136 
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. 
(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
137 
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being superseded under subsection (a); and 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) 
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,
138 
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-
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