Establishes requirements for the use of artificial intelligence, algorithm, or other software tools in utilization review and management; defines artificial intelligence.
This bill would regulate the use of artificial intelligence, algorithms, and other software tools in health insurance utilization review and utilization management. It defines “artificial intelligence” in the Insurance Law and applies the new requirements to health care service plans and specialized health care service plans that use, or contract with entities that use, these tools for coverage decisions.
Under the bill, AI-driven review tools must base determinations on an enrollee’s medical or dental history, the requesting provider’s clinical circumstances, and other relevant clinical information in the record. The bill also requires that these tools not replace provider decision-making, be open to inspection, be described in written policies and procedures, be periodically reviewed for accuracy and reliability, and not be used in a discriminatory or harmful way. It further limits patient data use to its intended and stated purpose, consistent with state law and HIPAA. Importantly, any denial, delay, or modification of services based on medical necessity must be made by a licensed physician or other qualified health care provider, not solely by AI.
The bill would amend the New York Insurance Law by adding a new definition of artificial intelligence and creating a new section governing AI use in utilization review and utilization management. It would impose operational, transparency, nondiscrimination, and privacy requirements on health plans and their vendors, and it would preserve final medical-necessity determinations for licensed clinicians. The measure would affect insurers, health care service plans, utilization review contractors, providers, and enrollees by limiting automated decision-making in coverage determinations.
Based on the bill text and the absence of recorded committee debate or votes in the provided materials, the overall sentiment appears supportive of stronger oversight of AI in health coverage decisions. The bill is framed as a consumer-protection and patient-safety measure, emphasizing clinician review, transparency, fairness, and data privacy. No contrary positions are documented in the supplied context.
The main policy tension in the bill is between the use of AI to streamline utilization review and concerns that automated tools may override clinical judgment, produce biased outcomes, or misuse patient data. Supporters would likely favor the requirement that a licensed clinician make final medical-necessity decisions and that AI tools remain inspectable and regularly reviewed. Potential opponents may object to the administrative burden, limits on automation, and the practical difficulty of ensuring compliance across insurers and vendors, especially where AI is used as part of outsourced utilization management.