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SEC. 4102. COVERAGE OF CERTAIN IMMUNIZATIONS.
(a) IN GENERAL.—Section 1861(s)(10) of the Social
Security Act (42 U.S.C. 1395x(s)(10)) is amended—
(1) in subparagraph (A)—
(A) by striking ‘‘, subject to section
4071(b) of the Omnibus Budget Reconciliation
Act of 1987,’’, and
(B) by striking ‘‘; and’’ and inserting a
comma;
(2) in subparagraph (B), by striking the semi-
colon at the end and inserting ‘‘, and’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(C) tetanus-diphtheria booster and its admin-
istration;’’.
(b) 
LIMITATION
ON
FREQUENCY.—Section
1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), as
amended by section 4101(b)(4)(A) of this Act, is amend-
ed—
(1) in subparagraph (F), by striking ‘‘and’’ at
the end;
(2) in subparagraph (G), by striking the semi-
colon at the end and inserting ‘‘, and’’; and
(3) by adding at the end the following new sub-
paragraph:
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‘‘(H) in the case of an influenza vaccine, which
is administered within the 11 months after a pre-
vious influenza vaccine, and, in the case of a teta-
nus-diphtheria booster, which is administered within
the 119 months after a previous tetanus-diphtheria
booster;’’.
(c) CONFORMING AMENDMENT.—Section 1862(a)(7)
of such Act (42 U.S.C. 1395y(a)(7)), as amended by sec-
tion 4101(b)(4)(B) of this Act, is amended by striking ‘‘or
(G)’’ and inserting ‘‘(G), or (H)’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to influenza vaccines and tetanus-
diphtheria boosters administered on or after January 1,
1995.
SEC. 4103. COVERAGE OF WELL-CHILD CARE.
(a) IN GENERAL.—Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as amended by sec-
tion 13553(a) of the Omnibus Budget Reconciliation Act
of 1993, is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (P);
(2) by striking the semicolon at the end of sub-
paragraph (Q) and inserting ‘‘; and’’; and
(3) by adding at the end the following new sub-
paragraph:
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‘‘(R) well-child services (as defined in sub-
section (ll)(1)) provided to an individual entitled to
benefits under this title who is under 7 years of
age;’’.
(b) SERVICES DEFINED.—Section 1861 of such Act
(42 U.S.C. 1395x) is amended—
(1) by redesignating the subsection (jj) added
by section 4156(a)(2) of the Omnibus Budget Rec-
onciliation Act of 1990 as subsection (kk); and
(2) by inserting after subsection (kk) (as so re-
designated) the following new subsection:
‘‘Well-Child Services
‘‘(ll)(1) The term ‘well-child services’ means well-
child care, including routine office visits, routine immuni-
zations (including the vaccine itself), routine laboratory
tests, and preventive dental care, provided in accordance
with the periodicity schedule established with respect to
the services under paragraph (2).
‘‘(2) The Secretary, in consultation with the Amer-
ican Academy of Pediatrics, the Advisory Committee on
Immunization Practices, and other entities considered ap-
propriate by the Secretary, shall establish a schedule of
periodicity which reflects the appropriate frequency with
which the services referred to in paragraph (1) should be
provided to healthy children.’’.
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(c) 
CONFORMING
AMENDMENTS.—(1) 
Section
1861(s)(2)(O) of such Act (42 U.S.C. 1395x(s)(2)(O)) is
amended by striking ‘‘subsection (jj)’’ and inserting ‘‘sub-
section (kk)’’.
(2) Section 1862(a)(1) of such Act (42 U.S.C.
1395y(a)(1)), as amended by sections 4101(b)(4)(A) and
4102(b) of this Act, is amended—
(A) in subparagraph (G), by striking ‘‘and’’ at
the end;
(B) in subparagraph (H), by striking the semi-
colon at the end and inserting ‘‘, and’’; and
(C) by adding at the end the following new sub-
paragraph:
‘‘(I) in the case of well-child services, which are
provided more frequently than is provided under the
schedule of periodicity established by the Secretary
under section 1861(ll)(2) for such services;’’.
(3) Section 1862(a)(7) of such Act (42 U.S.C.
1395y(a)(7)), as amended by sections 4101(b)(4)(B) and
4102(c) of this Act, is amended by striking ‘‘or (H)’’ and
inserting ‘‘(H), or (I)’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to well-child services provided on
or after January 1, 1995.
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SEC. 4104. ANNUAL SCREENING MAMMOGRAPHY.
(a) 
ANNUAL
SCREENING
MAMMOGRAPHY
FOR
WOMEN OVER AGE 64.—Section 1834(c)(2)(A) of the So-
cial Security Act (42 U.S.C. 1395m(b)(2)(A)) is amend-
ed—
(1) in clause (iv), by striking ‘‘but under 65
years of age,’’, and
(2) by striking clause (v).
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to screening mammography per-
formed on or after January 1, 1995.
SEC. 4105. FINANCING OF ADDITIONAL BENEFITS.
(a) PREMIUM FOR 1995.—Section 1839(e)(1)(B)(v)
of the Social Security Act (42 U.S.C. 1395r(e)(1)(B)(v))
is amended by striking ‘‘$46.10’’ and inserting ‘‘$47.50’’.
(b) PREMIUMS FOR 1996–1998.—(1) Section 1839 of
such Act (42 U.S.C. 1395r) is amended by adding at the
end the following new subsection:
‘‘(g) Except as provided in subsections (b) and (f),
the monthly premium otherwise determined, without re-
gard to this subsection, for each individual enrolled under
this part shall be increased by $1.40 for each month in
1996, 1997, and 1998.’’.
(2) Section 1839 of such Act (42 U.S.C. 1395r) is
amended—
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advance 
directives 
(as 
defined 
in 
section
1866(f)(3)).’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to notices provided under section
1804 of the Social Security Act on or after January 1
of the first year beginning after the date of the enactment
of this Act.
TITLE V—MALPRACTICE
REFORM
Subtitle A—Findings; Purpose;
Definitions
SEC. 5001. FINDINGS; PURPOSE.
(a) FINDINGS.—Congress finds that—
(1) the health care and insurance industries are
industries affecting interstate commerce and the
medical malpractice litigation systems existing
throughout the United States affect interstate com-
merce by contributing to the high cost of health care
and premiums for malpractice insurance purchased
by health care providers; and
(2) the Federal Government has a major inter-
est in health care as a direct provider of health care
and as a source of payment for health care, and has
a demonstrated interest in assessing the quality of
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care, access to care, and the costs of care through
the evaluative activities of several Federal agencies.
(b) PURPOSE.—It is the purpose of this title to—
(1) provide grants to States to develop alter-
native dispute resolution procedures to attain a more
efficient, expeditious, and equitable resolution of
health care malpractice disputes;
(2) enhance general knowledge concerning the
benefits of different forms of alternative dispute res-
olution mechanisms; and
(3) establish uniformity and curb excesses in
the State-based medical liability systems through
Federally-mandated reforms.
SEC. 5002. DEFINITIONS.
As used in this title:
(1) ALTERNATIVE DISPUTE RESOLUTION SYS-
TEM.—The term ‘‘alternative dispute resolution sys-
tem’’ means a system that is enacted or adopted by
a State to resolve medical malpractice claims other
than through a medical malpractice liability action.
(2) CLAIMANT.—The term ‘‘claimant’’ means
any person who brings a health care liability action
and, in the case of an individual who is deceased, in-
competent, or a minor, the person on whose behalf
such an action is brought.
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(3) CLEAR AND CONVINCING EVIDENCE.—The
term ‘‘clear and convincing evidence’’ is that meas-
ure or degree of proof that will produce in the mind
of the trier of fact a firm belief or 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 reasonable doubt.
(4) 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.
(5) 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.
(6) 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 that is required by State law
or regulation to be licensed or certified by the State
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to engage in the delivery of such services in the
State.
(7) INJURY.—The term ‘‘injury’’ means any ill-
ness, disease, or other harm that is the subject of
a medical malpractice claim.
(8) MEDICAL
MALPRACTICE
LIABILITY
AC-
TION.—The term ‘‘medical malpractice liability ac-
tion’’ means any civil action brought pursuant to
State law in which a plaintiff alleges a medical mal-
practice claim against a health care provider or
health care professional, but does not include any
action in which the plaintiff’s sole allegation is an al-
legation of an intentional tort.
(9) MEDICAL MALPRACTICE CLAIM.—The term
‘‘medical malpractice claim’’ means any claim relat-
ing to the provision of (or the failure to provide)
health care services or the use of a medical product,
without regard to the theory of liability asserted,
and includes any third-party claim, cross-claim,
counterclaim, or contribution claim in a medical
malpractice liability action.
(10) MEDICAL PRODUCT.—
(A) IN
GENERAL.—The term ‘‘medical
product’’ means, with respect to the allegation
of a claimant, a drug (as defined in section
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201(g)(1) of the Federal Food, Drug, and Cos-
metic Act (21 U.S.C. 321(g)(1)) or a medical
device (as defined in section 201(h) of the Fed-
eral Food, Drug, and Cosmetic Act (21 U.S.C.
321(h)) if—
(i) such drug or device was subject to
premarket approval under section 505,
507, or 515 of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C. 355, 357, or
360e) or section 351 of the Public Health
Service Act (42 U.S.C. 262) with respect
to the safety of the formulation or per-
formance of the aspect of such drug or de-
vice which is the subject of the claimant’s
allegation or the adequacy of the packag-
ing or labeling of such drug or device, and
such drug or device is approved by the
Food and Drug Administration; or
(ii) the drug or device is generally rec-
ognized as safe and effective under regula-
tions issued by the Secretary of Health
and Human Services under section 201(p)
of the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 321(p)).
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(B) EXCEPTION
IN
CASE
OF
MISREPRE-
SENTATION OR FRAUD.—Notwithstanding sub-
paragraph (A), the term ‘‘medical product’’
shall not include any product described in such
subparagraph if the claimant shows that the
product is approved by the Food and Drug Ad-
ministration for marketing as a result of with-
held information, misrepresentation, or an ille-
gal payment by manufacturer of the product.
(11) 
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.
(12) PUNITIVE DAMAGES.—The term ‘‘punitive
damages’’ means compensation, in addition to com-
pensation for actual harm suffered, that is awarded
for the purpose of punishing a person for conduct
deemed to be malicious, wanton, willful, or exces-
sively reckless.
(13) 
SECRETARY.—The 
term 
‘‘Secretary’’
means the Secretary of Health and Human Services.
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(14) STATE.—The term ‘‘State’’ means each of
the several States, the District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands,
and Guam.
Subtitle B—Uniform Standards for
Malpractice Claims
SEC. 5101. APPLICABILITY.
Except as provided in section 5111, this subtitle shall
apply to any medical malpractice liability action brought
in a Federal or State court, and to any medical mal-
practice claim subject to an alternative dispute resolution
system, that is initiated on or after January 1, 1995.
SEC. 5102. REQUIREMENT FOR INITIAL RESOLUTION OF AC-
TION THROUGH ALTERNATIVE DISPUTE RES-
OLUTION.
(a) IN GENERAL.—
(1) STATE CASES.—A medical malpractice li-
ability action may not be brought in any State court
during a calendar year unless the medical mal-
practice liability claim that is the subject of the ac-
tion has been initially resolved under an alternative
dispute resolution system certified for the year by
the Secretary under section 5202(a), or, in the case
of a State in which such a system is not in effect
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for the year, under the alternative Federal system
established under section 5202(b).
(2) FEDERAL DIVERSITY ACTIONS.—A medical
malpractice liability action may not be brought in
any Federal court under section 1332 of title 28,
United States Code, during a calendar year unless
the medical malpractice liability claim that is the
subject of the action has been initially resolved
under the alternative dispute resolution system re-
ferred to in paragraph (1) that applied in the State
whose law applies in such action.
(3) CLAIMS AGAINST UNITED STATES.—
(A) ESTABLISHMENT
OF
PROCESS
FOR
CLAIMS.—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 chapter 171 of title 28,
United States Code. Under such process, the
resolution of a claim shall occur after the com-
pletion of the administrative claim process ap-
plicable to the claim under section 2675 of such
title.
(B) REQUIREMENT FOR INITIAL RESOLU-
TION UNDER PROCESS.—A medical malpractice
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liability action based on a medical malpractice
liability claim described in subparagraph (A)
may not be brought in any Federal court unless
the claim has been initially resolved under the
alternative dispute resolution process estab-
lished by the Attorney General under such sub-
paragraph.
(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.
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(2) DEADLINE FOR FILING ACTION.—A medical
malpractice liability action may not be brought by a
party unless—
(A) the party has filed the notice of intent
required by paragraph (1); and
(B) the party files the action in a court of
competent jurisdiction not later than 90 days
after the decision resolving the medical mal-
practice liability claim that is the subject of the
action is issued under the applicable 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) 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
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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. 5103. PROCEDURAL REQUIREMENTS FOR FILING OF
ACTIONS.
(a) CERTIFICATE OF MERIT.—
(1) IN GENERAL.—Each individual who files a
medical malpractice liability action shall, not later
than 90 days after filing the action—
(A) submit a certificate of merit described
in subsection (b); or
(B) post a surety (or equivalent security)
bond of $4,000 (or, during the 45-day period
that begins on the date the action is filed, a
cost bond of $2,000) with the court.
(2) EXTENSION OF DEADLINE.—On the motion
of any party to the action or upon a written agree-
ment of the parties filed with the court, the court
may extend the deadline specified in paragraph (1)
for a period not to exceed 30 days.
(3) DISMISSAL
FOR
FAILURE
TO
MEET
RE-
QUIREMENT.—If an individual filing a medical mal-
practice liability action fails to meet the require-
ments of paragraph (1)—
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(A) the court shall dismiss the action with-
out prejudice to the refiling of the action by the
individual; and
(B) require the individual to pay any court
costs incurred by the defendants as a result of
the filing of the action.
(4) WAIVER FOR GOOD CAUSE.—The court may
waive the application of paragraph (1) to a plaintiff
if the plaintiff shows good cause that such para-
graph should not apply.
(5) CERTIFICATE
OF
MERIT
DESCRIBED.—In
paragraph (1), a ‘‘certificate of merit’’ is, with re-
spect to an individual filing a medical malpractice li-
ability action, an affidavit declaring that the individ-
ual (or the individual’s attorney) has obtained a
written opinion from a medical expert who is knowl-
edgeable of the relevant medical issues involved in
the action that the defendant was negligent and the
defendant’s conduct was a proximate cause of the al-
leged injury that is the subject of the action.
(b) RESPONSE
TO STANDARD INTERROGATORIES
AND REQUESTS FOR DOCUMENTS.—
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(1) DEADLINE.—Each party to a medical mal-
practice liability action shall respond to the standard
set of interrogatories and requests for production of
documents developed pursuant to paragraph (4) as
follows:
(A) In the case of a plaintiff, the party
shall provide the defendant (or the defendant’s
attorney) with full and complete responses not
later than 45 days after filing the action.
(B) In the case of a defendant, the party
shall provide the plaintiff (or the plaintiff’s at-
torney) with full and complete responses not
later than 45 days after receiving the plaintiff’s
responses under subparagraph (A).
(C) In the case of a party who is added to
the action after the action is filed, the party
shall provide all other parties (or such parties’
attorneys) with full and complete responses not
later than 45 days after the date of the filing
of the pleading by which the party is added to
the action.
(2) EXTENSION OF DEADLINE.—On the motion
of any party to the action that is supported by good
cause, or upon a written agreement of the parties
filed with the court, the court shall extend the dead-
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line specified in paragraph (1) for a period not to
exceed 30 days.
(3) IMPOSITION OF SANCTIONS FOR FAILURE
TO RESPOND.—If a party to a medical malpractice
liability action fails to respond to the standard set
of interrogatories and requests for production of
documents as required under paragraph (1), the
party shall be subject to sanctions by the court
under any applicable laws, rules, and regulations
governing the imposition of sanctions by the court.
(4) DEVELOPMENT OF STANDARD INTERROG-
ATORIES AND REQUESTS.—
(A) APPOINTMENT OF EXPERT PANELS.—
The Governor of each State shall appoint a
panel to develop the standard set of interrog-
atories and requests for production of docu-
ments that will be used for purposes of this
subsection in the courts of the State. The set
shall be comprehensive and designed to expedite
the discovery process in the courts. The Attor-
ney General shall appoint a panel to develop
such set that will be used for purposes of this
subsection in the Federal courts.
(B) COMPOSITION.—Each panel appointed
pursuant to subparagraph (A) shall consist of
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not less than 6 and not more than 12 members,
of whom an equal number shall be attorneys
who customarily represent plaintiffs in medical
malpractice liability actions and attorneys who
customarily represent defendants in such ac-
tions.
(C) DEADLINES.—Not later than October
1, 1994, each panel appointed pursuant to sub-
paragraph (A) shall complete and publish the
standard set of interrogatories and requests for
production of documents.
SEC. 5104. TREATMENT OF NONECONOMIC AND PUNITIVE
DAMAGES.
(a) LIMITATION ON NONECONOMIC DAMAGES.—The
total amount of noneconomic damages that may be award-
ed to a claimant and the members of the claimant’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) NO AWARD OF PUNITIVE DAMAGES AGAINST
MANUFACTURER OF MEDICAL PRODUCT.—In the case of
a medical malpractice liability action in which the plaintiff
alleges a claim against the manufacturer of a medical
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product, no punitive or exemplary damages may be award-
ed against such manufacturer.
(c) SEVERAL LIABILITY FOR NONECONOMIC DAM-
AGES.—The liability of each defendant for noneconomic
damages shall be several only and shall not be joint, and
each defendant shall be liable only for the amount of non-
economic damages allocated to the defendant in direct pro-
portion to the defendant’s percentage of responsibility (as
determined by the trier of fact).
(d) ALLOCATION
OF PUNITIVE DAMAGE AWARDS
FOR PROVIDER LICENSING AND DISCIPLINARY ACTIVI-
TIES.—
(1) IN GENERAL.—The total amount of any pu-
nitive damages awarded in a medical malpractice li-
ability action shall be paid to the State in which the
action is brought (or, in a case brought in Federal
court, in the State in which the health care services
that caused the injury that is the subject of the ac-
tion were provided) for the purposes of carrying out
the activities described in paragraph (2).
(2) ACTIVITIES DESCRIBED.—A State shall use
amounts paid pursuant to paragraph (1) to carry
out activities to assure the safety and quality of
health care services provided in the State, including
(but not limited to)—
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(A) licensing or certifying health care pro-
fessionals and health care providers in the
State;
(B) implementing health care quality as-
surance programs;
(C) carrying out public education programs
to increase awareness of the availability of com-
parative quality information on accountable
health plans;
(D) carrying out programs to reduce mal-
practice-related costs for providers volunteering
to provide services in medically underserved
areas; and
(E) implementing and operating a State
alternative dispute resolution system certified
by the Secretary under section 5202.
(3) MAINTENANCE OF EFFORT.—A State shall
use any amounts paid pursuant to paragraph (1) to
supplement and not to replace amounts spent by the
State for the activities described in paragraph (2).
(e) DEVELOPMENT
OF ALTERNATIVE LIMITS
ON
NONECONOMIC DAMAGES.—
(1) IN GENERAL.—Not later than 1 year after
the date of the enactment of this Act, the Health
Care Standards Commission shall develop and trans-
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mit to Congress alternative limits on the amount of
noneconomic damages that may be awarded with re-
spect to medical malpractice liability claims, together
with legislative specifications necessary to replace
the limit imposed under subsection (a) on the
amount of such damages with such alternative lim-
its. The purpose of the development of the limits is
to provide certainty and fairness in malpractice
awards and to avoid unwarranted disparities among
health care providers and health care professionals
who have engaged in similar conduct.
(2) ESTABLISHMENT OF SEPARATE LIMITS FOR
CATEGORIES
OF
INJURIES.—In developing limits
under paragraph (1), the Commission shall establish
separate limits for noneconomic damages resulting
from each of the following categories of injuries:
(A) Non-physical injuries.
(B) Insignificant physical injuries.
(C) Temporary minor physical injuries.
(D) Temporary major physical injuries.
(E) Permanent minor physical injuries.
(F) Permanent substantial physical inju-
ries.
(G) Permanent major physical injuries.
(H) Permanent grave physical injuries.