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S 46

Relates to falsely reporting incidents in an attempt to bring about the dispatch of a large number of police officers to a particular address or location

2025 Regular Session Introduced by Dean Murray and 3 co-sponsors

AI in utilization review must base decisions on individual clinical data and clinician input; cannot rely solely on AI, with audits and transparency required.

REFERRED TO CODES
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Bill Summary · S 46

Summary — S.46 (2025): An Act relative to the use of artificial intelligence and other software tools in healthcare decision‑making

Note on source materials
- The official bill text filed in the Massachusetts Senate (Senate Docket No. 268, filed 1/10/2025) is a state bill presented by Senator Michael O. Moore (with James B. Eldridge listed). Some supplied metadata (alternate title about false police reports, and a long list of federal senators as “sponsors”) appears inconsistent with the Massachusetts bill text below; this summary follows the bill language in the docketed Massachusetts filing.

Purpose
- To regulate and constrain the use of artificial intelligence (AI), algorithms, and other software tools by health insurers and utilization review organizations (UROs) when performing utilization review or utilization management, especially where determinations are based in whole or in part on medical necessity.

Key provisions
- New subsection (g) added to Section 12 of Chapter 176O requires carriers and UROs that use, contract with, or rely on AI/algorithms for utilization review/management to ensure the following:
- Decision inputs: Determinations must be based on applicable information such as the insured’s medical/clinical history, individual clinical circumstances supplied by the requesting provider, and other relevant clinical record information.
- Prohibition on sole reliance on group datasets: Tools may not base decisions solely on group datasets.
- Legal compliance: Criteria and guidelines used must comply with chapter 176O and applicable state and federal law.
- Provider primacy: AI must not supplant health care provider decision‑making.
- Non‑discrimination: Use must not discriminate (directly or indirectly) against insureds in violation of state or federal law (e.g., chapter 151B).
- Fair application: Tools must be applied fairly and equitably, following applicable agency guidance.
- Auditability: Tools must be open to inspection for audit or compliance reviews by the Division (insurance regulator) and the Executive Office of Health and Human Services (EOHHS).
- Transparency: Disclosures about AI use and oversight must be included in written policies and procedures.
- Continuous review: Performance, use, and outcomes must be periodically reviewed and revised to maximize accuracy and reliability.
- Data use limits: Patient data cannot be used beyond its intended and stated purpose and must comply with state and federal law.
- Safety: The tool must not directly or indirectly cause harm to the insured.

  • Human decision requirement: AI/algorithms may not deny, delay, or modify health care services on the basis of medical necessity. Determinations of medical necessity must be made by a licensed physician or other licensed health care professional competent for the clinical issue, and those reviewers must consider the requesting provider’s recommendation and the insured’s clinical history.

  • Scope and definitions:

    • “Artificial intelligence” is defined broadly as engineered or machine‑based systems that infer outputs from inputs to influence environments.
    • The rules apply to prospective, concurrent, and retrospective utilization reviews.

  • Implementation and federal coordination:

    • Health plans must follow applicable state and federal rules and guidance. The Division and EOHHS may issue implementation guidance within one year of state or federal rule/guidance on AI use; such guidance is explicitly not subject to Chapter 30A rulemaking procedures.
    • Applicability to MassHealth managed plans is conditional on obtaining any necessary federal approvals and not jeopardizing federal financial participation.

Who is affected
- Health insurers (carriers), utilization review organizations, vendors/contractors providing AI/algorithmic tools, health care providers (whose recommendations must be considered), insured individuals (patients), and MassHealth programs pending federal approvals. Regulators (Division of Insurance and EOHHS) gain explicit audit authority.

Potential impacts
- Strengthens patient protections by requiring individualized clinical inputs, human clinical review for medical necessity, auditability, transparency, and non‑discrimination safeguards.
- May increase compliance, documentation, audit, and vendor‑management costs for carriers/UROs.
- Could limit fully automated denials or modifications of care based solely on algorithmic outputs.
- Implementation timeline may follow later state/federal guidance; MassHealth changes wait on federal approvals.

Procedural status and timeline (selected)
- Introduced and filed Jan 9–10, 2025 (Senate Docket No. 268).
- Referred to committee (Advanced Information Technology, the Internet and Cybersecurity; and Finance references in docket).
- Hearing(s) rescheduled (noted hearing reschedule to 09/11/2025); a new draft accompanied by S.2632 (10/16/2025) is noted in the record.
- Current formal status in the supplied record: REFERRED TO CODES (some entries duplicate).

For more detail
- See full bill text (Section 12, Chapter 176O amendment) for exact statutory language, definitions, and cross‑references.

Compiled from official sources — confirm details with the bill’s official record.

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