WHAT THIS BILL REGULATES · 2 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.
(2-D) 1 For a claim submitted by a health care provider or health care facility with respect to a carrierCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) as defined in section 4301‑A, subsection 3 on or after January 1, 2026, a carrierCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) may not deny a claim based solely on the use of artificial intelligenceArtificial intelligence"Artificial intelligence" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8). For the purposes of this subsection, "artificial intelligenceArtificial intelligence"Artificial intelligence" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8)" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.
This section prohibits health insurance carriers from denying claims submitted by health care providers or facilities based solely on artificial intelligence, effective January 1, 2026. The prohibition is absolute — if a claim is submitted on or after the effective date, the carrier may not use AI as the sole basis for denial. The section provides its own inline definition of artificial intelligence as a computerized system capable of making decisions or recommendations based on algorithms and data analysis. Notably, this section addresses claim payment denials specifically, while Section 2 (§ 4304(8)) addresses the broader utilization review and coverage determination context.
(8) sentence 1 2 Beginning January 1, 2026, a carrierCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) may not make medical review or utilization review determinations relating to the approval, denial or adjustment of coverage for services under a health plan based solely on the use of artificial intelligenceArtificial intelligence"Artificial intelligence" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8).
(8) sentences 2–3 3 Before a carrierCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) denies benefits or reduces payment for services using artificial intelligenceArtificial intelligence"Artificial intelligence" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8), the carrierCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) shall conduct a utilization review done by a physician who is licensed in this State, including a review of the medical necessity of the services, the professional judgment of the enrollee's provider and the impact of any denial of benefits or reduction in payment on the enrollee's health outcomes. An enrollee or provider has the right to appeal any determination under this subsection in accordance with section 4303, subsection 4.
(8) sentence 4 For the purposes of this subsection, "artificial intelligenceArtificial intelligence"Artificial intelligence" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8)" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.
This section is the core operative provision of the bill. It prohibits carriers from making medical review or utilization review determinations — including approvals, denials, and adjustments of coverage — based solely on artificial intelligence, effective January 1, 2026. Beyond the prohibition, it imposes an affirmative obligation: before a carrier denies benefits or reduces payment using AI, a Maine-licensed physician must conduct a utilization review that includes assessment of medical necessity, the enrollee's provider's professional judgment, and the impact of any denial or reduction on the enrollee's health outcomes. The section also preserves enrollees' and providers' right to appeal any determination under existing appeal procedures at § 4303(4).
(9) The bureau shall adopt rules to implement the provisions of subsection 8 related to the use of artificial intelligenceArtificial intelligence"Artificial intelligence" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) by a carrierCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8). Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
This section directs the Bureau of Insurance to adopt rules implementing the AI utilization review restrictions in subsection 8. The rules are classified as routine technical rules under Maine's Administrative Procedure Act, meaning they do not require legislative approval. This is a rulemaking authorization that does not impose a direct compliance obligation on carriers.
(10) 4 Beginning April 15, 2026 and quarterly thereafter, a carrierCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) shall report to the bureau on the number of denials of coverage under subsection 8, the outcome of the review conducted by a licensed physician in accordance with subsection 8 and the number of appeals of a determination under subsection 8 and the outcome of those appeals. Beginning February 1, 2027 and annually thereafter, the bureau shall submit a report summarizing the quarterly reports from carriersCarrier"Carrier" as defined in section 4301‑A, subsection 3.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) to the joint standing committee of the Legislature having jurisdiction over health insurance matters.
This section imposes a quarterly reporting obligation on carriers and an annual reporting obligation on the Bureau of Insurance. Beginning April 15, 2026, carriers must report to the Bureau on the number of AI-related coverage denials, outcomes of physician reviews, and the number and outcomes of appeals. Beginning February 1, 2027, the Bureau must submit an annual summary of these quarterly reports to the legislative committee with jurisdiction over health insurance. The reporting requirement creates a structured ongoing compliance obligation for carriers and a transparency mechanism for the legislature.
No later than November 1, 2025, the Department of Professional and Financial Regulation, Bureau of Insurance shall adopt rules relating to the use of artificial intelligenceArtificial intelligence"Artificial intelligence" means a computerized system capable of making decisions or recommendations based on algorithms and data analysis.24-A MRSA § 2436(2-D); 24-A MRSA § 4304(8) as required by the Maine Revised Statutes, Title 24-A, section 4304, subsection 9.
This uncodified section sets a deadline of November 1, 2025 for the Bureau of Insurance to adopt the rules required by § 4304(9). This imposes a government-facing deadline rather than a carrier obligation.