The bill introduces a new chapter, titled "The Transparency and Accountability in Artificial Intelligence Use by Health Insurers to Manage Coverage and Claims Act," into Title 27 of the General Laws concerning insurance. Its primary purpose is to regulate the use of artificial intelligence (AI) by health insurers, ensuring transparency, accountability, and compliance with state and federal requirements in their claims and coverage management processes.

The bill defines key terms such as "adverse benefit determination," "artificial intelligence," "enrollee," "insurer," and "medically necessary care." It establishes requirements for insurers to disclose how they use AI in managing healthcare claims and coverage, including the types of AI models used, the role of AI in decision-making, training datasets, performance metrics, governance and risk management policies, and decisions influenced by AI.

Insurers are required to maintain documentation of AI decisions for at least five years, including adverse benefit determinations where AI was a substantial factor. Any adverse benefit determination made by an AI system regarding medically necessary care must be reviewed and approved by a qualified healthcare professional before finalization, with documentation of their rationale included in the enrollee's case record.

The Department of Business Regulation (DBR) and the Office of the Health Insurance Commissioner (OHIC) will provide an annual report to the governor, the senate president, and the speaker of the house detailing the use of AI by health insurers. This report will include information on the types of AI models used, the role of AI in decision-making, training and risk management measures, and performance metrics.

By June 30, 2026, DBR/OHIC shall promulgate rules and regulations to set forth the reporting requirements for health insurers covered under this chapter. The act is set to take effect on June 30, 2026.

Statutes affected:
13: 42-7.2-5, 42-14.5-3