Texas 2025 - 89th Regular

Texas House Bill HB4018 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	89R8701 SCL-D
2	2	By: Lalani H.B. No. 4018
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to use of artificial intelligence in utilization review
10	10	conducted for health benefit plans.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subchapter D, Chapter 4201, Insurance Code, is
13	13	amended by adding Section 4201.156 to read as follows:
14	14	Sec. 4201.156. USE OF ARTIFICIAL INTELLIGENCE. (a) In this
15	15	section, "artificial intelligence" means an engineered or
16	16	machine-based system that varies in autonomy and may, for explicit
17	17	or implicit objectives, infer from the input the system receives
18	18	how to generate outputs that can influence physical or virtual
19	19	environments.
20	20	(b) A utilization review agent that uses an artificial
21	21	intelligence-based algorithm or other software tool for
22	22	utilization review shall ensure that:
23	23	(1) the algorithm or tool bases its determination on
24	24	the following information, as applicable:
25	25	(A) an enrollee's medical or other clinical
26	26	history;
27	27	(B) individual clinical circumstances as
28	28	presented by the provider of record; and
29	29	(C) other relevant clinical information
30	30	contained in the enrollee's medical or other clinical record;
31	31	(2) the algorithm or tool does not base its
32	32	determination solely on a group dataset;
33	33	(3) the algorithm's or tool's criteria and guidelines
34	34	comply with this chapter and applicable state and federal law;
35	35	(4) the algorithm or tool does not override the
36	36	decision making of a physician or health care provider;
37	37	(5) the use of the algorithm or tool does not
38	38	discriminate, directly or indirectly, against enrollees in
39	39	violation of state or federal law;
40	40	(6) the algorithm or tool is fairly and equitably
41	41	applied, including in accordance with any applicable commissioner
42	42	rules;
43	43	(7) the algorithm or tool is available for review and
44	44	inspection under Section 4201.154;
45	45	(8) the use and oversight procedures of the algorithm
46	46	or tool are disclosed in writing to enrollees in the form and manner
47	47	provided by commissioner rule;
48	48	(9) the algorithm's or tool's performance, use, and
49	49	outcomes are periodically reviewed and revised to maximize accuracy
50	50	and reliability;
51	51	(10) patient information is not used beyond its
52	52	intended and stated purpose in accordance with state and federal
53	53	law; and
54	54	(11) the algorithm or tool does not directly or
55	55	indirectly cause harm to the enrollee other than assisting a
56	56	utilization review agent in making an adverse determination.
57	57	(c) A utilization review agent may not use an artificial
58	58	intelligence-based algorithm or other software tool as the sole
59	59	basis of a decision to wholly or partly deny, delay, or modify
60	60	health care services for an enrollee on the basis of medical
61	61	necessity or appropriateness of health care items and services.
62	62	Only a physician or licensed health care provider acting in
63	63	accordance with this chapter may determine medical necessity or
64	64	appropriateness of health care items and services.
65	65	SECTION 2. This Act takes effect September 1, 2025.