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A BILL TO BE ENTITLED
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AN ACT
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relating to the provision of durable medical equipment and home |
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health care services through informal and voluntary networks in the |
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workers' compensation system; providing penalties. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subsection (f), Section 408.027, Labor Code, is |
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amended to read as follows: |
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(f) Except as provided by Section 408.0281 or 408.0284, any |
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payment made by an insurance carrier under this section shall be in |
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accordance with the fee guidelines authorized under this subtitle |
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if the health care service is not provided through a workers' |
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compensation health care network under Chapter 1305, Insurance |
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Code, or at a contracted rate for that health care service if the |
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health care service is provided through a workers' compensation |
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health care network under Chapter 1305, Insurance Code. |
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SECTION 2. Subsection (a), Section 408.0282, Labor Code, is |
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amended to read as follows: |
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(a) Each informal or voluntary network described by Section |
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408.0281 or 408.0284 shall, not later than the 30th day after the |
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date the network is established, report the following information |
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to the division: |
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(1) the name of the informal or voluntary network and |
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federal employer identification number; |
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(2) an executive contact for official correspondence |
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for the informal or voluntary network; |
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(3) a toll-free telephone number by which a health |
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care provider may contact the informal or voluntary network; |
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(4) a list of each insurance carrier with whom the |
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informal or voluntary network contracts, including the carrier's |
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federal employer identification number; and |
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(5) a list of, and contact information for, each |
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entity with which the informal or voluntary network has a contract |
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or other business relationship that benefits or is entered into on |
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behalf of an insurance carrier, including an insurance carrier's |
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authorized agent or a subsidiary or other affiliate of the network. |
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SECTION 3. Subchapter B, Chapter 408, Labor Code, is |
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amended by adding Section 408.0284 to read as follows: |
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Sec. 408.0284. REIMBURSEMENT FOR DURABLE MEDICAL EQUIPMENT |
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AND HOME HEALTH CARE SERVICES; ADMINISTRATIVE VIOLATION. (a) In |
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this section: |
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(1) "Durable medical equipment" includes prosthetics |
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and orthotic devices and related medical equipment and supplies. |
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The term does not include: |
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(A) an object or device that is surgically |
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implanted, embedded, inserted, or otherwise applied; |
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(B) related equipment necessary to operate, |
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program, or recharge the object or device described by Paragraph |
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(A); or |
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(C) an intrathecal pump. |
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(2) "Informal network" means a network that: |
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(A) is established under a contract between an |
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insurance carrier or an insurance carrier's authorized agent and a |
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health care provider for the provision of durable medical equipment |
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or home health care services; and |
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(B) includes a specific fee schedule. |
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(3) "Voluntary network" means a voluntary workers' |
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compensation health care delivery network established under former |
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Section 408.0223, as that section existed before repeal by Chapter |
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265 (House Bill No. 7), Acts of the 79th Legislature, Regular |
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Session, 2005, by an insurance carrier for the provision of durable |
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medical equipment or home health care services. |
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(b) Notwithstanding any provision of Chapter 1305, |
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Insurance Code, or Section 504.053 of this code, durable medical |
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equipment and home health care services may be reimbursed in |
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accordance with the fee guidelines adopted by the commissioner or |
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at a voluntarily negotiated contract rate in accordance with this |
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section. |
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(c) Notwithstanding any other provision of this title or any |
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provision of Chapter 1305, Insurance Code, an insurance carrier may |
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pay a health care provider fees for durable medical equipment or |
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home health care services that are inconsistent with the fee |
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guidelines adopted by the commissioner only if the carrier or the |
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carrier's authorized agent has a contract with the health care |
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provider and that contract includes a specific fee schedule. An |
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insurance carrier or the carrier's authorized agent may use an |
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informal or voluntary network to obtain a contractual agreement |
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that provides for fees different from the fees authorized under the |
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fee guidelines adopted by the commissioner for durable medical |
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equipment or home health care services. If a carrier or the |
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carrier's authorized agent chooses to use an informal or voluntary |
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network to obtain a contractual fee arrangement, there must be a |
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contractual arrangement between: |
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(1) the carrier or authorized agent and the informal |
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or voluntary network that authorizes the network to contract with |
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health care providers for durable medical equipment or home health |
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care services on the carrier's behalf; and |
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(2) the informal or voluntary network and the health |
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care provider that includes a specific fee schedule and complies |
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with the notice requirements of this section. |
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(d) An informal or voluntary network, or the carrier or the |
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carrier's authorized agent shall, at least quarterly, notify each |
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health care provider of any person, other than an injured employee, |
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to which the network's contractual fee arrangements with the health |
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care provider are sold, leased, transferred, or conveyed. Notice |
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to each health care provider: |
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(1) must include: |
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(A) the contact information for the network, |
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including the name, physical address, and toll-free telephone |
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number at which a health care provider with which the network has a |
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contract may contact the network; and |
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(B) in the body of the notice: |
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(i) the name, physical address, and |
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telephone number of any person, other than an injured employee, to |
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which the network's contractual fee arrangement with the health |
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care provider is sold, leased, transferred, or conveyed; and |
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(ii) the start date and any end date of the |
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period during which the network's contractual fee arrangement with |
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the health care provider is sold, leased, transferred, or conveyed; |
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and |
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(2) may be provided: |
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(A) in an electronic format, if a paper version |
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is available on request by the division; and |
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(B) through an Internet website link, but only if |
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the website: |
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(i) contains the information described by |
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Subdivision (1); and |
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(ii) is updated at least monthly with |
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current and correct information. |
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(e) An informal or voluntary network, or the carrier or the |
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carrier's authorized agent, as appropriate, shall document the |
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delivery of the notice required under Subsection (d), including the |
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method of delivery, to whom the notice was delivered, and the date |
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of delivery. For purposes of Subsection (d), a notice is considered |
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to be delivered on, as applicable: |
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(1) the fifth day after the date the notice is mailed |
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via United States Postal Service; or |
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(2) the date the notice is faxed or electronically |
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delivered. |
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(f) An insurance carrier, or the carrier's authorized agent |
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or an informal or voluntary network at the carrier's request, shall |
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provide copies of each contract described by Subsection (c) to the |
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division on the request of the division. Information included in a |
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contract under Subsection (c) is confidential and is not subject to |
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disclosure under Chapter 552, Government Code. Notwithstanding |
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Subsection (c), the insurance carrier may be required to pay fees in |
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accordance with the division's fee guidelines if: |
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(1) the contract: |
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(A) is not provided to the division on the |
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division's request; |
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(B) does not include a specific fee schedule |
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consistent with Subsection (c); or |
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(C) does not clearly state that the contractual |
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fee arrangement is between the health care provider and the named |
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insurance carrier or the carrier's authorized agent; or |
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(2) the carrier or the carrier's authorized agent does |
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not comply with the notice requirements under Subsection (d). |
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(g) Failure to provide documentation described by |
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Subsection (e) to the division on the request of the division or |
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failure to provide notice as required under Subsection (d) creates |
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a rebuttable presumption in an enforcement action under this |
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subtitle and in a medical fee dispute under Chapter 413 that a |
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health care provider did not receive the notice. |
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(h) An insurance carrier or the carrier's authorized agent |
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commits an administrative violation if the carrier or agent |
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violates any provision of this section. Any administrative penalty |
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assessed under this subsection shall be assessed against the |
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carrier, regardless of whether the carrier or agent committed the |
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violation. |
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(i) Notwithstanding Section 1305.003(b), Insurance Code, in |
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the event of a conflict between this section and Section 413.016 or |
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any other provision of Chapter 413 of this code or Chapter 1305, |
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Insurance Code, this section prevails. |
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SECTION 4. Each informal or voluntary network described by |
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Section 408.0284, Labor Code, as added by this Act, that has a |
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contract between an insurance carrier or an insurance carrier's |
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authorized agent and a health care provider that is in effect on the |
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effective date of this Act shall file the report described by |
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Subsection (a), Section 408.0282, Labor Code, as amended by this |
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Act, not later than the 30th day after the effective date of this |
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Act. |
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SECTION 5. With respect to a contractual agreement that |
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provides for fees for durable medical equipment or home health care |
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services that are different from the fees authorized under the fee |
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guidelines adopted by the commissioner of workers' compensation |
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under Title 5, Labor Code, and that is entered into after the |
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effective date of this Act, the notice required under Subsection |
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(d), Section 408.0284, Labor Code, as added by this Act, shall be |
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sent not later than the 30th day after the effective date of the |
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contract, and subsequent notices required under that section shall |
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be sent on a quarterly basis. |
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SECTION 6. If any provision of this Act or its application |
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to any person or circumstance is held invalid, the invalidity does |
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not affect other provisions or applications of this Act that can be |
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given effect without the invalid provision or application, and to |
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this end the provisions of this Act are severable. |
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SECTION 7. This Act takes effect September 1, 2013. |