Massachusetts AI in Health Insurance Prior Authorization/Utilization Review Bill (H.4616)

Properties

jurisdiction: US-MA
level: state
domain: sectoral
status: proposed
scope: An Act improving the health insurance prior authorization process. Amends Chapter 176O of the Massachusetts General Laws to add a new section 12D governing carriers and utilization review organizations that use artificial intelligence, an algorithm, or other software tool for utilization review or utilization management functions based in whole or in part on medical necessity (including entities a carrier contracts with or works through for that purpose).
obligations: New section 12D would require that any AI, algorithm, or other software tool used for utilization review: base determinations on the enrollee's medical/clinical history, individual clinical circumstances, and other relevant clinical record information; not base determinations solely on a group dataset; comply with chapter 176O sections 12-16 and applicable state/federal law; not supplant health care provider decision-making; not discriminate against enrollees; be fairly and equitably applied; be open to inspection for audit/compliance review by the Division of Insurance; require carriers to disclose AI-algorithm use to the Division, in-network providers, enrollees, and on the carrier's public website, including algorithm criteria, training datasets, the algorithm itself, and outcomes; have performance periodically reviewed and revised; not use patient data beyond its stated purpose; and not directly or indirectly cause harm to the enrollee. New subsection 12D(c) provides that an AI-based algorithm or software tool shall not be the sole basis of a decision to deny, delay or modify health care services based on medical necessity; an adverse medical-necessity or preauthorization determination may only be made by a licensed physician or licensed health care provider competent to evaluate the specific clinical issues involved.
penalties: As drafted, the Division of Insurance would enforce sections 12 through 12D and section 16 of chapter 176O; a carrier or utilization review organization failing to come into compliance after a corrective action plan would be fined up to $5,000 per day of continued violation, with the commissioner able to impose additional penalties for repeated or wanton violations. Not yet enacted, so no penalties are currently in force.
appliesTo: Health insurance carriers licensed under chapters 175, 176A, 176B and 176G, and utilization review organizations, that use AI/algorithms/software tools for utilization review or utilization management of Massachusetts-covered health benefits
officialUrl: https://malegislature.gov/Bills/194/H4616
notes: House Bill 4616, accompanying a petition from Rep. Marjorie C. Decker (House No. 1136), was reported favorably by the Joint Committee on Financial Services on October 20, 2025 and referred to the House Committee on Health Care Financing; that committee recommended the bill 'ought to pass' on July 29, 2026 and referred it to the House Committee on Ways and Means. It has not yet passed either chamber and has not been signed. The bill's own effective-date sections (Section 13-16) were drafted assuming a 2026 enactment (most provisions including new section 12D pegged to January 1, 2026, except new section 12C pegged to January 1, 2027); those dates would need to be updated or would simply lapse relative to actual enactment timing given the bill is only now clearing committee. effectiveDate is left null here because the bill is not enacted. Distinct from the already-tracked ma-s3178-frontier-ai-safety (regulates large frontier AI model developers' catastrophic-risk safety frameworks, inside an economic-development bill): H.4616 is a separate, sector-specific bill regulating health insurers' and utilization review organizations' use of AI/algorithms in prior-authorization and medical-necessity decisions, with its own bill number, sponsor, and committee of origin.

Properties

jurisdiction

US-MA

level

state

domain

sectoral

status

proposed

scope

An Act improving the health insurance prior authorization process. Amends Chapter 176O of the Massachusetts General Laws to add a new section 12D governing carriers and utilization review organizations that use artificial intelligence, an algorithm, or other software tool for utilization review or utilization management functions based in whole or in part on medical necessity (including entities a carrier contracts with or works through for that purpose).

obligations

New section 12D would require that any AI, algorithm, or other software tool used for utilization review: base determinations on the enrollee's medical/clinical history, individual clinical circumstances, and other relevant clinical record information; not base determinations solely on a group dataset; comply with chapter 176O sections 12-16 and applicable state/federal law; not supplant health care provider decision-making; not discriminate against enrollees; be fairly and equitably applied; be open to inspection for audit/compliance review by the Division of Insurance; require carriers to disclose AI-algorithm use to the Division, in-network providers, enrollees, and on the carrier's public website, including algorithm criteria, training datasets, the algorithm itself, and outcomes; have performance periodically reviewed and revised; not use patient data beyond its stated purpose; and not directly or indirectly cause harm to the enrollee. New subsection 12D(c) provides that an AI-based algorithm or software tool shall not be the sole basis of a decision to deny, delay or modify health care services based on medical necessity; an adverse medical-necessity or preauthorization determination may only be made by a licensed physician or licensed health care provider competent to evaluate the specific clinical issues involved.

penalties

As drafted, the Division of Insurance would enforce sections 12 through 12D and section 16 of chapter 176O; a carrier or utilization review organization failing to come into compliance after a corrective action plan would be fined up to $5,000 per day of continued violation, with the commissioner able to impose additional penalties for repeated or wanton violations. Not yet enacted, so no penalties are currently in force.

appliesTo

Health insurance carriers licensed under chapters 175, 176A, 176B and 176G, and utilization review organizations, that use AI/algorithms/software tools for utilization review or utilization management of Massachusetts-covered health benefits

officialUrl

https://malegislature.gov/Bills/194/H4616

notes

House Bill 4616, accompanying a petition from Rep. Marjorie C. Decker (House No. 1136), was reported favorably by the Joint Committee on Financial Services on October 20, 2025 and referred to the House Committee on Health Care Financing; that committee recommended the bill 'ought to pass' on July 29, 2026 and referred it to the House Committee on Ways and Means. It has not yet passed either chamber and has not been signed. The bill's own effective-date sections (Section 13-16) were drafted assuming a 2026 enactment (most provisions including new section 12D pegged to January 1, 2026, except new section 12C pegged to January 1, 2027); those dates would need to be updated or would simply lapse relative to actual enactment timing given the bill is only now clearing committee. effectiveDate is left null here because the bill is not enacted. Distinct from the already-tracked ma-s3178-frontier-ai-safety (regulates large frontier AI model developers' catastrophic-risk safety frameworks, inside an economic-development bill): H.4616 is a separate, sector-specific bill regulating health insurers' and utilization review organizations' use of AI/algorithms in prior-authorization and medical-necessity decisions, with its own bill number, sponsor, and committee of origin.