ME LD1301

Effective January 1, 2026, health insurance carriers and their contracted third parties must comply with new requirements when using AI for medical review or utilization review decisions on coverage approvals, denials, delays, or modifications.

AI-derived determinations must be based on the enrollee's individual medical history and clinical circumstances, not supplant provider decision-making, and be free from discrimination based on race, age, sex, disability, quality of life, or other protected characteristics.

Carriers must disclose AI use in written policies, make AI systems open to inspection, and establish accountability policies that are regularly reviewed for accuracy and reliability.

Any denial, delay, modification, or adjustment of health care services based on medical necessity must be made by a qualified clinical peer competent to evaluate the specific clinical issues involved.

"Artificial intelligence" is defined as an engineered or machine-based system that can infer from inputs how to generate outputs influencing physical or virtual environments.