[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10210 Introduced in House (IH)]
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119th CONGRESS
2d Session
H. R. 10210
To amend title XXVII of the Public Health Service Act, the Employee
Retirement Income Security Act of 1974, and the Internal Revenue Code
of 1986 to regulate the use of artificial intelligence in the review of
claims by group health plans and health insurance issuers offering
group or individual health insurance coverage.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 1, 2026
Mr. Landsman (for himself, Mr. Carter of Georgia, Ms. Schrier, and Mr.
Barrett) introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committees on
Ways and Means, and Education and Workforce, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act, the Employee
Retirement Income Security Act of 1974, and the Internal Revenue Code
of 1986 to regulate the use of artificial intelligence in the review of
claims by group health plans and health insurance issuers offering
group or individual health insurance coverage.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Doctors Not AI Act of 2026''.
SEC. 2. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
(a) Definition of Artificial Intelligence System.--Section 2791 of
the Public Health Service Act (42 U.S.C. 30099-91) is amended by adding
at the end the following:
``(g) The term `artificial intelligence system' means an engineered
or machine-based system, including any algorithm, predictive model,
machine learning system, or automated decision-making software, that
processes data to generate predictions, classifications,
recommendations, or decisions and that is used to materially influence,
automate, or issue determinations regarding coverage of health care
items or services.''.
(b) Clinical Judgment and Artificial Intelligence.--The Public
Health Service Act is amended by inserting after section 2719A (42
U.S.C. 300gg-19a) the following new section:
``SEC. 2719B. CLINICAL JUDGMENT AND ARTIFICIAL INTELLIGENCE.
``(a) In General.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage shall
ensure that any adverse benefit determination, whether initially or
upon appeal, involving clinical judgment--
``(1) is not issued by an artificial intelligence system
and is not dictated or determined by the output of such system;
``(2) is made only by a licensed health care professional
who is acting within the scope of the professional's license
and who has training and experience in the provision of the
health care item or service that is the subject of the
determination;
``(3) reflects the independent clinical judgment of such
professional, who shall conduct an independent evaluation of
the enrollee's individual medical circumstances and shall not
treat any output of an artificial intelligence system as
presumptively valid or defer to such output in lieu of
independent clinical judgment applying generally accepted
standards of care;
``(4) includes, in the notice required under section 2719,
if an artificial intelligence system was used in connection
with the determination--
``(A) a statement that such system was used;
``(B) a description of its role in the review
process; and
``(C) the name, professional license, and
credentials of the licensed health care professional
who made the determination; and
``(5) is supported by documentation maintained as part of
the administrative record describing--
``(A) the artificial intelligence system used;
``(B) the role of such system in the review
process;
``(C) any outputs, scores, recommendations, or
determinations generated by such system; and
``(D) documentation demonstrating compliance with
subparagraph (C); and
such materials shall be considered part of the administrative
record and made available to the enrollee upon request.
``(b) Definitions.--For purposes of this section:
``(1) Adverse benefit determination.--The term `adverse
benefit determination' includes an initial determination and a
determination on internal appeal.
``(2) Adverse benefit determination involving clinical
judgment.--The term `adverse benefit determination involving
clinical judgment' means an adverse benefit determination that
is based, in whole or in part, on medical necessity,
appropriateness, experimental and investigational or similar
exclusions or limits, level of care, health care setting,
effectiveness, clinical guidelines, utilization review
criteria, other standards requiring evaluation of the
enrollee's medical condition or treatment needs, or generally
accepted standards of care for such treatment needs.''.
(c) Parity Treatment of Artificial Intelligence Systems.--Section
2726 of the Public Health Service Act (42 U.S.C. 300gg-26) is amended--
(1) in subsection (a)(8)(A), by adding at the end the
following new clause:
``(vi) Whether an artificial intelligence
system is used in, or materially influences,
the design, development, application, or
administration of such limitation and, if so,
sufficient information regarding the function,
operation, and effects of such system to enable
the Secretary to evaluate such function,
operation, and effects under such limitation
with respect to mental health or substance use
disorder benefits as compared to medical and
surgical benefits, both as written and in
operation.''; and
(2) by adding at the end the following:
``(f) Artificial Intelligence and Utilization Review.--The use of
an artificial intelligence system in connection with utilization review
shall constitute a treatment limitation for purposes of this
section.''.
SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) Definition of Artificial Intelligence System.--Section 3 of the
Employee Retirement Income Security Act of 1974 (29 U.S.C. 1002) is
amended by adding at the end the following:
``(48) The term `artificial intelligence system' means an
engineered or machine-based system, including any algorithm,
predictive model, machine learning system, or automated
decision-making software, that processes data to generate
predictions, classifications, recommendations, or decisions and
that is used to materially influence, automate, or issue
determinations regarding coverage of health care items or
services.''.
(b) Claims Procedure Requirements.--Section 503 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1133) is amended--
(1) in paragraph (2), by striking the period at the end and
inserting ``; and''; and
(2) by adding at the end the following:
``(3) ensure that any adverse benefit determination,
whether initially or upon appeal, involving clinical judgment--
``(A) is not issued by an artificial intelligence
system and is not dictated or determined by the output
of such system;
``(B) is made only by a licensed health care
professional who is acting within the scope of the
professional's license and who has training and
experience in the provision of the health care item or
service that is the subject of the determination;
``(C) reflects the independent clinical judgment of
such professional, who shall conduct an independent
evaluation of the participant's or beneficiary's
individual medical circumstances and shall not treat
any output of an artificial intelligence system as
presumptively valid or defer to such output in lieu of
independent clinical judgment applying generally
accepted standards of care;
``(D) includes, in the notice required under
paragraph (1), if an artificial intelligence system was
used in connection with the determination--
``(i) a statement that such system was
used;
``(ii) a description of its role in the
review process; and
``(iii) the name, professional license, and
credentials of the licensed health care
professional who made the determination; and
``(E) is supported by documentation maintained as
part of the administrative record describing--
``(i) the artificial intelligence system
used;
``(ii) the role of such system in the
review process;
``(iii) any outputs, scores,
recommendations, or determinations generated by
such system; and
``(iv) documentation demonstrating
compliance with subparagraph (C); and
such materials shall be considered part of the
administrative record and made available to the
participant or beneficiary upon request.
For purposes of this paragraph, the term `adverse benefit
determination' includes an initial determination and a
determination on internal appeal, and the term `adverse benefit
determination involving clinical judgment' means an adverse
benefit determination that is based, in whole or in part, on
medical necessity, appropriateness, experimental and
investigational or similar exclusions or limits, level of care,
health care setting, effectiveness, clinical guidelines,
utilization review criteria, other standards requiring
evaluation of the participant's or beneficiary's medical
condition or treatment needs, or generally accepted standards
of care for such treatment needs.''.
(c) Parity Treatment of Artificial Intelligence Systems.--Section
712 of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
1185a) is amended---
(1) in subsection (a)(8)(A), by adding at the end the
following new clause:
``(vi) Whether an artificial intelligence
system is used in, or materially influences,
the design, development, application, or
administration of such limitation and, if so,
sufficient information regarding the function,
operation, and effects of such system to enable
the Secretary to evaluate such function,
operation, and effects under such limitation
with respect to mental health or substance use
disorder benefits as compared to medical and
surgical benefits, both as written and in
operation.''; and
(2) by adding at the end the following:
``(h) Artificial Intelligence and Utilization Review.--The use of
an artificial intelligence system in connection with utilization review
shall constitute a treatment limitation for purposes of this
section.''.
SEC. 4. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.
(a) Definition of Artificial Intelligence System.--Section 9832 of
the Internal Revenue Code of 1986 is amended by adding at the end the
following new paragraph:
``(11) Artificial intelligence system.--The term
`artificial intelligence system' means an engineered or
machine-based system, including any algorithm, predictive
model, machine learning system, or automated decision-making
software, that processes data to generate predictions,
classifications, recommendations, or decisions and that is used
to materially influence, automate, or issue determinations
regarding coverage of health care items or services.''.
(b) Clinical Judgment and Artificial Intelligence.--Subchapter B of
chapter 100 of the Internal Revenue Code of 1986 is amended by
inserting after section 9815 the following new section:
``SEC. 9815A. CLINICAL JUDGMENT AND ARTIFICIAL INTELLIGENCE.
``(a) In General.--A group health plan shall ensure that any
adverse benefit determination, whether initially or upon appeal,
involving clinical judgment--
``(1) is not issued by an artificial intelligence system
and is not dictated or determined by the output of such system;
``(2) is made only by a licensed health care professional
who is acting within the scope of the professional's license
and who has training and experience in the provision of the
health care item or service that is the subject of the
determination;
``(3) reflects the independent clinical judgment of such
professional, who shall conduct an independent evaluation of
the participant's or beneficiary's individual medical
circumstances and shall not treat any output of an artificial
intelligence system as presumptively valid or defer to such
output in lieu of independent clinical judgment applying
generally accepted standards of care;
``(4) includes, in the notice required under this chapter,
if an artificial intelligence system was used in connection
with the determination--
``(A) a statement that such system was used;
``(B) a description of its role in the review
process; and
``(C) the name, professional license, and
credentials of the licensed health care professional
who made the determination;
``(5) is supported by documentation maintained as part of
the administrative record describing--
``(A) the artificial intelligence system used;
``(B) the role of such system in the review
process;
``(C) any outputs, scores, recommendations, or
determinations generated by such system; and
``(D) documentation demonstrating compliance with
subparagraph (C);
and such materials shall be considered part of the
administrative record and made available to the participant or
beneficiary upon request.
``(b) Definitions.--For purposes of this section--
``(1) Adverse benefit determination.--The term `adverse
benefit determination' includes an initial determination and a
determination on internal appeal.
``(2) Adverse benefit determination involving clinical
judgment.--The term `adverse benefit determination involving
clinical judgment' means an adverse benefit determination that
is based, in whole or in part, on medical necessity,
appropriateness, experimental and investigational or similar
exclusions or limits, level of care, health care setting,
effectiveness, clinical guidelines, utilization review
criteria, other standards requiring evaluation of the
participant's or beneficiary's medical condition or treatment
needs, or generally accepted standards of care for such
treatment needs.''.
(c) Parity Treatment.--Section 9812 of the Internal Revenue Code of
1986 is amended--
(1) in subsection (a)(8)(A), by adding at the end the
following new clause:
``(vi) Whether an artificial intelligence
system is used in, or materially influences,
the design, development, application, or
administration of such limitation and, if so,
sufficient information regarding the function,
operation, and effects of such system to enable
the Secretary to evaluate such function,
operation, and effects under such limitation
with respect to mental health or substance use
disorder benefits as compared to medical and
surgical benefits, both as written and in
operation.''; and
(2) by adding at the end the following:
``(f) Artificial Intelligence and Utilization Review.--The use of
an artificial intelligence system in connection with utilization review
shall constitute a treatment limitation for purposes of this
section.''.
(d) Clerical Amendment.--The table of sections for subchapter B of
chapter 100 of the Internal Revenue Code of 1986 is amended by
inserting after the item related to section 9815 the following new
item:
``Sec. 9815A. Clinical judgment and artificial intelligence.''.
SEC. 5. EFFECTIVE DATE.
The amendments made by this Act shall apply to plan years beginning
on or after January 1 of the first calendar year beginning not less
than 12 months after the date of the enactment of this Act.
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