Prohibits the Secretary of Health and Human Services from implementing the WISeR model, which aims to reduce wasteful and inappropriate services using prior authorization in Medicare. Amends Section 1115A(b)(2) of the Social Security Act to restrict testing of future Center for Medicare and Medicaid Innovation models that implement prior authorization, including those utilizing artificial intelligence, under traditional Medicare. Limits the Secretary's testing authority by ensuring that no new models providing for prior authorization, either independently or through AI, can be selected for items or services reimbursable under Medicare parts A and B.
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HR 6361 Ban AI Denials in Medicare Act 2025
ETO AGORA · U.S. federal laws · 2025
Summary
Prohibits the Secretary of Health and Human Services from implementing the WISeR model, which aims to reduce wasteful and inappropriate services using prior authorization in Medicare.
Amends Section 1115A(b)(2) of the Social Security Act to restrict testing of future Center for Medicare and Medicaid Innovation models that implement prior authorization, including those utilizing artificial intelligence, under traditional Medicare.
Limits the Secretary's testing authority by ensuring that no new models providing for prior authorization, either independently or through AI, can be selected for items or services reimbursable under Medicare parts A and B.
Prohibits HHS Secretary from testing the WISeR model and payment models under traditional Medicare.
A BILL
To prohibit the Secretary of Health and Human Services from testing the WISeR model, and to amend title XI of the Social Security Act to prohibit the implementation of payment models testing prior authorization under traditional Medicare.
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 ``Ban AI Denials in Medicare Act''.
Prohibits the implementation of the WISeR model or similar models in traditional Medicare.
SEC. 2. PROHIBITING IMPLEMENTATION OF CENTER FOR MEDICARE AND MEDICAID INNOVATION MODELS TESTING PRIOR AUTHORIZATION UNDER TRADITIONAL MEDICARE.
(a) Prohibiting Implementation of WISeR Model.--The Secretary of Health and Human Services may not implement the innovative payment and service delivery model described in the notice titled ``Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model'' (90 Fed. Reg. 28749 (July 1, 2025)), or any substantially similar model.
Prohibits the Secretary from testing models using AI for prior authorization in traditional Medicare without approval.
(b) Prohibiting Implementation of Future CMI Models Testing Prior Authorization (including Through the Use of AI) Under Traditional Medicare.--Section 1115A(b)(2) of the Social Security Act (42 U.S.C. 1315a(b)(2)) is amended--
(1) in subparagraph (A), by striking ``The Secretary shall select'' and inserting ``Subject to the limitation under subparagraph (D), the Secretary shall select''; and
(2) by adding at the end the following new subparagraph: ``(D) Limitation on models to be tested.--Beginning on the date of the enactment of this subparagraph, the Secretary may not select a model to be tested under subparagraph (A) if such model would provide for the implementation of prior authorization (including through the use of artificial intelligence) with respect to items or services for which payment may be made under part A or part B of title XVIII.''.