Act of the 80th Legislature, Regular Session, |
|
2007, relating to nonsubstantive additions to and corrections in |
|
enacted codes (the General Code Update bill). |
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SECTION 3.03. This Act takes effect September 1, 2007. |