Ban AI Denials in Medicare Act

Bill Number

H.R. 6361

Origin Chamber

House

Congress

119th Congress, Session 1

Policy Area

Health

Status

Introduced

Latest Action

2025-12-02: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, 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.

Last Updated

2026-01-08T09:07:02Z

AI-Generated Summary

Purpose

The "Ban AI Denials in Medicare Act" (H.R. 6361) aims to prevent the U.S. Department of Health and Human Services (HHS) from implementing or testing certain payment models in traditional Medicare that involve prior authorization—a process where insurers or government programs require advance approval before covering specific medical services or items. It specifically targets models using artificial intelligence (AI) for these approvals, to avoid potential automated denials of care.

Key Provisions

• Short Title: The bill is titled the "Ban AI Denials in Medicare Act."
• Prohibition on WISeR Model: HHS cannot implement the Wasteful and Inappropriate Services Reduction (WISeR) model, as outlined in a July 1, 2025, Federal Register notice, or any substantially similar model. This model would have tested prior authorization for certain Medicare services to reduce wasteful spending.
• Ban on Future Models: The bill amends Section 1115A of the Social Security Act, which governs the Center for Medicare and Medicaid Innovation (CMMI—an HHS entity that tests new payment and care delivery approaches). It adds a new limitation preventing CMMI from selecting or testing any model that includes prior authorization (including via AI) for services covered under Medicare Parts A (hospital insurance) or B (medical insurance).

Significant Changes to Existing Law

• The amendment modifies the selection criteria for CMMI models under the Social Security Act by inserting a new subparagraph (D). This explicitly bars models involving prior authorization in traditional Medicare, whereas previously, CMMI had broad authority to test innovative payment models without this restriction.
• It does not affect prior authorization in Medicare Advantage (Part C) plans, which are privately run and already use such processes.

Potential Impacts

• On Government Agencies: Limits HHS and CMMI's flexibility to experiment with cost-saving innovations, potentially slowing efforts to address wasteful Medicare spending (estimated at billions annually). It may require agencies to redirect resources to other innovation areas.
• On Citizens: Protects Medicare beneficiaries (primarily seniors and people with disabilities) from potential delays or denials in accessing care due to AI-driven prior authorization, ensuring smoother coverage for hospital and medical services. However, it could indirectly allow more inappropriate or wasteful spending if alternative oversight tools are not developed.
• On International Relations: No direct impacts, as the bill focuses on domestic U.S. healthcare policy.

Main Stakeholders Affected

• Medicare Beneficiaries: Older adults and disabled individuals enrolled in traditional Medicare, who may benefit from reduced barriers to care.
• Healthcare Providers: Doctors, hospitals, and other providers serving Medicare patients, who could face fewer administrative hurdles for approvals.
• HHS and CMMI: The federal agencies responsible for Medicare administration and innovation, now restricted in testing certain models.
• Taxpayers: Indirectly affected through potential changes in Medicare spending efficiency.
• Advocacy Groups: Organizations representing patients, seniors (e.g., AARP), and healthcare providers, who may support or oppose based on views of AI in medicine.

Notable Legal, Constitutional, or Political Implications

• Legal: Reinforces congressional oversight of executive branch innovations by amending the Social Security Act, potentially setting a precedent for limiting administrative rulemaking in healthcare without new legislation. It does not raise constitutional issues but ensures compliance with existing Medicare statutes.
• Constitutional: No apparent challenges, as it aligns with Congress's authority to regulate federal spending and programs like Medicare.
• Political: Highlights debates over AI's role in government decisions, balancing innovation against risks of automated errors or biases in healthcare access. Introduced by bipartisan sponsors, it reflects concerns about protecting vulnerable populations from "AI denials," amid broader scrutiny of AI in public services.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Rep. Landsman, Greg [D-OH-1]

Cosponsors (3)

Rep. Watson Coleman, Bonnie [D-NJ-12], Rep. Costa, Jim [D-CA-21], Rep. Grijalva, Adelita S. [D-AZ-7]

Recent Actions

• 2025-12-02: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, 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.
• 2025-12-02: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, 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.
• 2025-12-02: Introduced in House
• 2025-12-02: Introduced in House

Bill Versions

• Ban AI Denials in Medicare Act — issued 2025-12-02 — PDF (3 pages)