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132nd MAINE LEGISLATURE
FIRST SPECIAL SESSION-2025
Legislative Document No. 1301
S.P. 531 In Senate, March 25, 2025
An Act to Prohibit the Use of Artificial Intelligence in the Denial of
Health Insurance Claims
Reference to the Committee on Health Coverage, Insurance and Financial Services
suggested and ordered printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator TIPPING of Penobscot.
Cosponsored by Representative GRAMLICH of Old Orchard Beach and
Senators: BAILEY of York, President DAUGHTRY of Cumberland, MARTIN of Oxford,
RENY of Lincoln, Representatives: ARFORD of Brunswick, CLUCHEY of Bowdoinham,
DODGE of Belfast, ZAGER of Portland.
Page 1 - 132LR1768(01)
1Be it enacted by the People of the State of Maine as follows:
2Sec. 1. 24-A MRSA §4304, sub-§8 is enacted to read:
38. Use of artificial intelligence. Beginning January 1, 2026, the use of artificial
4 intelligence by a carrier, or by any 3rd party contracted by a carrier, to make medical review
5 or utilization review determinations relating to the approval, denial, delay, modification or
6 adjustment of coverage for services under a health plan is governed by this subsection.
7 A. Determinations derived from the use of artificial intelligence, including algorithms
8 and other software tools, must:
9 (1) Be based upon an enrollee's medical history, as applicable, and individual
10 clinical circumstances as presented by the requesting provider, as well as other
11 relevant clinical information contained in the enrollee's medical record, and not
12 supplant provider decision making;
13 (2) Not directly or indirectly discriminate against an enrollee on the basis of race,
14 color, religion, national origin, ancestry, age, sex, gender, gender identity, gender
15 expression, sexual orientation, present or predicted disability, expected length of
16 life, degree of medical dependency, quality of life or other health conditions;
17 (3) Be fairly and equitably applied; and
18 (4) Be open to inspection, and the use of artificial intelligence must be disclosed in
19 the written policies and procedures to an enrollee.
20 Use of artificial intelligence pursuant to this paragraph must be governed by policies
21 that establish accountability for performance, use and outcomes that are reviewed and
22 revised for accuracy and reliability. Data under this paragraph may not be used beyond
23 its intended and stated purpose. Data under this paragraph must be protected from risk
24 that may directly or indirectly cause harm to the enrollee.
25 B. A denial, delay, modification or adjustment of health care services based on medical
26 necessity must be made by a clinical peer competent to evaluate the specific clinical
27 issues involved in the health care services requested by the enrollee's provider. The
28 clinical peer making the medical review or utilization review determination shall
29 consider the enrollee's provider's recommendation and the enrollee's medical history,
30 as applicable, and individual clinical circumstances.
31 For purposes of this subsection, "artificial intelligence" means an engineered or machine-
32 based system that varies in its level of autonomy and that can, for explicit or implicit
33 objectives, infer from the input it receives how to generate outputs that can influence
34 physical or virtual environments.
35SUMMARY
36 This bill establishes requirements, beginning January 1, 2026, for health insurance
37 carriers that use artificial intelligence to make medical review or utilization review
38 determinations relating to the approval, denial, delay, modification or adjustment of
39 coverage for services under a health plan. The bill requires that any denial, delay,
40 modification or adjustment of health care services based on medical necessity be made by
41 a clinical peer.
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