CMS, Senate Seek to Crack Down on Insurer Use of AI

February 16

In a recent memo, the Biden administration clarified restrictions on the use of artificial intelligence in Medicare Advantage coverage decisions. Congress may also eventually weigh in on AI use in federal health insurance programs: The Senate Finance Committee on Feb. 8 held a hearing in which senators indicated they may tighten the rules on payer and provider use of AI, particularly in Medicare and Medicaid.

In its Feb. 6 memo, CMS sought to address questions it received after finalizing a rule last April that made technical changes to the MA program. The frequently asked questions (FAQ) document confirmed that “an algorithm or software tool can be used to assist MA plans in making coverage determinations,” but it also emphasized that plans must base coverage decisions “on the individual patient’s circumstances.” According to one D.C. insider, the rule may force plans to move faster to curb misuse of AI and algorithms in decision making.

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Health Plan Weekly

Peter Johnson

Peter has worked as a journalist since 2011 and has covered health care since 2020. At AIS Health, Peter covers trends in finance, business and policy that affect the health insurance and pharma sectors. For Health Plan Weekly, he covers all aspects of the U.S. health insurance sector, including employer-sponsored insurance, Medicaid managed care, Medicare Advantage and the Affordable Care Act individual marketplaces. In Radar on Drug Benefits, Peter covers the operations of (and conflicts between) pharmacy benefit managers and pharmaceutical manufacturers, with a particular focus on pricing dynamics and market access. Before joining AIS Health, Peter covered transportation, public safety and local government for various outlets in Seattle, his hometown and current place of residence. He graduated with a B.A. from Colby College.