Doctors Not AI Act of 2026

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.

The Public Health Service Act is amended by inserting after section 2719A (42 U.S.C. 300gg–19a) the following new section:

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— such materials shall be considered part of the administrative record and made available to the enrollee upon request.

(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

For purposes of this section:

The term adverse benefit determination includes an initial determination and a determination on internal appeal.

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.

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:

The use of an artificial intelligence system in connection with utilization review shall constitute a treatment limitation for purposes of this section.

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.

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: 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.

(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— such materials shall be considered part of the administrative record and made available to the participant or beneficiary upon request.

(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

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:

The use of an artificial intelligence system in connection with utilization review shall constitute a treatment limitation for purposes of this section.

Section 9832 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:

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.

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by inserting after section 9815 the following new section:

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— and such materials shall be considered part of the administrative record and made available to the participant or beneficiary upon request.

(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);

For purposes of this section—

The term adverse benefit determination includes an initial determination and a determination on internal appeal.

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.

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:

The use of an artificial intelligence system in connection with utilization review shall constitute a treatment limitation for purposes of this section.

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: