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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 treatment for certain |
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brain injuries. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1352.001, Insurance Code, is amended to |
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read as follows: |
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Sec. 1352.001. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan, including a small employer |
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health benefit plan written under Chapter 1501, that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) a reciprocal exchange operating under Chapter 942; |
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(6) a Lloyd's plan operating under Chapter 941; |
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(7) a health maintenance organization operating under |
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Chapter 843; |
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(8) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(9) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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(b) Notwithstanding Section 172.014, Local Government Code, |
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or any other law, this chapter applies to health and accident |
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coverage provided by a risk pool created under Chapter 172, Local |
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Government Code. |
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(c) Notwithstanding any provision in Chapter 1551, 1575, |
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1579, or 1601 or any other law, this chapter applies to: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; |
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(3) a primary care coverage plan under Chapter 1579; |
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and |
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(4) basic coverage under Chapter 1601. |
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SECTION 2. Section 1352.003, Insurance Code, is amended to |
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read as follows: |
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Sec. 1352.003. REQUIRED COVERAGES [EXCLUSION OF COVERAGE
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PROHIBITED]. (a) A health benefit plan must include [may not
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exclude] coverage for cognitive rehabilitation therapy, cognitive |
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communication therapy, neurocognitive therapy and rehabilitation, |
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neurobehavioral, neurophysiological, neuropsychological, and [or] |
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psychophysiological testing and [or] treatment, neurofeedback |
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therapy, and remediation required for and related to treatment of |
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an acquired brain injury. |
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(b) A health benefit plan must include coverage for [,] |
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post-acute transition services, [or] community reintegration |
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services, including outpatient day treatment services, or other |
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post-acute care treatment services necessary as a result of and |
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related to an acquired brain injury. |
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(c) A health benefit plan may not include, in any lifetime |
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limitation on the number of days of acute care treatment covered |
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under the plan, any post-acute care treatment covered under the |
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plan. Any limitation imposed under the plan on days of post-acute |
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care treatment must be separately stated in the plan. |
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(d) Except as provided by Subsection (c), a health benefit |
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plan must include the same payment limitations, deductibles, |
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copayments, and coinsurance factors for coverage [(b) Coverage] |
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required under this chapter as [may be subject to deductibles,
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copayments, coinsurance, or annual or maximum payment limits that
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are consistent with the deductibles, copayments, coinsurance, or
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annual or maximum payment limits] applicable to other similar |
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coverage provided under the health benefit plan. |
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(e) To ensure that appropriate post-acute care treatment is |
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provided, a health benefit plan must include coverage for |
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reasonable expenses related to periodic reevaluation of the care of |
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an individual covered under the plan who: |
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(1) has incurred an acquired brain injury; |
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(2) has been unresponsive to treatment; and |
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(3) becomes responsive to treatment at a later date. |
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(f) A determination of whether expenses, as described by |
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Subsection (e), are reasonable may include consideration of factors |
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including: |
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(1) cost; |
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(2) the time that has expired since the previous |
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evaluation; |
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(3) any difference in the expertise of the physician |
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or practitioner performing the evaluation; |
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(4) changes in technology; and |
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(5) advances in medicine. |
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(g) [(c)] The commissioner shall adopt rules as necessary |
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to implement this chapter [section]. |
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SECTION 3. Section 1352.004(b), Insurance Code, is amended |
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to read as follows: |
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(b) The commissioner by rule shall require a health benefit |
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plan issuer to provide adequate training to personnel responsible |
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for preauthorization of coverage or utilization review under the |
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plan. The purpose of the training is to prevent denial of coverage |
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in violation of Section 1352.003 and to avoid confusion of medical |
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benefits with mental health benefits. The commissioner, in |
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consultation with the Texas Traumatic Brain Injury Advisory |
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Council, shall prescribe by rule the basic requirements for the |
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training described by this subsection. |
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SECTION 4. Chapter 1352, Insurance Code, is amended by |
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adding Sections 1352.005, 1352.006, 1352.007, and 1352.008 to read |
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as follows: |
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Sec. 1352.005. NOTICE TO INSUREDS AND ENROLLEES. (a) A |
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health benefit plan issuer subject to this chapter must notify each |
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insured or enrollee under the plan in writing about the coverages |
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described by Section 1352.003. |
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(b) The commissioner, in consultation with the Texas |
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Traumatic Brain Injury Advisory Council, shall prescribe by rule |
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the specific contents and wording of the notice required under this |
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section. |
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(c) The notice required under this section must include: |
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(1) a description of the benefits listed under Section |
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1352.003; |
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(2) a statement that the fact that an acquired brain |
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injury does not result in hospitalization or receipt of a specific |
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treatment or service described by Section 1352.003 for acute care |
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treatment does not affect the right of the insured or enrollee to |
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receive benefits described by Section 1352.003 commensurate with |
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the condition of the insured or enrollee; and |
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(3) a statement of the fact that benefits described by |
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Section 1352.003 may be provided in a facility listed in Section |
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1352.007. |
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(d) The notice described by this section must be provided |
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not later than the 10th day after the date on which the health |
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benefit plan issuer receives a claim for coverage for treatment |
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that would reasonably indicate that the insured or enrollee has |
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incurred an acquired brain injury. |
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Sec. 1352.006. DETERMINATION OF MEDICAL NECESSITY; |
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EXTENSION OF COVERAGE. (a) In this section, "utilization review" |
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has the meaning assigned by Section 4201.002. |
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(b) Notwithstanding Chapter 4201 or any other law relating |
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to the determination of medical necessity under this code, a health |
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benefit plan shall respond to a person requesting utilization |
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review or appealing for an extension of coverage based on an |
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allegation of medical necessity not later than three business days |
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after the date on which the person makes the request or submits the |
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appeal. The person must make the request or submit the appeal in |
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the manner prescribed by the terms of the plan's health insurance |
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policy or agreement, contract, evidence of coverage, or similar |
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coverage document. To comply with the requirements of this |
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section, the health benefit plan issuer must respond through a |
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direct telephone contact made by a representative of the issuer. |
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(c) Notwithstanding Section 4201.152 or any other law of |
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this state, a physician or other health care practitioner who |
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determines the medical necessity of a health care service provided |
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under this chapter to a resident of this state must be licensed to |
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practice in this state. |
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Sec. 1352.007. TREATMENT FACILITIES. A health benefit plan |
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may not deny coverage under this chapter based solely on the fact |
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that the treatment or services are provided at a facility other than |
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a hospital. Treatment for an acquired brain injury may be provided |
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under the coverage required by this chapter, as appropriate, at a |
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facility at which appropriate services may be provided, including: |
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(1) a hospital regulated under Chapter 241, Health and |
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Safety Code, including an acute rehabilitation hospital; |
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(2) an assisted living facility regulated under |
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Chapter 247, Health and Safety Code; |
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(3) a nursing home regulated under Chapter 242, Health |
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and Safety Code; |
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(4) a community home; |
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(5) an acute or post-acute rehabilitation facility, |
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including a residential or outpatient facility; or |
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(6) a medical office. |
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Sec. 1352.008. CONSUMER INFORMATION. The commissioner |
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shall prepare information for use by consumers, purchasers of |
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health benefit plan coverage, and self-insurers regarding |
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coverages recommended for acquired brain injuries. The department |
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shall publish information prepared under this section on the |
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department's Internet website. |
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SECTION 5. This Act applies only to a health benefit plan |
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delivered, issued for delivery, or renewed on or after January 1, |
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2008. A health benefit plan delivered, issued for delivery, or |
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renewed before January 1, 2008, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2007. |