Texas 2025 - 89th Regular

Texas Senate Bill SB815 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		By: Schwertner, et al. S.B. No. 815
2		-	(Spiller, et al.)
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7	6		A BILL TO BE ENTITLED
8	7		AN ACT
9	8		relating to the use of certain automated systems in, and certain
10	9		adverse determinations made in connection with, the health benefit
11	10		claims process.
12	11		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	12		SECTION 1. Section 4201.002, Insurance Code, is amended by
14	13		amending Subdivision (1) and adding Subdivisions (1-a), (1-b), and
15	14		(1-c) to read as follows:
16	15		(1) "Adverse determination" means a determination by a
17	16		utilization review agent that health care services provided or
18	17		proposed to be provided to a patient are not medically necessary or
19	18		appropriate or are experimental or investigational.
20	19		(1-a) "Algorithm" means a computerized procedure
21	20		consisting of a set of steps used to accomplish a determined task.
22	21		(1-b) "Artificial intelligence system" means any
23	22		machine learning-based system that, for any explicit or implicit
24	23		objective, infers from the inputs the system receives how to
25	24		generate outputs, including content, decisions, predictions, and
26	25		recommendations, that can influence physical or virtual
27	26		environments.
28	27		(1-c) "Automated decision system" means an algorithm,
29	28		including an algorithm incorporating an artificial intelligence
30	29		system, that uses data-based analytics to make, suggest, or
31	30		recommend certain determinations, decisions, judgments, or
32	31		conclusions.
33	32		SECTION 2. Subchapter D, Chapter 4201, Insurance Code, is
34	33		amended by adding Section 4201.156 to read as follows:
35	34		Sec. 4201.156. USE OF AUTOMATED DECISION SYSTEM FOR ADVERSE
36	35		DETERMINATIONS. (a) A utilization review agent may not use an
37	36		automated decision system to make, wholly or partly, an adverse
38	37		determination.
39	38		(b) The commissioner may audit and inspect at any time a
40	39		utilization review agent's use of an automated decision system for
41	40		utilization review.
42	41		(c) This section does not prohibit the use of an algorithm,
43	42		artificial intelligence system, or automated decision system for
44	43		administrative support or fraud-detection functions.
45	44		SECTION 3. Section 4201.303(a), Insurance Code, is amended
46	45		to read as follows:
47	46		(a) Notice of an adverse determination must include:
48	47		(1) the principal reasons for the adverse
49	48		determination;
50	49		(2) the clinical basis for the adverse determination;
51	50		(3) a description of and [or] the source of the
52	51		screening criteria and review procedures used as guidelines in
53	52		making the adverse determination; and
54	53		(4) a description of the procedure for the complaint
55	54		and appeal process, including notice to the enrollee of the
56	55		enrollee's right to appeal an adverse determination to an
57	56		independent review organization and of the procedures to obtain
58	57		that review.
59	58		SECTION 4. Chapter 4201, Insurance Code, as amended by this
60	59		Act, applies only to utilization review conducted for a health
61	60		benefit plan delivered, issued for delivery, or renewed on or after
62	61		January 1, 2026. Utilization review conducted for a health benefit
63	62		plan delivered, issued for delivery, or renewed before January 1,
64	63		2026, is governed by the law as it existed immediately before the
65	64		effective date of this Act, and that law is continued in effect for
66	65		that purpose.
67	66		SECTION 5. This Act takes effect September 1, 2025.