HB4018 - Relating to use of artificial intelligence in utilization review conducted for health benefit plans.

  89R8701 SCL-D     By: Lalani H.B. No. 4018       A BILL TO BE ENTITLED   AN ACT   relating to use of artificial intelligence in utilization review   conducted for health benefit plans.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subchapter D, Chapter 4201, Insurance Code, is   amended by adding Section 4201.156 to read as follows:           Sec.   4201.156.     USE OF ARTIFICIAL INTELLIGENCE. (a)   In this   section, "artificial intelligence" means an engineered or   machine-based system that varies in autonomy and may, for explicit   or implicit objectives, infer from the input the system receives   how to generate outputs that can influence physical or virtual   environments.           (b)     A utilization review agent that uses an artificial   intelligence-based algorithm or other software tool for   utilization review shall ensure that:                 (1)     the algorithm or tool bases its determination on   the following information, as applicable:                       (A)     an enrollee's medical or other clinical   history;                       (B)     individual clinical circumstances as   presented by the provider of record; and                       (C)     other relevant clinical information   contained in the enrollee's medical or other clinical record;                 (2)     the algorithm or tool does not base its   determination solely on a group dataset;                 (3)     the algorithm's or tool's criteria and guidelines   comply with this chapter and applicable state and federal law;                 (4)     the algorithm or tool does not override the   decision making of a physician or health care provider;                 (5)     the use of the algorithm or tool does not   discriminate, directly or indirectly, against enrollees in   violation of state or federal law;                 (6)     the algorithm or tool is fairly and equitably   applied, including in accordance with any applicable commissioner   rules;                 (7)     the algorithm or tool is available for review and   inspection under Section 4201.154;                 (8)     the use and oversight procedures of the algorithm   or tool are disclosed in writing to enrollees in the form and manner   provided by commissioner rule;                 (9)     the algorithm's or tool's performance, use, and   outcomes are periodically reviewed and revised to maximize accuracy   and reliability;                 (10)     patient information is not used beyond its   intended and stated purpose in accordance with state and federal   law; and                 (11)     the algorithm or tool does not directly or   indirectly cause harm to the enrollee other than assisting a   utilization review agent in making an adverse determination.           (c)     A utilization review agent may not use an artificial   intelligence-based algorithm or other software tool as the sole   basis of a decision to wholly or partly deny, delay, or modify   health care services for an enrollee on the basis of medical   necessity or appropriateness of health care items and services.     Only a physician or licensed health care provider acting in   accordance with this chapter may determine medical necessity or   appropriateness of health care items and services.          SECTION 2.  This Act takes effect September 1, 2025.