Health Care Price Transparency Act of 2023, Sec. 301 ("Establishing Requirements With Respect to the Use of Prior Authorization Under Medicare Advantage Plans")

• Authority: United States Congress
• Parent authority: Federal government
• Jurisdiction: United States
• Collections: U.S. federal laws
• Most recent activity: Defunct
• Most recent activity date: 2025-01-03

Risk subdomain coverage

Minimal coverage — Brief mention but no specific mitigations, recommendations or governance measures relating to the risk subdomain are described.

• Lack of transparency or interpretability

All other risk subdomains had no coverage in this document.

Risk Coverage Summary

The document has minimal coverage of AI risk domains, with the only substantive coverage being subdomain 7.4 (Lack of transparency or interpretability) which receives a score of 2. The document briefly mentions AI use in prior authorization decisions and requires disclosure of such technology, but does not address the risks or harms associated with AI systems. Other risk domains are not covered as the document focuses on procedural requirements for Medicare Advantage plans rather than AI-specific risks.

Sector coverage

Good coverage — Comprehensive governance measures or mitigations with clear procedures relating to the sector are explicitly described.

• Health Care & Social Assistance

Minimal coverage — Brief mention but no specific mitigations, recommendations or governance measures relating to the sector are described.

• Finance & Insurance

All other sectors had no coverage in this document.

Sectors Summary

This document exclusively governs the Health Care and Social Assistance sector, specifically Medicare Advantage plans and their use of prior authorization systems. It establishes comprehensive requirements for electronic prior authorization programs, transparency in AI-assisted decision-making, and reporting obligations for health insurance plans operating within the Medicare Advantage program.

Legislative Status

Hard Law

Legislative Status Summary

This is a binding federal statute enacted by the United States Congress that amends the Social Security Act, establishing mandatory requirements for Medicare Advantage plans with specific enforcement mechanisms, timelines, and regulatory oversight by the Secretary of Health and Human Services.

Actors

Proposer

• Entity Types: AI_Governance_Actor
• Entities: United States Congress
• Summary: The document is Section 301 of the Health Care Price Transparency Act of 2023, which is federal legislation enacted by the United States Congress. The authority is explicitly stated as 'United States Congress' in the document information.

Target

• Entity Types: AI_Deployer
• Entities: Medicare Advantage plans; Medicare Advantage organizations
• Summary: The legislation explicitly targets Medicare Advantage plans that impose prior authorization requirements. These plans are the entities required to establish electronic prior authorization programs, meet transparency requirements, and comply with enrollee protection standards. They are deploying AI technology in their prior authorization decision-making processes.

Enforcer

• Entity Types: AI_Governance_Actor
• Entities: Secretary of Health and Human Services; Centers for Medicare & Medicaid Services
• Summary: The Secretary of Health and Human Services is granted extensive enforcement authority throughout the document, including rulemaking powers, specification of requirements, publication of compliance information, and oversight of Medicare Advantage plans. CMS is explicitly mentioned as the agency responsible for publishing compliance information.

Monitor

• Entity Types: AI_Governance_Actor
• Entities: Secretary of Health and Human Services; Centers for Medicare & Medicaid Services; Medicare Payment Advisory Commission (MedPAC); Government Accountability Office (GAO); Congress
• Summary: Multiple entities are assigned monitoring responsibilities. The Secretary/CMS monitors through mandatory reporting requirements and publishes compliance data. MedPAC is required to analyze and report on prior authorization information. GAO must evaluate implementation. Congress receives biennial reports from HHS on compliance.

AI Lifecycle Stages

Lifecycle stages covered by the documents, as defined in the OECD Framework for the Classification of AI Systems

• Deploy
• Operate and Monitor

AI Lifecycle Summary

The document primarily addresses the Deploy and Operate and Monitor stages of the AI lifecycle. It requires Medicare Advantage plans to disclose AI technology use in prior authorization decisions and report on outcomes, but does not cover earlier stages like planning, data collection, or model development.

Technical Scope

Terms relating to technical scope that are mentioned or implicitly referenced in the document

• Task-specific AI

Technical Scope Summary

The document explicitly mentions AI technology in the context of prior authorization decision-making systems. It references 'artificial intelligence technology' alongside related technologies like machine learning and clinical decision-making technology. However, it does not define or distinguish between AI models, AI systems, or specific categories like frontier AI, general purpose AI, or foundation models.