Medicare Advantage
Medicare Part C: private plans delivering Medicare benefits under CMS contract. AI-assisted denials there answer to federal rules, not only state law.
Medicare Advantage is the private-plan side of Medicare, known in statute as Part C. The federal definitions are worth reading literally: an MA organization is an entity “organized and licensed by a State as a risk-bearing entity” that CMS has certified as meeting the MA contract requirements, and an MA plan is the health benefits coverage that organization offers at a uniform premium and uniform cost-sharing across its service area. So two regulators are in the room at once. The state licenses the company; CMS writes the program rules the plan runs on.
For AI governance that split decides which rulebook applies to a decision. A denial issued by a Medicare Advantage plan is an organization determination under Part 422, and the federal regulation is specific about who signs it. Where the plan expects to issue a partly or fully adverse decision that turns on medical necessity, the determination has to be reviewed first by a physician or other suitably qualified health professional, one with expertise in the relevant field and knowledge of Medicare coverage criteria. A model may prepare the ground for it, but the qualified person is the one who determines the outcome, and the file has to name them.
This is also the population where AI in health insurance is most visible in public. Medicare Advantage enrollment is large, prior authorization volumes are reported, and payment runs through risk adjustment scores built from submitted diagnoses. That combination puts three different AI workflows inside one program, each with a different failure mode. Our health insurance map separates them by regulator and appeal path, and the UnitedHealth case study follows what happened when the question reached litigation.