WHAT THIS BILL REGULATES · 5 REQUIREMENT TYPES
How Is This Bill Enforced
Verbatim statutory text on the left; plain-language analysis and a per-section checklist on the right. Numbered markers cross-link to the matching checklist row.
(b)(2)(i)–(v) In addition to the requirements of Subtitle 10B of this title, an internal grievance process established by a carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3) under this section shall: (i) include an expedited procedure for use in an emergency case for purposes of rendering a grievance decision within 24 hours of the date a grievance is filed with the carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3); (ii) provide that a carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3) render a final decision in writing on a grievance within 30 working days after the date on which the grievance is filed unless: 1. the grievance involves an emergency case under item (i) of this paragraph; 2. the member, the member's representative, or a health care provider filing a grievance on behalf of a member agrees in writing to an extension for a period of no longer than 30 working days; or 3. the grievance involves a retrospective denial under item (iv) of this paragraph; (iii) allow a grievance to be filed on behalf of a member by a health care provider or the member's representative; (iv) provide that a carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3) render a final decision in writing on a grievance within 45 working days after the date on which the grievance is filed when the grievance involves a retrospective denial; (v) for a retrospective denial, allow a member, the member's representative, or a health care provider on behalf of a member to file a grievance for at least 180 days after the member receives an adverse decision; AND
(b)(2)(VI) 1 FOR A GRIEVANCE RESULTING FROM AN ADVERSE DECISION MADE USING ARTIFICIAL INTELLIGENCEArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), ALGORITHM, OR OTHER SOFTWARE TOOLS, PROVIDE FOR THE HUMAN REVIEW OF THE ADVERSE DECISION, INCLUDING FOR COMPLIANCE WITH § 15–10B–05.1 OF THIS TITLE.
This section amends the existing internal grievance process requirements for carriers by adding a new subsection (vi). The new provision requires that when a grievance results from an adverse decision made using artificial intelligence, an algorithm, or other software tools, the carrier must provide for human review of that adverse decision, including review for compliance with § 15–10B–05.1 (which governs the substantive requirements for AI use in utilization review).
This is the bill's core patient-protection mechanism: it ensures that no AI-driven coverage denial can survive a grievance without meaningful human scrutiny, and specifically requires that the human reviewer assess whether the AI tool met the individualized clinical data, non-discrimination, and oversight requirements of the existing AI utilization review statute.
(a)(1)(iii)(9) 2 9. THE TOTAL NUMBER OF GRIEVANCES REVIEWED UNDER § 15–10A–02(B)(2)(VI) OF THIS SUBTITLE AND AGGREGATED BY: A. TYPE OF CLAIM; B. RACE, GENDER, AND PROFESSION OF MEMBER; AND C. TYPE OF POLICY, INCLUDING INDIVIDUAL, SMALL GROUP, OR LARGE GROUP AND WHETHER THE POLICY WAS PURCHASED ON THE HEALTH BENEFIT EXCHANGE; AND
(a)(3) 3 IF, WITHIN A 6–MONTH PERIOD, MORE THAN A SPECIFIED PERCENTAGE, AS DETERMINED BY THE COMMISSIONER, OF A CARRIERCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3)'S ADVERSE DECISIONS MADE USING THE SAME ARTIFICIAL INTELLIGENCEArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), ALGORITHM, OR SOFTWARE TOOL RESULT IN A GRIEVANCE, THE CARRIERCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3) SHALL PROVIDE FOR A MODEL REVIEW PROCESS OF THE ARTIFICIAL INTELLIGENCEArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), ALGORITHM, OR SOFTWARE TOOL AND SUBMIT THE FINDINGS IN THE REPORT REQUIRED UNDER PARAGRAPH (1) OF THIS SUBSECTION.
This section amends the carrier's existing quarterly reporting obligation to the Commissioner by adding two new requirements. First, it adds item 9 to the list of reportable data: carriers must report the total number of grievances reviewed under the new § 15–10A–02(b)(2)(vi) (AI-related human review), disaggregated by type of claim, member race/gender/profession, and type of policy (including individual, small group, large group, and whether purchased on the Health Benefit Exchange).
Second, new paragraph (3) creates a model review trigger: if, within any six-month period, more than a Commissioner-specified percentage of a carrier's adverse decisions made using the same AI tool result in grievances, the carrier must conduct a model review of that AI tool and submit findings in its quarterly report. This mechanism converts grievance rates into an automatic quality-assurance trigger for AI tools used in utilization review.
(a)(1)–(3) In this section the following words have the meanings indicated. (2) "Artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2)" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments. (3) "CarrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3)" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.
(b) This section applies to: (1) a carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3) that: (i) uses an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool for the purpose of utilization review; or (ii) contracts with or otherwise works through an entity that uses an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool for the purpose of utilization review; and (2) a pharmacy benefits manager or private review agent that: (i) contracts with a carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3) to provide utilization review on behalf of the carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3); and (ii) uses an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool for the purpose of conducting utilization review on behalf of the carrierCarrier"Carrier" means: (i) an insurer; (ii) a nonprofit health service plan; (iii) a health maintenance organization; (iv) a dental plan organization; or (v) any other person that provides health benefit plans subject to regulation by the State.Md. Code Ann., Insurance § 15–10B–05.1(a)(3).
(c)(1)–(2) 4 Subject to subsection (d) of this section, an entity subject to this section shall ensure that: (1) an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool bases its determinations on: (i) an enrollee's medical or other clinical history; (ii) individual clinical circumstances as presented by a requesting provider; or (iii) other relevant clinical information contained in the enrollee's medical or other clinical record; (2) an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool does not base its determinations solely on a group dataset;
(c)(3) 4 the criteria and guidelines for using an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool for making determinations comply with the requirements of this title;
(c)(4) 5 an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool does not replace the role of a health care provider in the determination process under § 15–10B–07 of this subtitle;
(c)(5)–(6) 6 the use of an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool does not result in unfair discrimination; (6) an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by the federal Department of Health and Human Services;
(c)(7) 7 an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool is open to inspection for audit or compliance reviews by the Commissioner;
(c)(8) 8 written policies and procedures are included in the utilization plan submitted under § 15–10B–05 of this subtitle, including how an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool will be used and what oversight will be provided;
(c)(9) 9 the performance, use, and outcomes of an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool are reviewed and revised, if necessary and at least on a quarterly basis, to maximize accuracy and reliability;
(c)(10) 10 patient data is not used beyond its intended and stated purpose, consistent with the federal Health Insurance Portability and Accountability Act of 1996, as applicable;
(c)(11) 11 an artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool does not directly or indirectly cause harm to an enrollee.
(d) 12 An artificial intelligenceArtificial intelligence"Artificial intelligence" means an engineered or machine–based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.Md. Code Ann., Insurance § 15–10B–05.1(a)(2), algorithm, or other software tool may not deny, delay, or modify health care services.
Section 15–10B–05.1 is reenacted without amendment. It contains the existing substantive requirements governing the use of AI, algorithms, and other software tools in utilization review. The section applies to carriers that use or contract for AI-based utilization review, as well as pharmacy benefits managers and private review agents that contract with carriers for that purpose.
The section imposes a comprehensive set of requirements: AI tools must base determinations on individualized enrollee clinical data (not solely group datasets), must comply with the title's criteria and guidelines, must not replace the role of a healthcare provider in the determination process, must not result in unfair discrimination, must be fairly and equitably applied, must be open to Commissioner inspection, must have written policies and procedures included in the utilization plan, must be reviewed quarterly for accuracy and reliability, must not use patient data beyond its intended purpose consistent with HIPAA, and must not directly or indirectly cause harm to enrollees. Subsection (d) prohibits AI tools from denying, delaying, or modifying health care services outright.
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2026.
Section 2 establishes October 1, 2026 as the effective date for all provisions of this Act.