tion associated with health care provided by the
plan; and
(B) the administrative and funding capac-
ity of the plan to support and emphasize pre-
ventive care, utilization, access and availability,
cost effectiveness, acceptable treatment modali-
ties, specialists referrals, the peer review proc-
ess, and the efficiency of the administrative
process.
(2) FUNCTIONS.—A quality improvement pro-
gram established pursuant to paragraph (1) shall—
(A) assess the performance of the plan and
its participating health professionals and pro-
viders and report the results of such assessment
to plan purchasers, participating health profes-
sionals and providers, and administrative per-
sonnel;
(B) demonstrate measurable improvements
in clinical outcomes and plan performance
measured by identified criteria, including those
specified in paragraph (1)(A); and
(C) analyze quality assessment data to de-
termine specific interactions in the delivery sys-
tem (both the design and funding of the plan
and the clinical provision of care) that have an
adverse impact on the quality of care.
(3) COLLABORATION.—(A) Congress shall ap-
point a time-limited commission, consisting of health
care consumers, providers, and experts in the field,
to devise and recommend to the Secretary a mecha-
nism for ongoing collaboration among health profes-
sionals and providers, consumers, and experts on
quality assurance to provide for—
(i) educational intervention when services
are 
characterized 
by 
underutilization,
overutilization, or poor clinical quality;
(ii) organizational and financial consulta-
tion when a health plan is characterized by poor
access, availability, and utilization of services,
limitations in the scope of acceptable treatment
modalities, or high administrative costs; and
(iii) other remedies if the interventions de-
scribed in subparagraphs (A) and (B) are un-
successful.
(B) The Secretary shall, in consultation with
the commission created in section (A), develop a
mechanism for ongoing collaboration among health
professionals and providers, consumers, and experts
on quality assurance, for the purposes delineated in
Section (A) subparts (i), (ii), and (iii).
(b) CASE REVIEW.—By January 1, 1998, a health
plan meets the requirements of this section only if the plan
has replaced individual case review with the analysis of
practice profiles, except for cases of health professionals
and providers identified as outliers which would require
individual case review to explain the health professional’s
or provider’s outlier status.
SEC. 210. RELATED PROVISIONS.
(a) INCENTIVES TO SERVE UNDERSERVED AREAS.—
The Secretary shall study and report to the Congress on
the feasibility and desirability of voluntary participation
by health plans in a system that—
(1) uses a risk adjustment mechanism to arrive
at appropriately enhanced premium payments to
health plans serving high risk or underserved popu-
lations, and
(2) requires part of such premiums to be passed
through to health professionals and providers serving
such populations in the form of bonus payments or
higher reimbursement rates.
TITLE III—ENFORCEMENT
SEC. 301. HEALTH PLAN STANDARDS.
The Secretary shall promulgate such regulations as
are necessary and appropriate to provide for the enforce-
ment of the requirements of this Act. The remedies speci-
fied in subsection (i) of section 1876 of the Social Security
Act shall apply to health plans under this Act in the same
manner as they apply to eligible organizations under title
XVIII of such Act.
SEC. 302. HEALTH PLAN LIABILITY.
(a) HEALTH PLAN LIABILITY.—No health plan may
engage in any activity that has the effect of inappropri-
ately limiting or denying care to any individual enrolled
in such plan through any utilization review or cost con-
tainment technique. Any such individual who alleges an
injury caused by the application of a clinically or medically
inappropriate decision resulting from defects in the design
or application of any utilization review or cost containment
technique by a health plan may commence a civil action
against the health plan in the appropriate State court or
district court of the United States.
(b) INDEMNITY RESTRICTION.—No health plan may
require any health professional or provider to indemnify
the plan for any recovery by an individual in an action
brought under subsection (a).
(c) RELIEF.—In any action commenced under sub-
section (a), a court that finds for the individual commenc-
ing the action may award appropriate relief to such indi-
vidual.
(d) PREEMPTION.—Notwithstanding any other provi-
sion of law, no State may limit the liability of a health
plan for any claim that is brought under subsection (a).
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