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A BILL TO BE ENTITLED
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AN ACT
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relating to use of artificial intelligence in utilization review |
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conducted for health benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter D, Chapter 4201, Insurance Code, is |
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amended by adding Section 4201.156 to read as follows: |
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Sec. 4201.156. USE OF ARTIFICIAL INTELLIGENCE. (a) In this |
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section, "artificial intelligence" means an engineered or |
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machine-based system that varies in autonomy and may, for explicit |
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or implicit objectives, infer from the input the system receives |
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how to generate outputs that can influence physical or virtual |
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environments. |
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(b) A utilization review agent that uses an artificial |
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intelligence-based algorithm or other software tool for |
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utilization review shall ensure that: |
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(1) the algorithm or tool bases its determination on |
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the following information, as applicable: |
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(A) an enrollee's medical or other clinical |
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history; |
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(B) individual clinical circumstances as |
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presented by the provider of record; and |
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(C) other relevant clinical information |
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contained in the enrollee's medical or other clinical record; |
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(2) the algorithm or tool does not base its |
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determination solely on a group dataset; |
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(3) the algorithm's or tool's criteria and guidelines |
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comply with this chapter and applicable state and federal law; |
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(4) the algorithm or tool does not override the |
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decision making of a physician or health care provider; |
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(5) the use of the algorithm or tool does not |
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discriminate, directly or indirectly, against enrollees in |
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violation of state or federal law; |
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(6) the algorithm or tool is fairly and equitably |
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applied, including in accordance with any applicable commissioner |
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rules; |
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(7) the algorithm or tool is available for review and |
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inspection under Section 4201.154; |
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(8) the use and oversight procedures of the algorithm |
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or tool are disclosed in writing to enrollees in the form and manner |
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provided by commissioner rule; |
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(9) the algorithm's or tool's performance, use, and |
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outcomes are periodically reviewed and revised to maximize accuracy |
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and reliability; |
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(10) patient information is not used beyond its |
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intended and stated purpose in accordance with state and federal |
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law; and |
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(11) the algorithm or tool does not directly or |
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indirectly cause harm to the enrollee other than assisting a |
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utilization review agent in making an adverse determination. |
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(c) A utilization review agent may not use an artificial |
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intelligence-based algorithm or other software tool as the sole |
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basis of a decision to wholly or partly deny, delay, or modify |
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health care services for an enrollee on the basis of medical |
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necessity or appropriateness of health care items and services. |
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Only a physician or licensed health care provider acting in |
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accordance with this chapter may determine medical necessity or |
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appropriateness of health care items and services. |
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SECTION 2. This Act takes effect September 1, 2025. |