Summary
Regulates the use of artificial intelligence by insurers in making determinations of coverage under health benefit plans, including requirements related to clinical review, disclosures, and annual certification.
Healthcare Implications
Directly constrains payer use of artificial intelligence in utilization review and coverage determinations. Health plans must maintain clinical oversight and documentation, while providers and patients gain added protection against algorithm-only decisions.
Operational Implications
- AI may not supplant healthcare provider decisionmaking; medical-necessity determinations must be made by licensed clinicians.
- AI determinations must be based on enrollee's individual medical history and clinical circumstances; may not rely solely on group datasets.
- AI must be fairly and equitably applied and must not discriminate.
- AI must be open to inspection for audit or compliance reviews by the department.
- AI performance, use, and outcomes must be periodically reviewed and revised to maximize accuracy and reliability; annual certification required.
- Disclosures pertaining to use and oversight of AI must be contained in written policies and procedures.