House adds AI rules, longer runway to primary care bill

Politics admin July 29, 2026 0 Comments

House adds AI rules, longer runway to primary care bill

House Democrats advanced a highly anticipated primary care reform package Wednesday that also imposes new guardrails on the use of artificial intelligence, bolsters oversight of pharmacy benefit managers, and creates an accelerated process for state public health regulators to vet certain Determination of Need applications.

House Speaker Ron Mariano previously voiced skepticism over the Senate’s primary care bill (S 3141) that passed on a 35-4 vote last month. But the redrafted approach the House Ways and Means Committee released on Wednesday morning echoes a critical provision from the Senate — establishing a primary care spending target.

The legislation is up for a vote Thursday, according to a joint statement from Mariano, Ways and Means Chair Aaron Michlewitz, and Health Care Financing Co-chair Representative John Lawn.

“For many Massachusetts residents, an unsustainable rise in health care costs has made it increasingly difficult to access and afford basic health care services,” the House leaders said. “To confront that challenge, this legislation makes critical investments in primary care by strengthening reimbursement rates, investing in our primary care workforce, expanding timely access to appointments, and by easing the administrative burdens that contribute to provider burnout.”

The bill cleared the Ways and Means Committee on a 19-0 vote. Representatives Michael Chaisson, John Marsi, Joseph McKenna, Kelly Pease, Todd Smola, Alyson Sullivan-Almeida, Marcus Vaughn, and Steven Xiarhos reserved their rights in the poll. Representatives Patricia Duffy, Ryan Hamilton, Russell Holmes, Kristin Kassner, Lindsay Sabadosa, Alan Silvia, and Chynah Tyler took no action.

Under the House Ways and Means bill, primary care should represent 9 percent of all healthcare spending by 2030. The target would climb to 12 percent by 2033 and 15 percent by 2036. It’s a longer runway than the Senate bill, which envisions reaching the 15 percent target by 2030.

A primary care payment collaborative within the Division of Insurance would establish at least one advanced primary care payment model, aimed at supporting value-based care and moving away from the traditional fee-for-service structure. Instead, the model promotes predictable capitated monthly payments for members. Insurers would be required to embrace at least one model and offer it to contracted primary care providers and provider organizations.

Going beyond the scope of the Senate’s bill, the House Ways and Means bill regulates the use of automated utilization review tools, defined as AI, an algorithm or other software “used to conduct, or to generate information relied upon in, utilization review based in whole or in part on medical necessity.”

The bill clarifies that automated tools cannot be the “sole basis for an adverse determination” — and that a decision must be made by a licensed physician or healthcare professional. Insurers and utilization review organizations must disclose the use of automated tools on its website, and outline in written notices whether the tools were used in adverse determinations.

Building on last session’s prescription drug reform law, the House Ways and Means bill requires insurers, pharmacy benefit managers and “affiliated entities” to apply at least 80 percent of estimated prescription drug rebates in order to “reduce patient cost-sharing at the pharmacy counter,” according to a House summary. The bill also boosts oversight of affiliated entities and other organizations that are vertically integrated with pharmacy benefit managers.

“The bill also lowers out-of-pocket costs by ensuring that patients benefit from prescription drug rebates at the pharmacy counter, and that insurance companies cannot deny patients the full benefit of prescription drug coupons,” Mariano, Michlewitz and Lawn said. “We look forward to continued conversations with the Membership, and to passing this important legislation tomorrow.”

The legislation also invests an initial $25 million into a new workforce development fund, ensures insurance parity for community health centers, shores up funding for the strained Health Safety Net Fund, and requires insurers to cover mobile integrated health services.

Community hospitals could also benefit from an expedited Determination of Need process if they’re looking to expand primary care, behavioral health, maternal health and services in underserved communities. The projects would receive priority, with decisions issued with 60 days after an application is filed.