Health Insurance - Artificial Intelligence - Grievance Process and Reporting (AI Health Insurance Accountability Act of 2026)

EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
*hb0795*

HOUSE BILL 795
J5 6lr2074

By: Delegates Wu, Schindler, and Terrasa
Introduced and read first time: February 4, 2026
Assigned to: Health

A BILL ENTITLED

AN ACT concerning 1

Health Insurance – Artificial Intelligence – Grievance Process and Reporting 2
(AI Health Insurance Accountability Act of 2026) 3

FOR the purpose of requiring that a carrier’s internal grievance process provide for human 4
review of grievances resulting from adverse decisions made using artificial 5
intelligence, algorithm, or other software tools; requiring carriers to report certain 6
information on grievances resulting from adverse decisions made using artificial 7
intelligence, algorithm, or other software tools; requiring carriers to provide for a 8
model review process of certain artificial intelligence, algorithm, or other software 9
tools under certain circumstances; and generally relating to health insurance and 10
the use of artificial intelligence. 11

BY repealing and reenacting, with amendments, 12
Article – Insurance 13
Section 15–10A–02(b)(2) and 15–10A–06 14
Annotated Code of Maryland 15
(2017 Replacement Volume and 2025 Supplement) 16

BY repealing and reenacting, without amendments, 17
Article – Insurance 18
Section 15–10B–05.1 19
Annotated Code of Maryland 20
(2017 Replacement Volume and 2025 Supplement) 21

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 22
That the Laws of Maryland read as follows: 23

Article – Insurance 24

15–10A–02. 25

2 HOUSE BILL 795

(b) (2) In addition to the requirements of Subtitle 10B of this title, an internal 1
grievance process established by a carrier under this section shall: 2

(i) include an expedited procedure for use in an emergency case for 3
purposes of rendering a grievance decision within 24 hours of the date a grievance is filed 4
with the carrier; 5

(ii) provide that a carrier render a final decision in writing on a 6
grievance within 30 working days after the date on which the grievance is filed unless: 7

1. the grievance involves an emergency case under item (i) of 8
this paragraph; 9

2. the member, the member’s representative, or a health care 10
provider filing a grievance on behalf of a member agrees in writing to an extension for a 11
period of no longer than 30 working days; or 12

3. the grievance involves a retrospective denial under item 13
(iv) of this paragraph; 14

(iii) allow a grievance to be filed on behalf of a member by a health 15
care provider or the member’s representative; 16

(iv) provide that a carrier render a final decision in writing on a 17
grievance within 45 working days after the date on which the grievance is filed when the 18
grievance involves a retrospective denial; [and] 19

(v) for a retrospective denial, allow a member, the member’s 20
representative, or a health care provider on behalf of a member to file a grievance for at 21
least 180 days after the member receives an adverse decision; AND 22

(VI) FOR A GRIEVANCE RESULTING FROM AN ADVERSE DECISION 23
MADE USING ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOLS, 24
PROVIDE FOR THE HUMAN REVIEW OF THE ADVERSE DECISION, INCLUDING FOR 25
COMPLIANCE WITH § 15–10B–05.1 OF THIS TITLE. 26

15–10A–06. 27

(a) (1) On a quarterly basis, each carrier shall submit to the Commissioner, on 28
the form the Commissioner requires, a report that describes the following information 29
aggregated by zip code as required by the Commissioner: 30

(i) the number of members entitled to health care benefits under a 31
policy, plan, or certificate issued or delivered in the State by the carrier; 32

HOUSE BILL 795 3

(ii) the number of clean claims for reimbursement processed by the 1
carrier; 2

(iii) the activities of the carrier under this subtitle, including: 3

1. the outcome of each grievance filed with the carrier; 4

2. the number and outcomes of cases that were considered 5
emergency cases under § 15–10A–02(b)(2)(i) of this subtitle; 6

3. the time within which the carrier made a grievance 7
decision on each emergency case; 8

4. the time within which the carrier made a grievance 9
decision on all other cases that were not considered emergency cases; 10

5. the number of grievances filed with the carrier that 11
resulted from an adverse decision involving length of stay for inpatient hospitalization as 12
related to the medical procedure involved; 13

6. the number of adverse decisions issued by the carrier 14
under § 15 –10A–02(f) of this subtitle, whether the adverse decision involved a prior 15
authorization or step therapy protocol, the type of service at issue in the adverse decisions, 16
and whether an artificial intelligence, algorithm, or other software tool was used in making 17
the adverse decision; 18

7. the number of adverse decisions overturned after a 19
reconsideration request under § 15–10B–06 of this title; [and] 20

8. the n umber of requests made and granted under § 21
15–831(c)(1) and (2) of this title; and 22

9. THE TOTAL NUMBER OF GRIEVANCES REVIEWED 23
UNDER § 15–10A–02(B)(2)(VI) OF THIS SUBTITLE AND AGGREGATED BY: 24

A. TYPE OF CLAIM; 25

B. RACE, GENDER, AND PROFESSION OF MEMBER; AND 26

C. TYPE OF POLICY , INCLUDING INDIVIDUAL, SMALL 27
GROUP, OR LARGE GROUP AND WHETHER THE POLI CY WAS PURCHASED ON THE 28
HEALTH BENEFIT EXCHANGE; AND 29

(iv) the number and outcome of all other cases that are not subject to 30
activities of the carrier under this subtitle that resulted from an adverse decision involving 31
the length of stay for inpatient hospitalization as related to the medical procedure involved. 32
4 HOUSE BILL 795

(2) If the number of adverse decisions issued by a c arrier for a type of 1
service has grown by 10% or more in the immediately preceding calendar year or 25% or 2
more in the immediately preceding 3 calendar years, the carrier shall submit in the report 3
required under paragraph (1) of this subsection: 4

(i) a description of any changes in medical management 5
contributing to the rise in adverse decisions for the type of service; 6

(ii) any other known reasons for the increase; and 7

(iii) a description of the carrier’s efforts and actions taken to 8
determine the reason for the increase. 9

(3) IF, WITHIN A 6–MONTH PERIOD , MORE THAN A SPECIFIE D 10
PERCENTAGE, AS DETERMINED BY THE COMMISSIONER, OF A CARRIER’S ADVERSE 11
DECISIONS MADE USING THE SAME ARTIFICIAL INTELLIGENCE, ALGORITHM, OR 12
SOFTWARE TOOL RESULT IN A GRIEVANC E, THE CARRIER SHALL PROVIDE FOR A 13
MODEL REVIEW PROCESS OF THE ARTIFICIAL INTEL LIGENCE, ALGORITHM, OR 14
SOFTWARE TOOL AND SUBMIT THE FINDI NGS IN THE REPORT RE QUIRED UNDER 15
PARAGRAPH (1) OF THIS SUBSECTION. 16

(b) The Commissioner shall: 17

(1) compile an annual summary report based on the information provided: 18

(i) under subsection (a) of this section; and 19

(ii) by the Secretary under § 19 –705.2(e) of the Health – General 20
Article; 21

(2) report any violations or actions taken under § 15–10B–11 of this title; 22
and 23

(3) provide copies of the summary report to the Governor and, subject to § 24
2–1257 of the State Government Article, to the General Assembly. 25

(c) The Commissioner may use information provided under subsection (a) of this 26
section as the basis for an examination under Title 2, Subtitle 2 of this article. 27

15–10B–05.1. 28

(a) (1) In this section the following words have the meanings indicated. 29

(2) “Artificial intelligence” means an engineered or machine–based system 30
that varies in its level of autonomy and that can, for explicit or implicit objectives, infer 31
HOUSE BILL 795 5

from the input it receives how to generate outputs that can influence physical or virtual 1
environments. 2

(3) “Carrier” means: 3

(i) an insurer; 4

(ii) a nonprofit health service plan; 5

(iii) a health maintenance organization; 6

(iv) a dental plan organization; or 7

(v) any other person that provides health benefit plans subject to 8
regulation by the State. 9

(b) This section applies to: 10

(1) a carrier that: 11

(i) uses an artificial intelligence, algorithm, or other software tool 12
for the purpose of utilization review; or 13

(ii) contracts with or otherwise works through an entity that uses an 14
artificial intelligence, algorithm, or other software tool for the purpose of utilization review; 15
and 16

(2) a pharmacy benefits manager or private review agent that: 17

(i) contracts with a carrier to provide utilization review on behalf of 18
the carrier; and 19

(ii) uses an artificial intelligence, algorithm, or other software tool 20
for the purpose of conducting utilization review on behalf of the carrier. 21

(c) Subject to subsection (d) of this section, an entity subject to this section shall 22
ensure that: 23

(1) an artificial intelligence, algorithm, or other software tool bases its 24
determinations on: 25

(i) an enrollee’s medical or other clinical history; 26

(ii) individual clinical circumstances as presented by a requesting 27
provider; or 28

6 HOUSE BILL 795

(iii) other relevant clinical information contained in the enrollee’s 1
medical or other clinical record; 2

(2) an artificial intelligence, algorithm, or other software tool does not base 3
its determinations solely on a group dataset; 4

(3) the criteria and guidelines for using an artificial intelligence, algorithm, 5
or other software tool for making determinations comply with the requirements of this title; 6

(4) an artificial intelligence, algorithm, or other software tool does not 7
replace the role of a health care provider in the determination process under § 15 –10B–07 8
of this subtitle; 9

(5) the use of an artificial intelligence, algorithm, or other software tool 10
does not result in unfair discrimination; 11

(6) an artificial intelligence, algorithm, or other software tool is fairly and 12
equitably applied, including in accor dance with any applicable regulations and guidance 13
issued by the federal Department of Health and Human Services; 14

(7) an artificial intelligence, algorithm, or other software tool is open to 15
inspection for audit or compliance reviews by the Commissioner; 16

(8) written policies and procedures are included in the utilization plan 17
submitted under § 15 –10B–05 of this subtitle, including how an artificial intelligence, 18
algorithm, or other software tool will be used and what oversight will be provided; 19

(9) the performance, use, and outcomes of an artificial intelligence, 20
algorithm, or other software tool are reviewed and revised, if necessary and at least on a 21
quarterly basis, to maximize accuracy and reliability; 22

(10) patient data is not used beyond its intended and stated purpose, 23
consistent with the federal Health Insurance Portability and Accountability Act of 1996, as 24
applicable; and 25

(11) an artificial intelligence, algorithm, or other software tool does not 26
directly or indirectly cause harm to an enrollee. 27

(d) An artificial intelligence, algorithm, or other software tool may not deny, 28
delay, or modify health care services. 29

SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 30
October 1, 2026. 31