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A BILL TO BE ENTITLED
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AN ACT
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relating to unlawful acts against and criminal offenses involving |
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the Medicaid program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 36.002, Human Resources Code, is amended |
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to read as follows: |
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Sec. 36.002. UNLAWFUL ACTS. A person commits an unlawful |
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act if the person: |
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(1) knowingly makes or causes to be made a false |
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statement or misrepresentation of a material fact to permit a |
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person to receive a benefit or payment under the Medicaid program |
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that is not authorized or that is greater than the benefit or |
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payment that is authorized; |
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(2) knowingly conceals or fails to disclose |
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information that permits a person to receive a benefit or payment |
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under the Medicaid program that is not authorized or that is greater |
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than the benefit or payment that is authorized; |
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(3) knowingly applies for and receives a benefit or |
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payment on behalf of another person under the Medicaid program and |
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converts any part of the benefit or payment to a use other than for |
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the benefit of the person on whose behalf it was received; |
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(4) knowingly makes, causes to be made, induces, or |
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seeks to induce the making of a false statement or |
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misrepresentation of material fact concerning: |
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(A) the conditions or operation of a facility in |
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order that the facility may qualify for certification or |
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recertification required by the Medicaid program, including |
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certification or recertification as: |
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(i) a hospital; |
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(ii) a nursing facility or skilled nursing |
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facility; |
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(iii) a hospice; |
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(iv) an intermediate care facility for the |
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mentally retarded; |
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(v) an assisted living facility; or |
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(vi) a home health agency; or |
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(B) information required to be provided by a |
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federal or state law, rule, regulation, or provider agreement |
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pertaining to the Medicaid program; |
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(5) except as authorized under the Medicaid program, |
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knowingly pays, charges, solicits, accepts, or receives, in |
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addition to an amount paid under the Medicaid program, a gift, |
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money, a donation, or other consideration as a condition to the |
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provision of a service or product or the continued provision of a |
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service or product if the cost of the service or product is paid |
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for, in whole or in part, under the Medicaid program; |
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(6) knowingly presents or causes to be presented a |
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claim for payment under the Medicaid program for a product provided |
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or a service rendered by a person who: |
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(A) is not licensed to provide the product or |
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render the service, if a license is required; or |
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(B) is not licensed in the manner claimed; |
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(7) knowingly makes or causes to be made a claim under |
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the Medicaid program for: |
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(A) a service or product that has not been |
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approved or acquiesced in by a treating physician or health care |
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practitioner; |
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(B) a service or product that is substantially |
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inadequate or inappropriate when compared to generally recognized |
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standards within the particular discipline or within the health |
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care industry; or |
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(C) a product that has been adulterated, debased, |
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mislabeled, or that is otherwise inappropriate; |
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(8) makes a claim under the Medicaid program and |
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knowingly fails to indicate the type of license and the |
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identification number of the licensed health care provider who |
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actually provided the service; |
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(9) conspires to commit a violation of Subdivision |
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(1), (2), (3), (4), (5), (6), (7), (8), (10), (11), (12), or (13) |
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[knowingly enters into an agreement, combination, or conspiracy to
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defraud the state by obtaining or aiding another person in
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obtaining an unauthorized payment or benefit from the Medicaid
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program or a fiscal agent]; |
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(10) is a managed care organization that contracts |
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with the Health and Human Services Commission or other state agency |
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to provide or arrange to provide health care benefits or services to |
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individuals eligible under the Medicaid program and knowingly: |
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(A) fails to provide to an individual a health |
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care benefit or service that the organization is required to |
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provide under the contract; |
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(B) fails to provide to the commission or |
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appropriate state agency information required to be provided by |
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law, commission or agency rule, or contractual provision; or |
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(C) engages in a fraudulent activity in |
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connection with the enrollment of an individual eligible under the |
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Medicaid program in the organization's managed care plan or in |
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connection with marketing the organization's services to an |
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individual eligible under the Medicaid program; |
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(11) knowingly obstructs an investigation by the |
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attorney general of an alleged unlawful act under this section; |
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(12) knowingly makes, uses, or causes the making or |
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use of a false record or statement material to [conceal, avoid, or
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decrease] an obligation to pay or transmit money or property to this |
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state under the Medicaid program, or knowingly conceals or |
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knowingly and improperly avoids or decreases an obligation to pay |
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or transmit money or property to this state under the Medicaid |
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program; or |
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(13) knowingly engages in conduct that constitutes a |
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violation under Section 32.039(b). |
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SECTION 2. Subsection (b), Section 36.104, Human Resources |
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Code, is amended to read as follows: |
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(b) If the state declines to take over the action, the |
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person bringing the action may proceed without the state's |
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participation. On request by the state, the state is entitled to be |
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served with copies of all pleadings filed in the action and be |
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provided at the state's expense with copies of all deposition |
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transcripts. If the person bringing the action proceeds without |
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the state's participation, the court, without limiting the status |
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and right of that person, may permit the state to intervene at a |
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later date on a showing of good cause. A person pursuing an action |
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under this subsection may file suit for claims that accrued on or |
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after September 1, 1995, the effective date of this statute. |
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SECTION 3. Subsections (b) and (c), Section 36.110, Human |
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Resources Code, are amended to read as follows: |
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(b) If the court finds that the action is based primarily on |
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disclosures of specific information, other than information |
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provided by the person bringing the action, relating to allegations |
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or transactions in a state criminal or civil hearing, in a state |
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legislative or administrative report, hearing, audit, or |
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investigation, or from the news media, the court may award the |
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amount the court considers appropriate but not more than 10 [seven] |
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percent of the proceeds of the action. The court shall consider the |
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significance of the information and the role of the person bringing |
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the action in advancing the case to litigation. |
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(c) A payment to a person under this section shall be made |
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from the proceeds of the action. A person receiving a payment under |
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this section is also entitled to receive from the defendant an |
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amount for reasonable expenses, reasonable attorney's fees, and |
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costs that the court finds to have been necessarily incurred. The |
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court's determination of expenses, fees, and costs to be awarded |
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under this subsection shall be made only after the defendant has |
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been found liable in the action or the claim is settled [state
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settles an action with a defendant that the court determined, after
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a hearing, was fair, adequate, and reasonable in accordance with
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Section 36.107(c)]. |
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SECTION 4. Subsection (b), Section 36.113, Human Resources |
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Code, is amended to read as follows: |
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(b) The court shall dismiss [A person may not bring] an |
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action or claim under this subchapter, unless opposed by the |
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attorney general, if substantially the same [that is based on the
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public disclosure of] allegations or transactions as alleged in the |
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action or claim were publicly disclosed in a state criminal or civil |
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hearing in which the state or an agent of the state is a party, in a |
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state legislative or administrative report, or other state hearing, |
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audit, or investigation, or from the news media, unless the person |
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bringing the action is an original source of the information. In |
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this subsection, "original source" means an individual who: |
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(1) prior to a public disclosure under this |
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subsection, has voluntarily disclosed to the state the information |
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on which allegations or transactions in a claim are based [has
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direct and independent knowledge of the information on which the
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allegations are based and has voluntarily provided the information
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to the state before filing an action under this subchapter that is
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based on the information]; or |
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(2) has knowledge that is independent of and |
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materially adds to the publicly disclosed allegation or |
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transactions [allegations] and who has voluntarily provided the |
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information to the state before filing an action under this |
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subchapter [that is based on the information]. |
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SECTION 5. Section 36.115, Human Resources Code, is amended |
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by amending Subsection (a) and adding Subsection (c) to read as |
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follows: |
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(a) A person, including an employee, contractor, or agent, |
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who is discharged, demoted, suspended, threatened, harassed, or in |
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any other manner discriminated against in the terms and conditions |
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of employment because of a lawful act taken by the person or |
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associated others in furtherance of an action under this |
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subchapter, including investigation for, initiation of, testimony |
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for, or assistance in an action filed or to be filed under this |
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subchapter, or other efforts taken by the person to stop one or more |
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violations of Section 36.002 is entitled to: |
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(1) reinstatement with the same seniority status the |
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person would have had but for the discrimination; and |
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(2) not less than two times the amount of back pay, |
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interest on the back pay, and compensation for any special damages |
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sustained as a result of the discrimination, including litigation |
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costs and reasonable attorney's fees. |
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(c) A person must bring suit on an action under this section |
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not later than the third anniversary of the date on which the cause |
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of action accrues. For purposes of this section, the cause of |
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action accrues on the date the retaliation occurs. |
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SECTION 6. Subsection (c), Section 36.113, Human Resources |
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Code, is repealed. |
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SECTION 7. The changes in law made by this Act to Section |
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36.002, Human Resources Code, apply only to conduct that occurs on |
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or after the effective date of this Act. Conduct that occurs before |
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the effective date of this Act is governed by the law in effect at |
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the time the conduct occurred, and that law is continued in effect |
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for that purpose. |
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SECTION 8. The changes in law made by this Act to Sections |
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36.110 and 36.113, Human Resources Code, apply only to a civil |
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action for a violation of Section 36.002, Human Resources Code, as |
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amended by this Act, commenced on or after the effective date of |
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this Act. A civil action commenced before the effective date of |
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this Act is governed by the law in effect immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 9. The changes in law made by this Act to Section |
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36.115, Human Resources Code, apply only to a cause of action that |
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accrues on or after the effective date of this Act. A cause of |
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action that accrued before the effective date of this Act is |
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governed by the law applicable to the cause of action immediately |
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before the effective date of this Act, and that law is continued in |
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effect for that purpose. |
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SECTION 10. This Act takes effect September 1, 2013. |
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