148
TITLE 
II—APPLICATION 
OF
QUALITY CARE STANDARDS
TO GROUP HEALTH PLANS
AND 
HEALTH 
INSURANCE
COVERAGE UNDER THE PUB-
LIC HEALTH SERVICE ACT
SEC. 201. APPLICATION TO GROUP HEALTH PLANS AND
GROUP HEALTH INSURANCE COVERAGE.
(a) IN GENERAL.—Subpart 2 of part A of title
XXVII of the Public Health Service Act is amended by
adding at the end the following new section:
‘‘SEC. 2707. PATIENT PROTECTION STANDARDS.
‘‘Each group health plan shall comply with patient
protection requirements under title I of the Bipartisan Pa-
tient Protection Act, and each health insurance issuer
shall comply with patient protection requirements under
such title with respect to group health insurance coverage
it offers, and such requirements shall be deemed to be in-
corporated into this subsection.’’.
(b) 
CONFORMING
AMENDMENT.—Section
2721(b)(2)(A) of such Act (42 U.S.C. 300gg–21(b)(2)(A))
is amended by inserting ‘‘(other than section 2707)’’ after
‘‘requirements of such subparts’’.
149
SEC. 202. APPLICATION TO INDIVIDUAL HEALTH INSUR-
ANCE COVERAGE.
Part B of title XXVII of the Public Health Service
Act is amended by inserting after section 2752 the fol-
lowing new section:
‘‘SEC. 2753. PATIENT PROTECTION STANDARDS.
‘‘Each health insurance issuer shall comply with pa-
tient protection requirements under title I of the Bipar-
tisan Patient Protection Act with respect to individual
health insurance coverage it offers, and such requirements
shall be deemed to be incorporated into this subsection.’’.
SEC. 203. COOPERATION BETWEEN FEDERAL AND STATE
AUTHORITIES.
Part C of title XXVII of the Public Health Service
Act (42 U.S.C. 300gg–91 et seq.) is amended by adding
at the end the following:
‘‘SEC. 2793. COOPERATION BETWEEN FEDERAL AND STATE
AUTHORITIES.
‘‘(a) AGREEMENT WITH STATES.—A State may enter
into an agreement with the Secretary for the delegation
to the State of some or all of the Secretary’s authority
under this title to enforce the requirements applicable
under title I of the Bipartisan Patient Protection Act with
respect to health insurance coverage offered by a health
insurance issuer and with respect to a group health plan
that is a non-Federal governmental plan.
150
‘‘(b) DELEGATIONS.—Any department, agency, or in-
strumentality of a State to which authority is delegated
pursuant to an agreement entered into under this section
may, if authorized under State law and to the extent con-
sistent with such agreement, exercise the powers of the
Secretary under this title which relate to such authority.’’.
TITLE III—APPLICATION OF PA-
TIENT PROTECTION STAND-
ARDS TO FEDERAL HEALTH
INSURANCE PROGRAMS
SEC. 301. APPLICATION OF PATIENT PROTECTION STAND-
ARDS TO FEDERAL HEALTH INSURANCE PRO-
GRAMS.
(a) SENSE OF CONGRESS.—It is the sense of Con-
gress that enrollees in Federal health insurance programs
should have the same rights and privileges as those af-
forded under title I and under the amendments made by
title IV to participants and beneficiaries under group
health plans.
(b) CONFORMING FEDERAL HEALTH INSURANCE
PROGRAMS.—It is the sense of Congress that the Presi-
dent should require, by executive order, the Federal offi-
cial with authority over each Federal health insurance pro-
gram, to the extent feasible, to take such steps as are nec-
151
essary to implement the rights and privileges described in
subsection (a) with respect to such program.
(c) GAO REPORT
ON
ADDITIONAL
STEPS
RE-
QUIRED.—Not later than 1 year after the date of the en-
actment of this Act, the Comptroller General of the United
States shall submit to Congress a report on statutory
changes that are required to implement such rights and
privileges in a manner that is consistent with the missions
of the Federal health insurance programs and that avoids
unnecessary duplication or disruption of such programs.
(d) FEDERAL HEALTH INSURANCE PROGRAM.—In
this section, the term ‘‘Federal health insurance program’’
means a Federal program that provides creditable cov-
erage (as defined in section 2701(c)(1) of the Public
Health Service Act) and includes a health program of the
Department of Veterans Affairs.
152
TITLE IV—AMENDMENTS TO THE
EMPLOYEE RETIREMENT IN-
COME SECURITY ACT OF 1974
SEC. 401. APPLICATION OF PATIENT PROTECTION STAND-
ARDS TO GROUP HEALTH PLANS AND GROUP
HEALTH INSURANCE COVERAGE UNDER THE
EMPLOYEE RETIREMENT INCOME SECURITY
ACT OF 1974.
Subpart B of part 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 is
amended by adding at the end the following new section:
‘‘SEC. 714. PATIENT PROTECTION STANDARDS.
‘‘(a) IN GENERAL.—Subject to subsection (b), a
group health plan (and a health insurance issuer offering
group health insurance coverage in connection with such
a plan) shall comply with the requirements of title I of
the Bipartisan Patient Protection Act (as in effect as of
the date of the enactment of such Act), and such require-
ments shall be deemed to be incorporated into this sub-
section.
‘‘(b) PLAN SATISFACTION OF CERTAIN REQUIRE-
MENTS.—
‘‘(1) SATISFACTION
OF
CERTAIN
REQUIRE-
MENTS
THROUGH
INSURANCE.—For purposes of
subsection (a), insofar as a group health plan pro-
153
vides benefits in the form of health insurance cov-
erage through a health insurance issuer, the plan
shall be treated as meeting the following require-
ments of title I of the Bipartisan Patient Protection
Act with respect to such benefits and not be consid-
ered as failing to meet such requirements because of
a failure of the issuer to meet such requirements so
long as the plan sponsor or its representatives did
not cause such failure by the issuer:
‘‘(A) Section 111 (relating to consumer
choice option).
‘‘(B) Section 112 (relating to choice of
health care professional).
‘‘(C) Section 113 (relating to access to
emergency care).
‘‘(D) Section 114 (relating to timely access
to specialists).
‘‘(E) Section 115 (relating to patient ac-
cess to obstetrical and gynecological care).
‘‘(F) Section 116 (relating to access to pe-
diatric care).
‘‘(G) Section 117 (relating to continuity of
care), but only insofar as a replacement issuer
assumes the obligation for continuity of care.
155
‘‘(3) INTERNAL APPEALS.—With respect to the
internal appeals process required to be established
under section 103 of such Act, in the case of a
group health plan that provides benefits in the form
of health insurance coverage through a health insur-
ance issuer, the Secretary shall determine the cir-
cumstances under which the plan is not required to
provide for such process and system (and is not lia-
ble for the issuer’s failure to provide for such proc-
ess and system), if the issuer is obligated to provide
for (and provides for) such process and system.
‘‘(4) EXTERNAL APPEALS.—Pursuant to rules
of the Secretary, insofar as a group health plan en-
ters into a contract with a qualified external appeal
entity for the conduct of external appeal activities in
accordance with section 104 of such Act, the plan
shall be treated as meeting the requirement of such
section and is not liable for the entity’s failure to
meet any requirements under such section.
‘‘(5) APPLICATION TO PROHIBITIONS.—Pursu-
ant to rules of the Secretary, if a health insurance
issuer offers health insurance coverage in connection
with a group health plan and takes an action in vio-
lation of any of the following sections of the Bipar-
tisan Patient Protection Act, the group health plan
156
shall not be liable for such violation unless the plan
caused such violation:
‘‘(A) Section 131 (relating to prohibition of
interference with certain medical communica-
tions).
‘‘(B) Section 132 (relating to prohibition
of discrimination against providers based on li-
censure).
‘‘(C) Section 133 (relating to prohibition
against improper incentive arrangements).
‘‘(D) Section 135 (relating to protection
for patient advocacy).
‘‘(6) CONSTRUCTION.—Nothing in this sub-
section shall be construed to affect or modify the re-
sponsibilities of the fiduciaries of a group health
plan under part 4 of subtitle B.
‘‘(7) TREATMENT OF SUBSTANTIALLY COMPLI-
ANT STATE LAWS.—For purposes of applying this
subsection in connection with health insurance cov-
erage, any reference in this subsection to a require-
ment in a section or other provision in the Bipar-
tisan Patient Protection Act with respect to a health
insurance issuer is deemed to include a reference to
a requirement under a State law that substantially
complies (as determined under section 152(c) of
157
such Act) with the requirement in such section or
other provisions.
‘‘(8) APPLICATION TO CERTAIN PROHIBITIONS
AGAINST RETALIATION.—With respect to compliance
with the requirements of section 135(b)(1) of the Bi-
partisan Patient Protection Act, for purposes of this
subtitle the term ‘group health plan’ is deemed to in-
clude a reference to an institutional health care pro-
vider.
‘‘(c) ENFORCEMENT OF CERTAIN REQUIREMENTS.—
‘‘(1) COMPLAINTS.—Any protected health care
professional who believes that the professional has
been retaliated or discriminated against in violation
of section 135(b)(1) of the Bipartisan Patient Pro-
tection Act may file with the Secretary a complaint
within 180 days of the date of the alleged retaliation
or discrimination.
‘‘(2) INVESTIGATION.—The Secretary shall in-
vestigate such complaints and shall determine if a
violation of such section has occurred and, if so,
shall issue an order to ensure that the protected
health care professional does not suffer any loss of
position, pay, or benefits in relation to the plan,
issuer, or provider involved, as a result of the viola-
tion found by the Secretary.
158
‘‘(d) CONFORMING REGULATIONS.—The Secretary
shall issue regulations to coordinate the requirements on
group health plans and health insurance issuers under this
section with the requirements imposed under the other
provisions of this title. In order to reduce duplication and
clarify the rights of participants and beneficiaries with re-
spect to information that is required to be provided, such
regulations shall coordinate the information disclosure re-
quirements under section 121 of the Bipartisan Patient
Protection Act with the reporting and disclosure require-
ments imposed under part 1, so long as such coordination
does not result in any reduction in the information that
would otherwise be provided to participants and bene-
ficiaries.’’.
(b) SATISFACTION OF ERISA CLAIMS PROCEDURE
REQUIREMENT.—Section 503 of such Act (29 U.S.C.
1133) is amended by inserting ‘‘(a)’’ after ‘‘SEC. 503.’’
and by adding at the end the following new subsection:
‘‘(b) In the case of a group health plan (as defined
in section 733), compliance with the requirements of sub-
title A of title I of the Bipartisan Patient Protection Act,
and compliance with regulations promulgated by the Sec-
retary, in the case of a claims denial, shall be deemed com-
pliance with subsection (a) with respect to such claims de-
nial.’’.
159
(c) CONFORMING AMENDMENTS.—(1) Section 732(a)
of such Act (29 U.S.C. 1185(a)) is amended by striking
‘‘section 711’’ and inserting ‘‘sections 711 and 714’’.
(2) The table of contents in section 1 of such Act
is amended by inserting after the item relating to section
713 the following new item:
‘‘Sec. 714. Patient protection standards.’’.
(3) Section 502(b)(3) of such Act (29 U.S.C.
1132(b)(3)) is amended by inserting ‘‘(other than section
135(b))’’ after ‘‘part 7’’.
SEC. 402. AVAILABILITY OF CIVIL REMEDIES.
(a) AVAILABILITY OF FEDERAL CIVIL REMEDIES IN
CASES NOT INVOLVING MEDICALLY REVIEWABLE DECI-
SIONS.—
(1) IN GENERAL.—Section 502 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1132) is amended by adding at the end the following
new subsections:
‘‘(n) CAUSE OF ACTION RELATING TO PROVISION OF
HEALTH BENEFITS.—
‘‘(1) IN GENERAL.—In any case in which—
‘‘(A) a person who is a fiduciary of a
group health plan, a health insurance issuer of-
fering health insurance coverage in connection
with the plan, or an agent of the plan, issuer,
or plan sponsor, upon consideration of a claim
160
for benefits of a participant or beneficiary
under section 102 of the Bipartisan Patient
Protection Act (relating to procedures for initial
claims for benefits and prior authorization de-
terminations) or upon review of a denial of such
a claim under section 103 of such Act (relating
to internal appeal of a denial of a claim for ben-
efits), fails to exercise ordinary care in making
a decision—
‘‘(i) regarding whether an item or
service is covered under the terms and con-
ditions of the plan or coverage,
‘‘(ii) regarding whether an individual
is a participant or beneficiary who is en-
rolled under the terms and conditions of
the plan or coverage (including the applica-
bility of any waiting period under the plan
or coverage), or
‘‘(iii) as to the application of cost-
sharing requirements or the application of
a specific exclusion or express limitation on
the amount, duration, or scope of coverage
of items or services under the terms and
conditions of the plan or coverage, and
161
‘‘(B) such failure is a proximate cause of
personal injury to, or the death of, the partici-
pant or beneficiary,
such plan, plan sponsor, or issuer shall be liable to
the participant or beneficiary (or the estate of such
participant or beneficiary) for economic and non-
economic damages (but not exemplary or punitive
damages) in connection with such personal injury or
death.
‘‘(2) CAUSE
OF
ACTION
MUST
NOT
INVOLVE
MEDICALLY REVIEWABLE DECISION.—
‘‘(A) IN GENERAL.—A cause of action is
established under paragraph (1)(A) only if the
decision referred to in paragraph (1)(A) does
not include a medically reviewable decision.
‘‘(B) 
MEDICALLY
REVIEWABLE
DECI-
SION.—For purposes of this subsection, the
term ‘medically reviewable decision’ means a de-
nial of a claim for benefits under the plan
which is described in section 104(d)(2) of the
Bipartisan Patient Protection Act (relating to
medically reviewable decisions).
‘‘(3) LIMITATION REGARDING CERTAIN TYPES
OF ACTIONS SAVED FROM PREEMPTION OF STATE
LAW.—A cause of action is not established under
162
paragraph (1)(A) in connection with a failure de-
scribed in paragraph (1)(A) to the extent that a
cause of action under State law (as defined in sec-
tion 514(c)) for such failure would not be preempted
under section 514.
‘‘(4) DEFINITIONS AND RELATED RULES.—For
purposes of this subsection.—
‘‘(A) ORDINARY
CARE.—The term ‘ordi-
nary care’ means, with respect to a determina-
tion on a claim for benefits, that degree of care,
skill, and diligence that a reasonable and pru-
dent individual would exercise in making a fair
determination on a claim for benefits of like
kind to the claims involved.
‘‘(B) PERSONAL INJURY.—The term ‘per-
sonal injury’ means a physical injury and in-
cludes an injury arising out of the treatment
(or failure to treat) a mental illness or disease.
‘‘(C) CLAIM FOR BENEFITS; DENIAL.—The
terms ‘claim for benefits’ and ‘denial of a claim
for benefits’ have the meanings provided such
terms in section 102(e) of the Bipartisan Pa-
tient Protection Act.
‘‘(D) TERMS AND CONDITIONS.—The term
‘terms and conditions’ includes, with respect to
163
a group health plan or health insurance cov-
erage, requirements imposed under title I of the
Bipartisan Patient Protection Act.
‘‘(E) TREATMENT
OF
EXCEPTED
BENE-
FITS.—Under section 154(a) of the Bipartisan
Patient Protection Act, the provisions of this
subsection and subsection (a)(1)(C) do not
apply to certain excepted benefits.
‘‘(5) EXCLUSION OF EMPLOYERS AND OTHER
PLAN SPONSORS.—
‘‘(A) CAUSES
OF
ACTION
AGAINST
EM-
PLOYERS AND PLAN SPONSORS PRECLUDED.—
Subject to subparagraph (B), paragraph (1)(A)
does not authorize a cause of action against an
employer or other plan sponsor maintaining the
plan (or against an employee of such an em-
ployer or sponsor acting within the scope of em-
ployment).
‘‘(B) CERTAIN
CAUSES
OF
ACTION
PER-
MITTED.—Notwithstanding subparagraph (A),
a cause of action may arise against an employer
or other plan sponsor (or against an employee
of such an employer or sponsor acting within
the scope of employment) under paragraph
(1)(A), to the extent there was direct participa-
164
tion by the employer or other plan sponsor (or
employee) in the decision of the plan under sec-
tion 102 of the Bipartisan Patient Protection
Act upon consideration of a claim for benefits
or under section 103 of such Act upon review
of a denial of a claim for benefits.
‘‘(C) DIRECT PARTICIPATION.—
‘‘(i) IN
GENERAL.—For purposes of
subparagraph (B), the term ‘direct partici-
pation’ means, in connection with a deci-
sion described in paragraph (1)(A), the ac-
tual making of such decision or the actual
exercise of control in making such decision.
‘‘(ii) RULES OF CONSTRUCTION.—For
purposes of clause (i), the employer or plan
sponsor (or employee) shall not be con-
strued to be engaged in direct participation
because of any form of decisionmaking or
other conduct that is merely collateral or
precedent to the decision described in
paragraph (1)(A) on a particular claim for
benefits of a participant or beneficiary, in-
cluding (but not limited to)—
‘‘(I) any participation by the em-
ployer or other plan sponsor (or em-
165
ployee) in the selection of the group
health plan or health insurance cov-
erage involved or the third party ad-
ministrator or other agent;
‘‘(II) any engagement by the em-
ployer or other plan sponsor (or em-
ployee) in any cost-benefit analysis
undertaken in connection with the se-
lection of, or continued maintenance
of, the plan or coverage involved;
‘‘(III) any participation by the
employer or other plan sponsor (or
employee) in the process of creating,
continuing, modifying, or terminating
the plan or any benefit under the
plan, if such process was not substan-
tially focused solely on the particular
situation of the participant or bene-
ficiary 
referred 
to 
in 
paragraph
(1)(A); and
‘‘(IV) any participation by the
employer or other plan sponsor (or
employee) in the design of any benefit
under the plan, including the amount