(ii) by striking ‘‘1217’’ and inserting
‘‘1227’’; and
(B) in subsection (b)—
(i) by striking ‘‘1233’’ and inserting
‘‘1242’’; and
(ii) by striking ‘‘1213’’ and inserting
‘‘1223’’;
(4) in section 1222—
(A) in subsection (a)—
(i) in paragraph (1), by striking
‘‘1211(a)’’ and inserting ‘‘1221(a)’’; and
(ii) in paragraph (2)(A), by striking
‘‘1211(c)’’ and inserting ‘‘1221(c)’’; and
(B) 
in 
subsection 
(b), 
by 
striking
‘‘1211(a)’’ and inserting ‘‘1221(a)’’;
(5) in section 1223—
(A) 
in 
subsection 
(a), 
by 
striking
‘‘1211(b)’’ and inserting ‘‘1221(b)’’;
(B) in subsection (b)—
(i) in paragraph (1), by striking
‘‘1211(a)’’ and inserting ‘‘1221(a)’’; and
(ii) in paragraph (3), by striking
‘‘1211(a)’’ and inserting ‘‘1221(a)’’; and
(C) 
in 
subsection 
(d), 
by 
striking
‘‘1211(a)’’ and inserting ‘‘1221(a)’’;
(6) in section 1224—
(A) in each of subsections (a) through (c),
by striking ‘‘1211(a)’’ and inserting ‘‘1221(a)’’;
and
(B) 
in 
subsection 
(b), 
by 
striking
‘‘1213(a)(7)’’ and inserting ‘‘1223(a)(7)’’;
(7) in section 1225—
(A) in subsection (a)—
(i) by striking ‘‘1211(a)’’ and insert-
ing ‘‘1221(a)’’; and
(ii) by striking ‘‘1233’’ and inserting
‘‘1242’’; and
(B) 
in 
subsection 
(b), 
by 
striking
‘‘1211(b)’’ and inserting ‘‘1221(b)’’;
(8) in section 1226, in each of subsections (a)
through (c), by striking ‘‘1211(a)’’ and inserting
‘‘1221(a)’’;
(9) in section 1227—
(A) by striking ‘‘1211(a)’’ and inserting
‘‘1221(a)’’; and
(B) by striking ‘‘1214’’ and inserting
‘‘1224’’;
(10) in section 1228—
(A) in each of subsections (a) through (c),
by striking ‘‘1211(a)’’ each place such term ap-
pears and inserting ‘‘1221(a)’’;
(B) in subsection (b), in each of para-
graphs 
(2)(A) 
and 
(3)(A), 
by 
striking
‘‘1232(a)’’ and inserting ‘‘1251(a)’’; and
(C) in subsection (c)(2)—
(i) by striking ‘‘1232(b)(3)’’ and in-
serting ‘‘1251(b)(3)’’; and
(ii) by striking ‘‘1217’’ and inserting
‘‘1227’’;
(11) in section 1229(a), by striking ‘‘1211(a)’’
each place such term appears and inserting
‘‘1221(a)’’;
(12) in section 1230(a), by striking ‘‘1211(a)’’
each place such term appears and inserting
‘‘1221(a)’’;
(13) in section 1231—
(A) in each of subsections (a) and (b), by
striking ‘‘1211(a)’’ each place such term ap-
pears and inserting ‘‘1221(a)’’; and
(B) in each of subsections (a) and (b), by
striking ‘‘1211(b)’’ and inserting ‘‘1221(b)’’;
(14) in section 1232, by striking ‘‘1211’’ and
inserting ‘‘1221’’;
(15) in section 1241—
(A) in the matter preceding paragraph (1),
by striking ‘‘this title’’ and inserting ‘‘this
part’’; and
(B) in paragraph (1), by striking ‘‘1213’’
and inserting ‘‘1223’’;
(16) in section 1242—
(A) in each of subsections (a) and (b), by
striking ‘‘1211’’ each place such term appears
and inserting ‘‘1221’’;
(B) in subsection (b)—
(i) by striking ‘‘part B’’ and inserting
‘‘subpart II’’; and
(ii) by striking ‘‘1214(c)(1)’’ and in-
serting ‘‘1224(c)(1)’’; and
(C) in subsection (c), by striking ‘‘1213’’
and inserting ‘‘1223’’; and
(17) in section 1251(c)(1)—
(A) by striking ‘‘1211(a)’’ and inserting
‘‘1221(a)’’;
(B) by striking ‘‘1218(a)(2)’’ and inserting
‘‘1228(a)(2)’’; and
(C) by striking ‘‘part B’’ and inserting
‘‘subpart II’’.
SEC. 176. EFFECTIVE DATE.
The amendments made by this part shall take effect
October 1, 1993, or upon the date of the enactment of
this Act, whichever occurs later.
PART 2—AIR TRANSPORT FOR RURAL VICTIMS OF
MEDICAL EMERGENCIES
SEC. 181. GRANTS TO STATES REGARDING AIRCRAFT FOR
TRANSPORTING RURAL VICTIMS OF MEDICAL
EMERGENCIES.
Title XII of the Public Health Service Act (42 U.S.C.
300d et seq.), as amended by part 1, is amended by adding
at the end thereof the following new part:
‘‘PART D—MISCELLANEOUS GRANT PROGRAMS AND
REQUIREMENTS
‘‘SEC. 1261. GRANTS FOR SYSTEMS TO TRANSPORT RURAL
VICTIMS OF MEDICAL EMERGENCIES.
‘‘(a) IN GENERAL.—The Secretary shall make grants
to States to assist such States in the creation or enhance-
ment of air medical transport systems that provide victims
of medical emergencies in rural areas with access to treat-
ments for the injuries or other conditions resulting from
such emergencies.
‘‘(b) APPLICATION AND PLAN.—
‘‘(1) APPLICATION.—To be eligible to receive a
grant under subsection (a), a State shall prepare
and submit to the Secretary an application in such
form, made in such manner, and containing such
agreements, assurances, and information, including
a State plan as required in paragraph (2), as the
Secretary determines to be necessary to carry out
this section.
‘‘(2) STATE PLAN.—An application submitted
under paragraph (1) shall contain a State plan that
shall—
‘‘(A) describe the intended uses of the
grant proceeds and the geographic areas to be
served;
‘‘(B) demonstrates that the geographic
areas to be served, as described under subpara-
graph (A), are rural in nature;
‘‘(C) demonstrate that there is a lack of
facilities available and equipped to deliver ad-
vanced levels of medical care in the geographic
areas to be served;
‘‘(D) demonstrate that in utilizing the
grant proceeds for the establishment or en-
hancement of air medical services the State
would be making a cost-effective improvement
to existing ground-based or air emergency medi-
cal service systems;
‘‘(E) demonstrate that the State will not
utilize the grant proceeds to duplicate the capa-
bilities of existing air medical systems that are
effectively meeting the emergency medical needs
of the populations they serve;
‘‘(F) demonstrate that in utilizing the
grant proceeds the State is likely to achieve a
reduction in the morbidity and mortality rates
of the areas to be served, as determined by the
Secretary;
‘‘(G) demonstrate that the State, in utiliz-
ing the grant proceeds, will—
‘‘(i) maintain the expenditures of the
State for air and ground medical transport
systems at a level equal to not less than
the level of such expenditures maintained
by the State for the fiscal year preceding
the fiscal year for which the grant is re-
ceived; and
‘‘(ii) ensure that recipients of direct
financial assistance from the State under
such grant will maintain expenditures of
such recipients for such systems at a level
at least equal to the level of such expendi-
tures maintained by such recipients for the
fiscal year preceding the fiscal year for
which the financial assistance is received;
‘‘(H) demonstrate that persons experienced
in the field of air medical service delivery were
consulted in the preparation of the State plan;
and
‘‘(I) contain such other information as the
Secretary may determine appropriate.
‘‘(c) CONSIDERATIONS IN AWARDING GRANTS.—In
determining whether to award a grant to a State under
this section, the Secretary shall—
‘‘(1) consider the rural nature of the areas to
be served with the grant proceeds and the services
to be provided with such proceeds, as identified in
the State plan submitted under subsection (b); and
‘‘(2) give preference to States with State plans
that demonstrate an effective integration of the pro-
posed air medical transport systems into a com-
prehensive network or plan for regional or statewide
emergency medical service delivery.
‘‘(d) 
STATE
ADMINISTRATION
AND
USE
OF
GRANT.—
‘‘(1) IN
GENERAL.—The Secretary may not
make a grant to a State under subsection (a) unless
the State agrees that such grant will be adminis-
tered by the State agency with principal responsibil-
ity for carrying out programs regarding the provi-
sion of medical services to victims of medical emer-
gencies or trauma.
‘‘(2) PERMITTED
USES.—A State may use
amounts received under a grant awarded under this
section to award subgrants to public and private en-
tities operating within the State.
‘‘(3) OPPORTUNITY FOR PUBLIC COMMENT.—
The Secretary may not make a grant to a State
under subsection (a) unless that State agrees that,
in developing and carrying out the State plan under
subsection (b)(2), the State will provide public notice
with respect to the plan (including any revisions
thereto) and facilitate comments from interested
persons.
‘‘(e) NUMBER
OF GRANTS.—The Secretary shall
award grants under this section to not less than 7 States.
‘‘(f) REPORTS.—
‘‘(1) REQUIREMENT.—A State that receives a
grant under this section shall annually (during each
year in which the grant proceeds are used) prepare
and submit to the Secretary a report that shall con-
tain—
‘‘(A) a description of the manner in which
the grant proceeds were utilized;
‘‘(B) a description of the effectiveness of
the air medical transport programs assisted
with grant proceeds; and
‘‘(C) such other information as the Sec-
retary may require.
‘‘(2) TERMINATION OF FUNDING.—In reviewing
reports submitted under paragraph (1), if the Sec-
retary determines that a State is not using amounts
provided under a grant awarded under this section
in accordance with the State plan submitted by the
State under subsection (b), the Secretary may termi-
nate the payment of amounts under such grant to
the State until such time as the Secretary deter-
mines that the State comes into compliance with
such plan.
‘‘(g) DEFINITION.—As used in this section, the term
‘rural areas’ means geographic areas that are located out-
side of standard metropolitan statistical areas, as identi-
fied by the Secretary.
‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—There
are authorized to be appropriated to make grants under
this section, $15,000,000 for fiscal year 1994, and such
sums as may be necessary for each of the fiscal years 1995
and 1996.’’.
PART 3—EXTENSION OF SPECIAL TREATMENT RULES
FOR MEDICARE-DEPENDENT, SMALL RURAL HOSPITALS
SEC. 191. EXTENSION OF SPECIAL TREATMENT RULES FOR
MEDICARE-DEPENDENT, SMALL RURAL HOS-
PITALS.
(a) IN GENERAL.—
(1) DETERMINATION OF PAYMENT AMOUNT.—
Section 1886(b)(3)(D) of the Social Security Act (42
U.S.C. 1395ww(b)(3)(D)) is amended by striking
‘‘March 31, 1993,’’ and inserting ‘‘March 31,
1994,’’.
(2) ELIGIBILITY
FOR
DESIGNATION.—Section
1886(d)(5)(G)(i) 
of 
such 
Act 
(42 
U.S.C.
1395ww(d)(5)(G)(i)) is amended by striking ‘‘March
31, 1993,’’ and inserting ‘‘March 31, 1994,’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall take effect as if included in the enact-
ment of section 6003(f) of the Omnibus Budget Reconcili-
ation Act of 1989.
TITLE II—HEALTH CARE COST
CONTAINMENT AND QUALITY
ENHANCEMENT
Subtitle A—Medical Malpractice
Liability Reform
PART 1—GENERAL PROVISIONS
SEC. 201. FEDERAL REFORM OF MEDICAL MALPRACTICE
LIABILITY ACTIONS.
(a) CONGRESSIONAL FINDINGS.—
(1) EFFECT
ON
INTERSTATE
COMMERCE.—
Congress finds that the health care and insurance
industries are industries affecting interstate com-
merce and the medical malpractice litigation systems
existing throughout the United States affect inter-
state commerce by contributing to the high cost of
health care and premiums for malpractice insurance
purchased by health care providers.
(2) EFFECT
ON
FEDERAL
SPENDING.—Con-
gress finds that the medical malpractice litigation
systems existing throughout the United States have
a significant effect on the amount, distribution, and
use of Federal funds because of—
(A) the large number of individuals who
receive health care benefits under programs op-
erated or financed by the Federal Government;
(B) the large number of individuals who
benefit because of the exclusion from Federal
taxes of the amounts spent by their employers
to provide them with health insurance benefits;
(C) the large number of health care provid-
ers and health care professionals who provide
items or services for which the Federal Govern-
ment makes payments; and
(D) the large number of such providers
and professionals who have received direct or
indirect financial assistance from the Federal
Government because of their status as such
professionals or providers.
(b) APPLICABILITY.—This subtitle shall apply with
respect to any medical malpractice liability claim and to
any medical malpractice liability action brought in any
State or Federal court, except that this subtitle shall not
apply to—
(1) a claim or action for damages arising from
a vaccine-related injury or death to the extent that
title XXI of the Public Health Service Act applies to
the action; or
(2) a claim or action in which the plaintiff’s
sole allegation is an allegation of an injury arising
from the use of a medical product.
(c) PREEMPTION OF STATE LAW.—Subject to section
221, this subtitle supersedes State law only to the extent
that State law differs from any provision of law estab-
lished by or under this subtitle. Any issue that is not gov-
erned by any provision of law established by or under this
subtitle shall be governed by otherwise applicable State or
Federal law.
(d) FEDERAL COURT JURISDICTION NOT ESTAB-
LISHED ON FEDERAL QUESTION GROUNDS.—Nothing in
this subtitle shall be construed to establish any jurisdiction
in the district courts of the United States over medical
malpractice liability actions on the basis of sections 1331
or 1337 of title 28, United States Code.
SEC. 202. DEFINITIONS.
As used in this subtitle:
(1) ALTERNATIVE DISPUTE RESOLUTION SYS-
TEM; ADR.—The term ‘‘alternative dispute resolu-
tion system’’ or ‘‘ADR’’ means a system established
by a State that provides for the resolution of medical
malpractice liability claims in a manner other than
through medical malpractice liability actions.
(2) CLAIMANT.—The term ‘‘claimant’’ means
any person who alleges a medical malpractice liabil-
ity claim, or, in the case of an individual who is de-
ceased, incompetent, or a minor, the person on
whose behalf such a claim is alleged.
(3) ECONOMIC DAMAGES.—The term ‘‘economic
damages’’ means damages paid to compensate an in-
dividual for losses for hospital and other medical ex-
penses, lost wages, lost employment, and other pecu-
niary losses.
(4) HEALTH CARE PROFESSIONAL.—The term
‘‘health care professional’’ means any individual who
provides health care services in a State and who is
required by State law or regulation to be licensed or
certified by the State to provide such services in the
State.
(5) HEALTH
CARE
PROVIDER.—The term
‘‘health care provider’’ means any organization or
institution that is engaged in the delivery of health
care services in a State and that is required by State
law or regulation to be licensed or certified by the
State to engage in the delivery of such services in
the State.
(6) INJURY.—The term ‘‘injury’’ means any ill-
ness, disease, or other harm that is the subject of
a medical malpractice liability action or claim.
(7) MEDICAL
MALPRACTICE
LIABILITY
AC-
TION.—The term ‘‘medical malpractice liability ac-
tion’’ means a civil action (other than an action in
which the plaintiff’s sole allegation is an allegation
of an intentional tort) brought in a State or Federal
court against a health care provider or health care
professional (regardless of the theory of liability on
which the action is based) in which the plaintiff al-
leges a medical malpractice liability claim.
(8) 
MEDICAL
MALPRACTICE
LIABILITY
CLAIM.—The term ‘‘medical malpractice liability
claim’’ means a claim in which the claimant alleges
that injury was caused by the provision of (or the
failure to provide) health care services.
(9) MEDICAL
PRODUCT.—The term ‘‘medical
product’’ means a device (as defined in section
201(h) of the Federal Food, Drug, and Cosmetic
Act) or a drug (as defined in section 201(g)(1) of
the Federal Food, Drug, and Cosmetic Act).
(10) 
NONECONOMIC
DAMAGES.—The 
term
‘‘noneconomic damages’’ means damages paid to
compensate an individual for losses for physical and
emotional pain, suffering, inconvenience, physical
impairment, mental anguish, disfigurement, loss of
enjoyment of life, loss of consortium, and other
nonpecuniary losses, but does not include punitive
damages.
(11) 
SECRETARY.—The 
term 
‘‘Secretary’’
means the Secretary of Health and Human Services.
(12) STATE.—The term ‘‘State’’ means each of
the several States, the District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands,
Guam, and American Samoa.
SEC. 203. EFFECTIVE DATE.
(a) IN GENERAL.—Except as provided in subsection
(b) and sections 219, 242, and 243, this subtitle shall
apply with respect to claims accruing or actions brought
on or after the expiration of the 3-year period that begins
on the date of the enactment of this Act.
(b) EXCEPTION FOR STATES REQUESTING EARLIER
IMPLEMENTATION OF REFORMS.—
(1) APPLICATION.—A State may submit an ap-
plication to the Secretary requesting the early imple-
mentation of this subtitle with respect to claims or
actions brought in the State.
(2) DECISION BY SECRETARY.—The Secretary
shall issue a response to a State’s application under
paragraph (1) not later than 90 days after receiving
the application. If the Secretary determines that the
State meets the requirements of this subtitle at the
time of submitting its application, the Secretary
shall approve the State’s application, and this sub-
title shall apply with respect to actions brought in
the State on or after the expiration of the 90-day
period that begins on the date the Secretary issues
the response. If the Secretary denies the State’s ap-
plication, the Secretary shall provide the State with
a written explanation of the grounds for the deci-
sion.
PART 2—UNIFORM STANDARDS FOR MEDICAL
MALPRACTICE LIABILITY ACTIONS
SEC. 211. STATUTE OF LIMITATIONS.
(a) IN GENERAL.—No medical malpractice liability
claim may be brought after the expiration of the 2-year
period that begins on the date the alleged injury that is
the subject of the action should reasonably have been dis-
covered, but in no event after the expiration of the 4-year
period that begins on the date the alleged injury occurred.
(b) EXCEPTION FOR MINORS.—In the case of an al-
leged injury suffered by a minor who has not attained 6
years of age, no medical malpractice liability claim may
be brought after the expiration of the 2-year period that
begins on the date the alleged injury that is the subject
of the action should reasonably have been discovered, but
in no event after the date on which the minor attains 10
years of age.
SEC. 212. REQUIREMENT FOR INITIAL RESOLUTION OF AC-
TION THROUGH ALTERNATIVE DISPUTE RES-
OLUTION.
(a) IN GENERAL.—No medical malpractice liability
action may be brought in any State court during a cal-
endar year unless the medical malpractice liability claim
that is the subject of the action has been initially resolved
under an alternative dispute resolution system certified for
the year by the Secretary under section 232(a), or, in the
case of a State in which such a system is not in effect
for the year, under the alternative Federal system estab-
lished under section 232(b).
(b) INITIAL
RESOLUTION
OF
CLAIMS
UNDER
ADR.—For purposes of subsection (a), an action is ‘‘ini-
tially resolved’’ under an alternative dispute resolution
system if—
(1) the ADR reaches a decision on whether the
defendant is liable to the plaintiff for damages; and
(2) if the ADR determines that the defendant
is liable, the ADR reaches a decision on the amount
of damages assessed against the defendant.
(c) PROCEDURES FOR FILING ACTIONS.—
(1) NOTICE
OF
INTENT
TO
CONTEST
DECI-
SION.—Not later than 60 days after a decision is is-
sued with respect to a medical malpractice liability
claim under an alternative dispute resolution system,
each party affected by the decision shall submit a
sealed statement to a court of competent jurisdiction
indicating whether or not the party intends to con-
test the decision.
(2) DEADLINE FOR FILING ACTION.—No medi-
cal malpractice liability action may be brought un-
less the action is filed in a court of competent juris-
diction not later than 90 days after the decision re-
solving the medical malpractice liability claim that is
the subject of the action is issued under the applica-
ble alternative dispute resolution system.
(3) COURT
OF
COMPETENT
JURISDICTION.—
For purposes of this subsection, the term ‘‘court of
competent jurisdiction’’ means—
(A) with respect to actions filed in a State
court, the appropriate State trial court; and
(B) with respect to actions filed in a Fed-
eral court, the appropriate United States dis-
trict court.
(d) EFFECT OF ADR DECISION ON BURDEN OF
PROOF IN SUBSEQUENT ACTION.—In any medical mal-
practice liability action, the trier of fact shall uphold the
decision made under the previous alternative dispute reso-
lution system with respect to the claim that is the subject
of the action unless the party contesting the decision
proves by a preponderance of the evidence that the deci-
sion was incorrect.
(e) LEGAL EFFECT OF UNCONTESTED ADR DECI-
SION.—The decision reached under an alternative dispute
resolution system shall, for purposes of enforcement by a
court of competent jurisdiction, have the same status in
the court as the verdict of a medical malpractice liability
action adjudicated in a State or Federal trial court. The
previous sentence shall not apply to a decision that is con-
tested by a party affected by the decision pursuant to sub-
section (c)(1).
SEC. 213. ESTABLISHMENT OF PROCESS FOR RESOLUTION
OF CLAIMS AGAINST UNITED STATES.
The Attorney General shall establish an alternative
dispute resolution process for the resolution of tort claims
consisting of medical malpractice liability claims brought
against the United States under the Federal Tort Claims
Act. Under such process, the resolution of the claim shall
occur after the completion of the administrative claim
process applicable to the claim under section 2675 of title
28, United States Code.
SEC. 214. MANDATORY PRE-TRIAL SETTLEMENT CON-
FERENCE.
(a) IN GENERAL.—Before the beginning of the trial
phase of any medical malpractice liability action, the par-
ties shall attend a conference called by the court for pur-
poses of determining whether grounds exist upon which
the parties may negotiate a settlement for the action.
(b) REQUIRING PARTIES TO SUBMIT SETTLEMENT
OFFERS.—At the conference called pursuant to subsection
(a), each party to a medical malpractice liability action
shall present an offer of settlement for the action.
SEC. 215. CALCULATION AND PAYMENT OF DAMAGES.
(a) LIMITATION ON NONECONOMIC DAMAGES.—The
total amount of noneconomic damages that may be award-
ed to a plaintiff and the members of the plaintiff’s family
for losses resulting from the injury which is the subject
of a medical malpractice liability action may not exceed
$250,000, regardless of the number of parties against
whom the action is brought or the number of actions
brought with respect to the injury.
(b) TREATMENT OF PUNITIVE DAMAGES.—
(1) 
LIMITATION
ON
AMOUNT.—The 
total
amount of punitive damages that may be imposed
under a medical malpractice liability action may not
exceed twice the total of the damages awarded to the
plaintiff and the members of the plaintiff’s family.
(2) PAYMENTS TO STATE FOR MEDICAL QUAL-
ITY ASSURANCE ACTIVITIES.—
(A) IN GENERAL.—Any punitive damages
imposed under a medical malpractice liability
action shall be paid to the State in which the
action is brought.
(B) ACTIVITIES
DESCRIBED.—A State
shall use amount paid pursuant to subpara-
graph (A) to carry out activities to assure the
safety and quality of health care services pro-
vided in the State, including (but not limited
to)—
(i) licensing or certifying health care
professionals and health care providers in
the State;
(ii) operating alternative dispute reso-
lution systems;
(iii) carrying out public education pro-
grams relating to medical malpractice and
the availability of alternative dispute reso-
lution systems in the State; and
(iv) carrying out programs to reduce
malpractice-related costs for retired provid-
ers or other providers volunteering to pro-
vide services in medically underserved
areas.
100
(C) MAINTENANCE OF EFFORT.—A State
shall use any amounts paid pursuant to sub-
paragraph (A) to supplement and not to replace
amounts spent by the State for the activities
described in subparagraph (B).
(c) PERIODIC PAYMENTS FOR FUTURE LOSSES.—If
more than $100,000 in damages for expenses to be in-
curred in the future is awarded to the plaintiff in a medi-
cal malpractice liability action, the defendant shall provide
for payment for such damages on a periodic basis deter-
mined appropriate by the court (based upon projections
of when such expenses are likely to be incurred), unless
the court determines that it is not in the plaintiff’s best
interest to receive payments for such damages on such a
periodic basis.
(d) MANDATORY OFFSETS FOR DAMAGES PAID BY
A COLLATERAL SOURCE.—
(1) IN GENERAL.—The total amount of dam-
ages received by a plaintiff in a medical malpractice
liability action shall be reduced (in accordance with
paragraph (2)) by any other payment that has been
or will be made to the individual to compensate the
plaintiff for the injury that was the subject of the
action, including payment under—
101
(A) Federal or State disability or sickness
programs;
(B) Federal, State, or private health insur-
ance programs;
(C) private disability insurance programs;
(D) employer wage continuation programs;
and
(E) any other source of payment intended
to compensate the plaintiff for such injury.
(2) AMOUNT OF REDUCTION.—The amount by
which an award of damages to a plaintiff shall be re-
duced under paragraph (1) shall be—
(A) the total amount of any payments
(other than such award) that have been made
or that will be made to the plaintiff to com-
pensate the plaintiff for the injury that was the
subject of the action; minus
(B) the amount paid by the plaintiff (or by
the spouse, parent, or legal guardian of the
plaintiff) to secure the payments described in
subparagraph (A).
SEC. 216. TREATMENT OF ATTORNEY’S FEES AND OTHER
COSTS.
(a) LIMITATION
ON ATTORNEY’S FEES.—If the
plaintiff in a medical malpractice liability action has en-
102
tered into an agreement with the plaintiff’s attorney to
pay the attorney’s fees on a contingency basis, the attor-
ney’s fees for the action may not exceed—
(1) 25 percent of the first $150,000 of any
award or settlement paid to the plaintiff; or
(2) 15 percent of any additional amounts paid
to the plaintiff.
(b) REQUIRING PARTY CONTESTING ADR RULING
TO PAY ATTORNEY’S FEES AND OTHER COSTS.—
(1) IN GENERAL.—The court in a medical mal-
practice liability action shall require the party that
(pursuant to section 212(c)(1)) contested the ruling
of the alternative dispute resolution system with re-
spect to the medical malpractice liability claim that
is the subject of the action to pay to the opposing
party the costs incurred by the opposing party under
the action, including attorney’s fees, fees paid to ex-
pert witnesses, and other litigation expenses (but not
including court costs, filing fees, or other expenses
paid directly by the party to the court, or any fees
or costs associated with the resolution of the claim
under the alternative dispute resolution system), but
only if—
(A) in the case of an action in which the
party that contested the ruling is the plaintiff,
103
the amount of damages awarded to the party
under the action does not exceed the amount of
damages awarded to the party under the ADR
system by at least 10 percent; and
(B) in the case of an action in which the
party that contested the ruling is the defendant,
the amount of damages assessed against the
party under the action is not at least 10 per-
cent less than the amount of damages assessed
under the ADR system.
(2) EXCEPTIONS.—Paragraph (1) shall not
apply if—
(A) the party contesting the ruling made
under the previous alternative dispute resolu-
tion system shows that—
(i) the ruling was procured by corrup-
tion, fraud, or undue means,
(ii) there was partiality or corruption
under the system,
(iii) there was other misconduct under
the system that materially prejudiced the
party’s rights, or
(iv) the ruling was based on an error
of law;
104
(B) the party contesting the ruling made
under the previous alternative dispute resolu-
tion system presents new evidence before the
trier of fact that was not available for presen-
tation under the ADR system;
(C) the medical malpractice liability action
raised a novel issue of law; or
(D) the court finds that the application of
such paragraph to a party would constitute an
undue hardship, and issues an order waiving or
modifying the application of such paragraph
that specifies the grounds for the court’s deci-
sion.
SEC. 217. JOINT AND SEVERAL LIABILITY.
The liability of each defendant in a medical mal-
practice liability action shall be several only and shall not
be joint, and each defendant shall be liable only for the
amount of damages allocated to the defendant in direct
proportion to the defendant’s percentage of responsibility
(as determined by the trier of fact).
SEC. 218. UNIFORM STANDARD FOR DETERMINING NEG-
LIGENCE.
Except as provided in subsection (b), a defendant in
a medical malpractice liability action may not be found
to have acted negligently unless the defendant’s conduct
105
at the time of providing the health care services that are
the subject of the action was not reasonable.
SEC. 219. APPLICATION OF MEDICAL PRACTICE GUIDE-
LINES IN MALPRACTICE LIABILITY ACTIONS.
(a) USE
OF GUIDELINES
AS AFFIRMATIVE DE-
FENSE.—In any medical malpractice liability action, it
shall be a complete defense to any allegation that the de-
fendant was negligent that, in the provision of (or the fail-
ure to provide) the services that are the subject of the
action, the defendant followed the appropriate practice
guideline.
(b) RESTRICTION ON GUIDELINES CONSIDERED AP-
PROPRIATE.—
(1) 
GUIDELINES
SANCTIONED
BY
SEC-
RETARY.—For purposes of subsection (a), a practice
guideline may not be considered appropriate with re-
spect to actions brought during a year unless the
Secretary has sanctioned the use of the guideline for
purposes of an affirmative defense to medical mal-
practice liability actions brought during the year in
accordance with paragraph (2) or (3).
(2) PROCESS FOR SANCTIONING GUIDELINES.—
Not less frequently than October 1 of each year (be-
ginning with 1994), the Secretary shall review the
practice guidelines and standards developed by the
106
Administrator for Health Care Policy and Research
pursuant to section 1142 of the Social Security Act,
and shall sanction those guidelines which the Sec-
retary considers appropriate for purposes of an af-
firmative defense to medical malpractice liability ac-
tions brought during the next calendar year as ap-
propriate practice guidelines for purposes of sub-
section (a).
(3) USE OF STATE GUIDELINES.—Upon the ap-
plication of a State, the Secretary may sanction
practice guidelines selected by the State for purposes
of an affirmative defense to medical malpractice li-
ability actions brought in the State as appropriate
practice guidelines for purposes of subsection (a) if
the guidelines meet such requirements as the Sec-
retary may impose.
(c) PROHIBITING APPLICATION OF FAILURE TO FOL-
LOW GUIDELINES AS PRIMA FACIE EVIDENCE OF NEG-
LIGENCE.—No plaintiff in a medical malpractice liability
action may be deemed to have presented prima facie evi-
dence that a defendant was negligent solely by showing
that the defendant failed to follow the appropriate practice
guideline.
107
SEC. 220. SPECIAL PROVISION FOR CERTAIN OBSTETRIC
SERVICES.
(a) IMPOSITION OF HIGHER STANDARD OF PROOF.—
(1) IN
GENERAL.—In the case of a medical
malpractice liability action relating to services pro-
vided during labor or the delivery of a baby, if the
defendant health care professional did not previously
treat the plaintiff for the pregnancy, the trier of fact
may not find that the defendant committed mal-
practice and may not assess damages against the de-
fendant unless the malpractice is proven by clear
and convincing evidence.
(2) APPLICABILITY TO GROUP PRACTICES OR
AGREEMENTS AMONG PROVIDERS.—For purposes of
paragraph (1), a health care professional shall be
considered to have previously treated an individual
for a pregnancy if the professional is a member of
a group practice whose members previously treated
the individual for the pregnancy or is providing serv-
ices to the individual during labor or the delivery of
a baby pursuant to an agreement with another pro-
fessional.
(b) CLEAR AND CONVINCING EVIDENCE DEFINED.—
In subsection (a), the term ‘‘clear and convincing evi-
dence’’ is that measure or degree of proof that will
produce in the mind of the trier of fact a firm belief or
108
conviction as to the truth of the allegations sought to be
established, except that such measure or degree of proof
is more than that required under preponderance of the evi-
dence, but less than that required for proof beyond a rea-
sonable doubt.
(c) EFFECTIVE DATE.—This section shall apply to
claims accruing or actions brought on or after the expira-
tion of the 2-year period that begins on the date of the
enactment of this Act.
SEC. 221. PREEMPTION.
(a) IN GENERAL.—This part supersedes any State
law only to the extent that State law—
(1) permits the recovery of a greater amount of
damages by a plaintiff;
(2) permits the collection of a greater amount
of attorneys’ fees by a plaintiff’s attorney;
(3) establishes a longer period during which a
medical malpractice liability claim may be initiated;
or
(4) establishes a stricter standard for determin-
ing whether a defendant was negligent or for deter-
mining the liability of defendants described in sec-
tion 220(a) in actions described in such section.
109
(b) EFFECT ON SOVEREIGN IMMUNITY AND CHOICE
OF LAW OR VENUE.—Nothing in subsection (a) shall be
construed to—
(1) waive or affect any defense of sovereign im-
munity asserted by any State under any provision of
law;
(2) waive or affect any defense of sovereign im-
munity asserted by the United States;
(3) affect the applicability of any provision of
the Foreign Sovereign Immunities Act of 1976;
(4) preempt State choice-of-law rules with re-
spect to claims brought by a foreign nation or a citi-
zen of a foreign nation; or
(5) affect the right of any court to transfer
venue or to apply the law of a foreign nation or to
dismiss a claim of a foreign nation or of a citizen
of a foreign nation on the ground of inconvenient
forum.
PART 3—REQUIREMENTS FOR ALTERNATIVE DISPUTE
RESOLUTION SYSTEMS (ADR)
SEC. 231. BASIC REQUIREMENTS.
(a) IN GENERAL.—A State’s alternative dispute reso-
lution system meets the requirements of this section if the
system—
110
(1) applies to all medical malpractice liability
claims under the jurisdiction of the State courts;
(2) requires that a written opinion resolving the
dispute be issued not later than 6 months after the
date by which each party against whom the claim is
filed has received notice of the claim (other than in
exceptional cases for which a longer period is re-
quired for the issuance of such an opinion), and that
the opinion contain—
(A) findings of fact relating to the dispute,
and
(B) a description of the costs incurred in
resolving the dispute under the system (includ-
ing any fees paid to the individuals hearing and
resolving the claim), together with an appro-
priate assessment of the costs against any of
the parties;
(3) requires individuals who hear and resolve
claims under the system to meet such qualifications
as the State may require (in accordance with regula-
tions of the Secretary);
(4) is approved by the State or by local govern-
ments in the State;
(5) with respect to a State system that consists
of multiple dispute resolution procedures—
111
(A) permits the parties to a dispute to se-
lect the procedure to be used for the resolution
of the dispute under the system, and
(B) if the parties do not agree on the pro-
cedure to be used for the resolution of the dis-
pute, assigns a particular procedure to the par-
ties;
(6) provides for the transmittal to the State
agency responsible for monitoring or disciplining
health care professionals and health care providers
of any findings made under the system that such a
professional or provider committed malpractice, un-
less, during the 90-day period beginning on the date
the system resolves the claim against the profes-
sional or provider, the professional or provider
brings a medical malpractice liability action contest-
ing the decision made under the system; and
(7) provides for the regular transmittal to the
Administrator for Health Care Policy and Research
of information on disputes resolved under the sys-
tem, in a manner that assures that the identity of
the parties to a dispute shall not be revealed.
(b) APPLICATION
OF
MALPRACTICE
LIABILITY
STANDARDS TO ALTERNATIVE DISPUTE RESOLUTION.—
The provisions of part 2 shall apply with respect to claims
112
brought under a State alternative dispute resolution sys-
tem or the alternative Federal system in the same manner
as such provisions apply with respect to medical mal-
practice liability actions brought in the State.
SEC. 232. CERTIFICATION OF STATE SYSTEMS; APPLICABIL-
ITY OF ALTERNATIVE FEDERAL SYSTEM.
(a) CERTIFICATION.—
(1) IN GENERAL.—Not later than October 1 of
each year (beginning with 1994), the Secretary, in
consultation with the Attorney General, shall deter-
mine whether a State’s alternative dispute resolution
system meets the requirements of this part for the
following calendar year.
(2) BASIS FOR CERTIFICATION.—The Secretary
shall certify a State’s alternative dispute resolution
system under this subsection for a calendar year if
the Secretary determines under paragraph (1) that
the system meets the requirements of section 231.
(b) APPLICABILITY OF ALTERNATIVE FEDERAL SYS-
TEM.—
(1) ESTABLISHMENT
AND
APPLICABILITY.—
Not later than October 1, 1994, the Secretary, in
consultation with the Attorney General, shall estab-
lish by rule an alternative Federal ADR system for
the resolution of medical malpractice liability claims
113
during a calendar year in States that do not have
in effect an alternative dispute resolution system
certified under subsection (a) for the year.
(2) REQUIREMENTS FOR SYSTEM.—Under the
alternative Federal ADR system established under
paragraph (1)—
(A) paragraphs (1), (2), (6), and (7) of
section 231(a) shall apply to claims brought
under the system;
(B) claims brought under the system shall
be heard and resolved by arbitrators appointed
by the Secretary in consultation with the Attor-
ney General; and
(C) with respect to a State in which the
system is in effect, the Secretary may (at the
State’s request) modify the system to take into
account the existence of dispute resolution pro-
cedures in the State that affect the resolution
of medical malpractice liability claims.
SEC. 233. REPORTS ON IMPLEMENTATION AND EFFECTIVE-
NESS OF ALTERNATIVE DISPUTE RESOLU-
TION SYSTEMS.
(a) IN GENERAL.—Not later than 5 years after the
date of the enactment of this Act, the Secretary shall pre-
pare and submit to Congress a report describing and eval-
114
uating State alternative dispute resolution systems oper-
ated pursuant to this part and the alternative Federal sys-
tem established under section 232(b).
(b) CONTENTS OF REPORT.—The Secretary shall in-
clude in the report prepared and submitted under sub-
section (a)—
(1) information on—
(A) the effect of such systems on the cost
of health care within each State,
(B) the impact of such systems on the ac-
cess of individuals to health care within the
State, and
(C) the effect of such systems on the qual-
ity of health care provided within the State; and
(2) to the extent that such report does not pro-
vide information on no-fault systems operated by
States as alternative dispute resolution systems pur-
suant to this part, an analysis of the feasibility and
desirability of establishing a system under which
medical malpractice liability claims shall be resolved
on a no-fault basis.
115
PART 4—OTHER REQUIREMENTS AND PROGRAMS
SEC. 241. FACILITATING DEVELOPMENT AND USE OF
MEDICAL PRACTICE GUIDELINES.
(a) INCREASE IN AUTHORIZATION OF APPROPRIA-
TIONS.—Section 1142(i)(1) of the Social Security Act (42
U.S.C. 1320b–12(i)(1)) is amended by striking ‘‘and’’ at
the end of subparagraph (D) and by striking subpara-
graph (E) and inserting the following:
‘‘(E) $195,000,000 for fiscal year 1994 (of
which $10,000,000 shall be used for sanction-
ing practice guidelines for purposes of an af-
firmative defense in medical malpractice liabil-
ity actions); and
‘‘(F) $20,000,000 for each of fiscal year
1995 and 1996, to be used for sanctioning
practice guidelines for purposes of an affirma-
tive defense in medical malpractice liability ac-
tions.’’.
(b) CONSIDERATION
OF MALPRACTICE LIABILITY
DATA IN DEVELOPING AND UPDATING GUIDELINES.—
Section 1142(c)(5) of such Act (42 U.S.C. 1320b–
12(c)(5)) is amended by striking ‘‘claims data’’ and all
that follows through ‘‘patients’’ and inserting the follow-
ing: ‘‘claims data, data on clinical and functional status