157 
gaining agreements which are reached pursuant to 
collective bargaining described in section 8(d) of the 
National Labor Relations Act (29 U.S.C. 158(d)) or 
paragraph Fourth of section 2 of the Railway Labor 
Act (45 U.S.C. 152, paragraph Fourth) or which are 
reached pursuant to labor-management negotiations 
under similar provisions of State public employee re-
lations laws, or 
‘‘(3) being a plan or arrangement described in 
section 3(40)(A)(i), 
shall, upon conviction, be imprisoned not more than 5 
years, be fined under title 18, United States Code, or 
both.’’. 
(b) CEASE ACTIVITIES ORDERS.—Section 502 of 
such Act (29 U.S.C. 1132) is amended by adding at the 
end the following new subsection: 
‘‘(n) ASSOCIATION HEALTH PLAN CEASE AND DE-
SIST ORDERS.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
upon application by the Secretary showing the oper-
ation, promotion, or marketing of an association 
health plan (or similar arrangement providing bene-
fits consisting of medical care (as defined in section 
733(a)(2))) that— 
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‘‘(A) is not certified under part 8, is sub-
ject under section 514(b)(6) to the insurance 
laws of any State in which the plan or arrange-
ment offers or provides benefits, and is not li-
censed, registered, or otherwise approved under 
the insurance laws of such State, or 
‘‘(B) is an association health plan certified 
under part 8 and is not operating in accordance 
with the requirements under part 8 for such 
certification, 
a district court of the United States shall enter an 
order requiring that the plan or arrangement cease 
activities. 
‘‘(2) EXCEPTION.—Paragraph (1) shall not 
apply in the case of an association health plan or 
other arrangement if the plan or arrangement shows 
that— 
‘‘(A) all benefits under it referred to in 
paragraph (1) consist of health insurance cov-
erage, and 
‘‘(B) with respect to each State in which 
the plan or arrangement offers or provides ben-
efits, the plan or arrangement is operating in 
accordance with applicable State laws that are 
not superseded under section 514. 
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159 
‘‘(3) ADDITIONAL
EQUITABLE
RELIEF.—The 
court may grant such additional equitable relief, in-
cluding any relief available under this title, as it 
deems necessary to protect the interests of the pub-
lic and of persons having claims for benefits against 
the plan.’’. 
(c) RESPONSIBILITY
FOR CLAIMS PROCEDURE.— 
Section 503 of such Act (29 U.S.C. 1133) is amended by 
inserting ‘‘(a) IN GENERAL.—’’ before ‘‘In accordance’’, 
and by adding at the end the following new subsection: 
‘‘(b) ASSOCIATION HEALTH PLANS.—The terms of 
each association health plan which is or has been certified 
under part 8 shall require the board of trustees or the 
named fiduciary (as applicable) to ensure that the require-
ments of this section are met in connection with claims 
filed under the plan.’’. 
SEC. 454. COOPERATION BETWEEN FEDERAL AND STATE 
AUTHORITIES. 
Section 506 of the Employee Retirement Income Se-
curity Act of 1974 (29 U.S.C. 1136) is amended by adding 
at the end the following new subsection: 
‘‘(d) CONSULTATION WITH STATES WITH RESPECT 
TO ASSOCIATION HEALTH PLANS.— 
‘‘(1) AGREEMENTS
WITH
STATES.—The Sec-
retary shall consult with the State recognized under 
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paragraph (2) with respect to an association health 
plan regarding the exercise of— 
‘‘(A) the Secretary’s authority under sec-
tions 502 and 504 to enforce the requirements 
for certification under part 8, and 
‘‘(B) the Secretary’s authority to certify 
association health plans under part 8 in accord-
ance with regulations of the Secretary applica-
ble to certification under part 8. 
‘‘(2) RECOGNITION
OF
PRIMARY
DOMICILE 
STATE.—In carrying out paragraph (1), the Sec-
retary shall ensure that only one State will be recog-
nized, with respect to any particular association 
health plan, as the State with which consultation is 
required. In carrying out this paragraph— 
‘‘(A) in the case of a plan which provides 
health insurance coverage (as defined in section 
812(a)(3)), such State shall be the State with 
which filing and approval of a policy type of-
fered by the plan was initially obtained, and 
‘‘(B) in any other case, the Secretary shall 
take into account the places of residence of the 
participants and beneficiaries under the plan 
and the State in which the trust is main-
tained.’’. 
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161 
SEC. 455. EFFECTIVE DATE AND TRANSITIONAL AND 
OTHER RULES. 
(a) EFFECTIVE DATE.—The amendments made by 
this subtitle shall take effect 1 year after the date of the 
enactment of this Act. The Secretary of Labor shall first 
issue all regulations necessary to carry out the amend-
ments made by this subtitle within 1 year after the date 
of the enactment of this Act. 
(b) TREATMENT
OF CERTAIN EXISTING HEALTH 
BENEFITS PROGRAMS.— 
(1) IN GENERAL.—In any case in which, as of 
the date of the enactment of this Act, an arrange-
ment is maintained in a State for the purpose of 
providing benefits consisting of medical care for the 
employees and beneficiaries of its participating em-
ployers, at least 200 participating employers make 
contributions to such arrangement, such arrange-
ment has been in existence for at least 10 years, and 
such arrangement is licensed under the laws of one 
or more States to provide such benefits to its par-
ticipating employers, upon the filing with the appli-
cable authority (as defined in section 812(a)(5) of 
the Employee Retirement Income Security Act of 
1974 (as amended by this subtitle)) by the arrange-
ment of an application for certification of the ar-
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162 
rangement under part 8 of subtitle B of title I of 
such Act— 
(A) such arrangement shall be deemed to 
be a group health plan for purposes of title I 
of such Act; 
(B) the requirements of sections 801(a) 
and 803(a) of the Employee Retirement Income 
Security Act of 1974 shall be deemed met with 
respect to such arrangement; 
(C) the requirements of section 803(b) of 
such Act shall be deemed met, if the arrange-
ment is operated by a board of directors 
which— 
(i) is elected by the participating em-
ployers, with each employer having one 
vote; and 
(ii) has complete fiscal control over 
the arrangement and which is responsible 
for all operations of the arrangement; 
(D) the requirements of section 804(a) of 
such Act shall be deemed met with respect to 
such arrangement; and 
(E) the arrangement may be certified by 
any applicable authority with respect to its op-
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163 
erations in any State only if it operates in such 
State on the date of certification. 
The provisions of this subsection shall cease to apply 
with respect to any such arrangement at such time 
after the date of the enactment of this Act as the 
applicable requirements of this subsection are not 
met with respect to such arrangement. 
(2) DEFINITIONS.—For purposes of this sub-
section, the terms ‘‘group health plan’’, ‘‘medical 
care’’, and ‘‘participating employer’’ shall have the 
meanings provided in section 812 of the Employee 
Retirement Income Security Act of 1974, except 
that the reference in paragraph (7) of such section 
to an ‘‘association health plan’’ shall be deemed a 
reference to an arrangement referred to in this sub-
section. 
Subtitle G—Greater Choice for 
Veterans 
SEC. 461. REMOVING BARRIERS TO HEALTH CARE CHOICE 
FOR CATEGORY 1 VETERANS AND MEDAL OF 
HONOR RECIPIENTS. 
Section 101(b)(2) of the Veterans Access, Choice, 
and Accountability Act of 2014 (Public Law 113–146; 38 
U.S.C. 1701 note) is amended— 
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164 
(1) in subparagraph (C)(ii), by striking the 
‘‘or’’ at the end; 
(2) in subparagraph (D)(ii)(II), by striking the 
period at the end and inserting ‘‘; or’’; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(E) is a veteran described in section 
1705(a)(1) of title 38, United States Code, or 
a veteran who was awarded the medal of honor 
under section 3741, 6241, or 8741 of title 10 
or section 491 of title 14.’’. 
TITLE V—REFORMING MEDICAL 
LIABILITY LAW 
SEC. 501. REQUIREMENTS FOR SELECTION OF CLINICAL 
PRACTICE GUIDELINES. 
(a) SELECTION.—Not later than 6 months after the 
date of enactment of this Act, eligible professional organi-
zations that have established, published, maintained, and 
updated on a regular basis, clinical practice guidelines, in-
cluding when applicable, appropriate use criteria, that in-
corporate best practices, may submit such guidelines to 
the Secretary. Not later than 6 months after the last day 
for submitting such guidelines, the Secretary shall select 
and designate one or more eligible professional organiza-
tions to provide and maintain such clinical practice guide-
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165 
lines on behalf of the Secretary. Not later than 6 months 
after designating each such eligible professional organiza-
tion, the Secretary shall enter into an agreement with each 
such eligible professional organization for maintenance, 
publication, and updating of such clinical practice guide-
lines. 
(b) MAINTENANCE.— 
(1) PERIODIC REVIEW.—Not later than 5 years 
the Secretary enters into an agreement with each el-
igible professional organization under subsection (a), 
and every 5 years thereafter, the Secretary shall re-
view the clinical practice guidelines of such organiza-
tion and shall, as necessary, enter into agreements 
with additional eligible professional organizations, as 
appropriate, in accordance with subsection (a). 
(2) UPDATE BY ELIGIBLE PROFESSIONAL ORGA-
NIZATION.—An eligible professional organization 
that collaborated in the establishment of a clinical 
practice guidelines may submit amendments to that 
clinical practice guideline at any time to the Sec-
retary for review by the Secretary. 
(3) NOTIFICATION REQUIRED FOR CERTAIN UP-
DATES.—An amendment under paragraph (2) may 
not add, materially change, or remove a guideline 
from a set of guidelines, unless notification of such 
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166 
update is made available to applicable eligible profes-
sionals. 
SEC. 502. DEVELOPMENT. 
(a) GUIDELINE STANDARDS.—The Secretary shall 
ensure that, to the extent practicable, the development of 
clinical practice guidelines are guided by the Standards 
for Developing Trustworthy Clinical Practice Guidelines of 
the Institute of Medicine and— 
(1) are developed through a transparent process 
that minimizes conflicts of interest; 
(2) are developed by a knowledgeable, multi-
disciplinary panel of experts and representatives 
from key affected groups; 
(3) take into consideration important patient 
subgroups and patient preferences, as appropriate; 
(4) are based on a systematic review of the ex-
isting evidence; 
(5) provide a clear explanation of the relation-
ship between care options and health outcomes; 
(6) provide ratings of both the quality of evi-
dence and strength of recommendation; 
(7) are reconsidered and revised when new evi-
dence emerges; and 
(8) clearly identify any exceptions to the appli-
cation of the clinical practice guideline. 
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167 
(b) REQUIRED DISCLOSURES FROM ELIGIBLE PRO-
FESSIONAL ORGANIZATIONS.—Any person who is affili-
ated with an eligible professional organization and who di-
rectly participated in the creation of a clinical practice 
guideline shall disclose any conflicts of interest pertaining 
to the development of the clinical practice guideline, in-
cluding any conflict of interest pertaining to any instru-
ment, medicine, drug, or any other substance, device, or 
means included in the clinical practice guideline. Disclo-
sures to the Secretary by eligible professional organiza-
tions shall be made promptly, upon submission of the 
guidelines, and during every review of the guidelines. Dis-
closures shall include the following: 
(1) Scientific methodology and evidence that 
supports clinical practice guidelines. 
(2) Outside collaborators. 
(3) Endorsements. 
SEC. 503. NO LIABILITY FOR GUIDELINE PRODUCERS. 
Neither an eligible professional organization nor the 
participants in its guideline development and approval 
process, may be held liable for any injury alleged to be 
caused by adhering to a clinical practice guideline to which 
they contributed. 
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168 
SEC. 504. INTERNET PUBLICATION OF GUIDELINES. 
The Secretary shall publish on the Internet through 
the National Guideline Clearinghouse or other appropriate 
sites or sources, all clinical practice guidelines, including 
all data and methodology used in the development and se-
lection of the guidelines in compliance with data disclosure 
standards in the Health Insurance Portability and Ac-
countability Act of 1996 (Public Law 104–191). 
SEC. 
505. 
STATE 
FLEXIBILITY 
AND 
PROTECTION 
OF 
STATES’ RIGHTS. 
(a) LIMITATION.—This Act shall not preempt or su-
persede any State or Federal law that— 
(1) imposes procedural or substantive protec-
tions for health care providers and health care orga-
nizations from liability, loss, or damages greater 
than such protections provided by this title; or 
(2) creates a cause of action related to the pro-
vision of health care goods or services. 
(b) STATE FLEXIBILITY.—No provision of this Act 
shall be construed to preempt any defense available to a 
party in a health care liability action under any other pro-
vision of State or Federal law. 
SEC. 506. FEDERAL CAUSE OF ACTION. 
(a) IN GENERAL.—Chapter 85 of title 28, United 
States Code, is amended by adding at the end the fol-
lowing: 
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169 
‘‘§ 1370. Health care liability claims 
‘‘(a) DEFINITIONS.—In this section, the terms ‘appli-
cable eligible professional’, ‘health care goods or services’, 
‘health care liability action’, ‘health care liability claim’, 
‘health care organization’, and ‘health care provider’ have 
the meaning given such terms in section 10 of the Saving 
Lives, Saving Costs Act. 
‘‘(b) JURISDICTION OF CLAIMS.—The district courts 
shall have original jurisdiction of a health care liability ac-
tion against an applicable eligible professional, health care 
provider, or health care organization. 
‘‘(c) SUBSTANTIVE LAW.—The substantive law for 
decision in a health care liability action brought under 
subsection (b) shall be derived from the law, including 
choice of law principles, of the State in which the provision 
of, use of, or payment for (or the failure to provide, use, 
or pay for) health care goods or services giving rise to 
the health care liability claim occurred unless such law is 
inconsistent with or preempted by Federal law.’’. 
(b) TECHNICAL AND CONFORMING AMENDMENT.— 
The table of sections for chapter 85 of title 28, United 
States Code, is amended by adding at the end the fol-
lowing: 
‘‘1370. Health care liability claims.’’. 
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170 
SEC. 507. RIGHT OF REMOVAL. 
Section 1441 of title 28, United States Code, is 
amended by adding at the end the following: 
‘‘(g) CERTAIN ACTIONS AGAINST MEDICAL PROFES-
SIONALS.—(1) A health care liability action brought in a 
State court against an applicable eligible professional, 
health care provider, or health care organization may be 
removed by any defendant or the defendants to the district 
court of the United States for the district and division em-
bracing the place where such action is pending. 
‘‘(2) In this subsection, the terms ‘applicable eligible 
professional’, ‘health care liability action’, ‘health care or-
ganization’, and ‘health care provider’ have the meaning 
given such terms in section 10 of the Saving Lives, Saving 
Costs Act.’’. 
SEC. 508. MANDATORY REVIEW BY INDEPENDENT MEDICAL 
PANEL. 
(a) IN GENERAL.—If, in any health care liability ac-
tion removed to Federal court pursuant to section 1441(g) 
of title 28, United States Code, against an applicable eligi-
ble professional, health care provider, or health care orga-
nization, the applicable eligible professional, health care 
provider, or health care organization alleges, in response 
to a filing of the claimant, that the applicable eligible pro-
fessional, health care provider, or health care organization 
adhered to an applicable clinical practice guideline in the 
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171 
provision of health care goods or services to the claimant, 
then the court shall suspend further proceedings on the 
health care liability action prior to discovery proceedings, 
until the completion of a review of the action by an inde-
pendent medical review panel. 
(b) INDEPENDENT MEDICAL REVIEW PANEL.— 
(1) COMPOSITION.—An independent medical re-
view panel under this section shall be composed of 
3 members who are experts in the relevant field of 
clinical practice, appointed in accordance with para-
graph (5). 
(2) 
REQUIREMENTS
FOR
MEMBER
ELIGI-
BILITY.— 
(A) IN GENERAL.—To be eligible to serve 
on an independent medical review panel, a 
member shall— 
(i) be an experienced physician cer-
tified by a board recognized by the Amer-
ican Board of Medical Specialties; 
(ii) not earlier than 2 years prior to 
the date of selection to the board, have 
been in active medical practice or devoted 
a substantial portion of his or her time to 
teaching at an accredited medical school, 
or have been engaged in university-based 
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172 
research in relation to the medical care 
and type of treatment at issue; and 
(iii) be approved by his or her spe-
cialty society. 
(B) REGIONAL PREFERENCE.—When pos-
sible, members should be from the region where 
the case in question originates to account for 
geographical practice variation. 
(3) NO CIVIL LIABILITY FOR MEMBERS.—No 
civil action shall be brought in any court against any 
member for any act, failure to act, or statement or 
opinion made, within the scope of his or her duties 
as a member of the independent medical review 
panel. 
(4) CONSIDERATIONS IN MAKING DETERMINA-
TIONS.—The members of the independent medical 
review panel shall acknowledge that, under certain 
circumstances, it may be appropriate for a physician 
to depart from the recommendations in clinical prac-
tice guidelines in the care of individual patients. 
(5) SELECTION OF MEMBERS.—Each member 
of the independent medical review panel shall be 
jointly selected by the parties. A member whose se-
lection one party does not concur in may not serve 
on the panel, except that, if, not later than 30 days 
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179 
ants, or other parties, or the number of causes of ac-
tion, in which the claimant alleges a health care li-
ability claim. 
(8) HEALTH
CARE
LIABILITY
CLAIM.—The 
term ‘‘health care liability claim’’ means a claim by 
any person against an applicable eligible profes-
sional, a health care provider, or a health care orga-
nization which is based upon the provision of, use of, 
or payment for (or the failure to provide, use, or pay 
for) health care goods or services for which at least 
partial payment was made by a Federal payor or 
which was mandated by Federal law, regardless of 
the theory of liability on which the claim is based. 
(9) HEALTH CARE ORGANIZATION.—The term 
‘‘health care organization’’ means any person or en-
tity which is obligated to provide or pay for health 
benefits under any health plan, including any person 
or entity acting under a contract or arrangement 
with a health care organization to provide or admin-
ister any health benefit. 
(10) HEALTH
CARE
PROVIDER.—The term 
‘‘health care provider’’ means any person or entity 
required by State or Federal laws or regulations to 
be licensed, registered, or certified to provide health 
care services, and being either so licensed, reg-
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