132 
plan or issuer or has a contract with the plan 
or issuer for provision of services for which ben-
efits are available under the plan or issuer; or 
(B) with respect to an institutional health 
care provider, is an employee of the provider or 
has a contract or other arrangement with the 
provider respecting the provision of health care 
services. 
Subtitle E—Definitions 
SEC. 151. DEFINITIONS. 
(a) INCORPORATION OF GENERAL DEFINITIONS.— 
Except as otherwise provided, the provisions of section 
2791 of the Public Health Service Act shall apply for pur-
poses of this title in the same manner as they apply for 
purposes of title XXVII of such Act. 
(b) SECRETARY.—Except as otherwise provided, the 
term ‘‘Secretary’’ means the Secretary of Health and 
Human Services, in consultation with the Secretary of 
Labor and the term ‘‘appropriate Secretary’’ means the 
Secretary of Health and Human Services in relation to 
carrying out this title under sections 2706 and 2751 of 
the Public Health Service Act and the Secretary of Labor 
in relation to carrying out this title under section 714 of 
the Employee Retirement Income Security Act of 1974.
133 
(c) ADDITIONAL DEFINITIONS.—For purposes of this 
title: 
(1) APPLICABLE AUTHORITY.—The term ‘‘ap-
plicable authority’’ means— 
(A) in the case of a group health plan, the 
Secretary of Health and Human Services and 
the Secretary of Labor; and 
(B) in the case of a health insurance issuer 
with respect to a specific provision of this title, 
the applicable State authority (as defined in 
section 2791(d) of the Public Health Service 
Act), or the Secretary of Health and Human 
Services, if such Secretary is enforcing such 
provision 
under 
section 
2722(a)(2) 
or 
2761(a)(2) of the Public Health Service Act. 
(2) ENROLLEE.—The term ‘‘enrollee’’ means, 
with respect to health insurance coverage offered by 
a health insurance issuer, an individual enrolled with 
the issuer to receive such coverage. 
(3) GROUP HEALTH PLAN.—The term ‘‘group 
health plan’’ has the meaning given such term in 
section 733(a) of the Employee Retirement Income 
Security Act of 1974, except that such term includes 
an employee welfare benefit plan treated as a group 
health plan under section 732(d) of such Act or de-
134 
fined as such a plan under section 607(1) of such 
Act. 
(4) HEALTH CARE PROFESSIONAL.—The term 
‘‘health care professional’’ means an individual who 
is licensed, accredited, or certified under State law 
to provide specified health care services and who is 
operating within the scope of such licensure, accredi-
tation, or certification. 
(5) HEALTH
CARE
PROVIDER.—The term 
‘‘health care provider’’ includes a physician or other 
health care professional, as well as an institutional 
or other facility or agency that provides health care 
services and that is licensed, accredited, or certified 
to provide health care items and services under ap-
plicable State law. 
(6) NETWORK.—The term ‘‘network’’ means, 
with respect to a group health plan or health insur-
ance issuer offering health insurance coverage, the 
participating health care professionals and providers 
through whom the plan or issuer provides health 
care items and services to participants, beneficiaries, 
or enrollees. 
(7) 
NONPARTICIPATING.—The 
term 
‘‘non-
participating’’ means, with respect to a health care 
provider that provides health care items and services
135 
to a participant, beneficiary, or enrollee under group 
health plan or health insurance coverage, a health 
care provider that is not a participating health care 
provider with respect to such items and services. 
(8) PARTICIPATING.—The term ‘‘participating’’ 
means, with respect to a health care provider that 
provides health care items and services to a partici-
pant, beneficiary, or enrollee under group health 
plan or health insurance coverage offered by a 
health insurance issuer, a health care provider that 
furnishes such items and services under a contract 
or other arrangement with the plan or issuer. 
(9) PRIOR AUTHORIZATION.—The term ‘‘prior 
authorization’’ means the process of obtaining prior 
approval from a health insurance issuer or group 
health plan for the provision or coverage of medical 
services. 
(10) TERMS
AND
CONDITIONS.—The term 
‘‘terms and conditions’’ includes, with respect to a 
group health plan or health insurance coverage, re-
quirements imposed under this title with respect to 
the plan or coverage.
136 
SEC. 152. PREEMPTION; STATE FLEXIBILITY; CONSTRUC-
TION. 
(a) CONTINUED APPLICABILITY
OF STATE LAW 
WITH RESPECT TO HEALTH INSURANCE ISSUERS.— 
(1) IN GENERAL.—Subject to paragraph (2), 
this title shall not be construed to supersede any 
provision of State law which establishes, implements, 
or continues in effect any standard or requirement 
solely relating to health insurance issuers (in connec-
tion with group health insurance coverage or other-
wise) except to the extent that such standard or re-
quirement prevents the application of a requirement 
of this title. 
(2) CONTINUED
PREEMPTION
WITH
RESPECT 
TO GROUP HEALTH PLANS.—Nothing in this title 
shall be construed to affect or modify the provisions 
of section 514 of the Employee Retirement Income 
Security Act of 1974 with respect to group health 
plans. 
(3) CONSTRUCTION.—In applying this section, 
a State law that provides for equal access to, and 
availability of, all categories of licensed health care 
providers and services shall not be treated as pre-
venting the application of any requirement of this 
title.
137 
(b) APPLICATION
OF SUBSTANTIALLY COMPLIANT 
STATE LAWS.— 
(1) IN GENERAL.—In the case of a State law 
that imposes, with respect to health insurance cov-
erage offered by a health insurance issuer and with 
respect to a group health plan that is a non-Federal 
governmental plan, a requirement that substantially 
complies (within the meaning of subsection (c)) with 
a patient protection requirement (as defined in para-
graph (3)) and does not prevent the application of 
other requirements under this Act (except in the 
case of other substantially compliant requirements), 
in applying the requirements of this title under sec-
tion 2707 and 2753 (as applicable) of the Public 
Health Service Act (as added by title II), subject to 
subsection (a)(2)— 
(A) the State law shall not be treated as 
being superseded under subsection (a); and 
(B) the State law shall apply instead of the 
patient protection requirement otherwise appli-
cable with respect to health insurance coverage 
and non-Federal governmental plans. 
(2) LIMITATION.—In the case of a group health 
plan covered under title I of the Employee Retire-
ment Income Security Act of 1974, paragraph (1)
138 
shall be construed to apply only with respect to the 
health insurance coverage (if any) offered in connec-
tion with the plan. 
(3) DEFINITIONS.—In this section: 
(A) 
PATIENT
PROTECTION
REQUIRE-
MENT.—The term ‘‘patient protection require-
ment’’ means a requirement under this title, 
and includes (as a single requirement) a group 
or related set of requirements under a section 
or similar unit under this title. 
(B) 
SUBSTANTIALLY
COMPLIANT.—The 
terms ‘‘substantially compliant’’, ‘‘substantially 
complies’’, or ‘‘substantial compliance’’ with re-
spect to a State law, mean that the State law 
has the same or similar features as the patient 
protection requirements and has a similar ef-
fect. 
(c) DETERMINATIONS
OF SUBSTANTIAL COMPLI-
ANCE.— 
(1) CERTIFICATION BY STATES.—A State may 
submit to the Secretary a certification that a State 
law provides for patient protections that are at least 
substantially compliant with one or more patient 
protection requirements. Such certification shall be 
accompanied by such information as may be re-
139 
quired to permit the Secretary to make the deter-
mination described in paragraph (2)(A). 
(2) REVIEW.— 
(A) IN
GENERAL.—The Secretary shall 
promptly review a certification submitted under 
paragraph (1) with respect to a State law to de-
termine if the State law substantially complies 
with the patient protection requirement (or re-
quirements) to which the law relates. 
(B) APPROVAL DEADLINES.— 
(i) INITIAL REVIEW.—Such a certifi-
cation is considered approved unless the 
Secretary notifies the State in writing, 
within 90 days after the date of receipt of 
the certification, that the certification is 
disapproved (and the reasons for dis-
approval) or that specified additional infor-
mation is needed to make the determina-
tion described in subparagraph (A). 
(ii) 
ADDITIONAL
INFORMATION.— 
With respect to a State that has been noti-
fied by the Secretary under clause (i) that 
specified additional information is needed 
to make the determination described in 
subparagraph (A), the Secretary shall
140 
make the determination within 60 days 
after the date on which such specified ad-
ditional information is received by the Sec-
retary. 
(3) APPROVAL.— 
(A) IN GENERAL.—The Secretary shall ap-
prove a certification under paragraph (1) un-
less— 
(i) the State fails to provide sufficient 
information to enable the Secretary to 
make a determination under paragraph 
(2)(A); or 
(ii) the Secretary determines that the 
State law involved does not provide for pa-
tient protections that substantially comply 
with the patient protection requirement (or 
requirements) to which the law relates. 
(B) STATE CHALLENGE.—A State that has 
a certification disapproved by the Secretary 
under subparagraph (A) may challenge such 
disapproval in the appropriate United States 
district court. 
(C) DEFERENCE
TO
STATES.—With re-
spect to a certification submitted under para-
graph (1), the Secretary shall give deference to
141 
the State’s interpretation of the State law in-
volved with respect to the patient protection in-
volved. 
(D) PUBLIC
NOTIFICATION.—The Sec-
retary shall— 
(i) provide a State with a notice of the 
determination to approve or disapprove a 
certification under this paragraph; 
(ii) promptly publish in the Federal 
Register a notice that a State has sub-
mitted a certification under paragraph (1); 
(iii) promptly publish in the Federal 
Register the notice described in clause (i) 
with respect to the State; and 
(iv) annually publish the status of all 
States with respect to certifications. 
(4) CONSTRUCTION.—Nothing in this sub-
section shall be construed as preventing the certifi-
cation (and approval of certification) of a State law 
under this subsection solely because it provides for 
greater protections for patients than those protec-
tions otherwise required to establish substantial 
compliance. 
(5) PETITIONS.—
142 
(A) PETITION PROCESS.—Effective on the 
date on which the provisions of this Act become 
effective, as provided for in section 601, a 
group health plan, health insurance issuer, par-
ticipant, beneficiary, or enrollee may submit a 
petition to the Secretary for an advisory opinion 
as to whether or not a standard or requirement 
under a State law applicable to the plan, issuer, 
participant, beneficiary, or enrollee that is not 
the subject of a certification under this sub-
section, is superseded under subsection (a)(1) 
because such standard or requirement prevents 
the application of a requirement of this title. 
(B) OPINION.—The Secretary shall issue 
an advisory opinion with respect to a petition 
submitted under subparagraph (A) within the 
60-day period beginning on the date on which 
such petition is submitted. 
(d) DEFINITIONS.—For purposes of this section: 
(1) STATE
LAW.—The term ‘‘State law’’ in-
cludes all laws, decisions, rules, regulations, or other 
State action having the effect of law, of any State. 
A law of the United States applicable only to the 
District of Columbia shall be treated as a State law 
rather than a law of the United States.
143 
(2) STATE.—The term ‘‘State’’ includes a 
State, the District of Columbia, Puerto Rico, the 
Virgin Islands, Guam, American Samoa, the North-
ern Mariana Islands, any political subdivisions of 
such, or any agency or instrumentality of such. 
SEC. 153. EXCLUSIONS. 
(a) NO BENEFIT REQUIREMENTS.—Nothing in this 
title shall be construed to require a group health plan or 
a health insurance issuer offering health insurance cov-
erage to include specific items and services under the 
terms of such a plan or coverage, other than those pro-
vided under the terms and conditions of such plan or cov-
erage. 
(b) EXCLUSION FROM ACCESS TO CARE MANAGED 
CARE PROVISIONS FOR FEE-FOR-SERVICE COVERAGE.— 
(1) IN GENERAL.—The provisions of sections 
111 through 117 shall not apply to a group health 
plan or health insurance coverage if the only cov-
erage offered under the plan or coverage is fee-for- 
service coverage (as defined in paragraph (2)). 
(2) FEE-FOR-SERVICE
COVERAGE
DEFINED.— 
For purposes of this subsection, the term ‘‘fee-for- 
service coverage’’ means coverage under a group 
health plan or health insurance coverage that—
144 
(A) reimburses hospitals, health profes-
sionals, and other providers on a fee-for-service 
basis without placing the provider at financial 
risk; 
(B) does not vary reimbursement for such 
a provider based on an agreement to contract 
terms and conditions or the utilization of health 
care items or services relating to such provider; 
(C) allows access to any provider that is 
lawfully authorized to provide the covered serv-
ices and that agrees to accept the terms and 
conditions of payment established under the 
plan or by the issuer; and 
(D) for which the plan or issuer does not 
require prior authorization before providing for 
any health care services. 
SEC. 154. TREATMENT OF EXCEPTED BENEFITS. 
(a) IN GENERAL.—The requirements of this title 
shall not apply to excepted benefits (as defined in section 
733(c) of such Act), other than benefits described in sec-
tion 733(c)(2)(A) of such Act, in the same manner as the 
provisions of part 7 of subtitle B of title I of such Act 
do not apply to such benefits under subsections (b) and 
(c) of section 732 of such Act.
145 
(b) COVERAGE
OF
CERTAIN
LIMITED
SCOPE 
PLANS.—Only for purposes of applying the requirements 
of this title under sections 2707 and 2753 of the Public 
Health Service Act, section 714 of the Employee Retire-
ment Income Security Act of 1974, and section 9813 of 
the Internal Revenue Code of 1986, the following sections 
shall be deemed not to apply: 
(1) Section 2791(c)(2)(A) of the Public Health 
Service Act. 
(2) Section 733(c)(2)(A) of the Employee Re-
tirement Income Security Act of 1974. 
(3) Section 9832(c)(2)(A) of the Internal Rev-
enue Code of 1986. 
SEC. 155. REGULATIONS. 
The Secretaries of Health and Human Services, 
Labor, and the Treasury shall issue such regulations as 
may be necessary or appropriate to carry out this title. 
Such regulations shall be issued consistent with section 
104 of Health Insurance Portability and Accountability 
Act of 1996. Such Secretaries may promulgate any in-
terim final rules as the Secretaries determine are appro-
priate to carry out this title.
146 
SEC. 156. INCORPORATION INTO PLAN OR COVERAGE DOC-
UMENTS. 
The requirements of this title with respect to a group 
health plan or health insurance coverage are, subject to 
section 154, deemed to be incorporated into, and made 
a part of, such plan or the policy, certificate, or contract 
providing such coverage and are enforceable under law as 
if directly included in the documentation of such plan or 
such policy, certificate, or contract. 
SEC. 157. PRESERVATION OF PROTECTIONS. 
(a) IN GENERAL.—The rights under this Act (includ-
ing the right to maintain a civil action and any other 
rights under the amendments made by this Act) may not 
be waived, deferred, or lost pursuant to any agreement 
not authorized under this Act. 
(b) EXCEPTION.—Subsection (a) shall not apply to 
an agreement providing for arbitration or participation in 
any other nonjudicial procedure to resolve a dispute if the 
agreement is entered into knowingly and voluntarily by the 
parties involved after the dispute has arisen or is pursuant 
to the terms of a collective bargaining agreement. Nothing 
in this subsection shall be construed to permit the waiver 
of the requirements of sections 103 and 104 (relating to 
internal and external review).
147 
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 Patient Pro-
tection Act of 2005, and each health insurance issuer shall 
comply with patient protection requirements under such 
title with respect to group health insurance coverage it of-
fers, and such requirements shall be deemed to be incor-
porated 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’’.
148 
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 Patient 
Protection Act of 2005 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 delega-
tion 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 Patient Protection Act of 2005 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.