TX SB815: Relating to the use of certain automated systems in, and certain adverse determinations made in connection with, the health benefit claims process.

In one paragraph

Texas's SB 815 bars utilization review agents from using an automated decision system to make, wholly or partly, an adverse determination (a finding that health care services are not medically necessary or appropriate, or are experimental or investigational). Such tools may still be used for administrative support or fraud detection, and the insurance commissioner may audit and inspect an agent's use of them at any time. Adverse determination notices must describe the screening criteria and review procedures used. Signed June 20, 2025; effective September 1, 2025; applies to utilization review for health benefit plans delivered, issued or renewed on or after January 1, 2026.

Plain-English summary, written with AI assistance. The official text controls.

What it means for business

Utilization review agents may not use automated decision systems to make, wholly or partly, adverse determinations for plans delivered, issued or renewed from Jan. 1, 2026 (administrative support and fraud detection uses are allowed). Notices must describe screening criteria and review procedures.

Key provisions

1. 1A utilization review agent may not use an automated decision system to make, wholly or partly, an adverse determination (Ins. Code § 4201.156(a))
2. 2Automated decision system: an algorithm, including one incorporating an AI system, that uses data-based analytics to make, suggest or recommend determinations, decisions, judgments or conclusions; "algorithm" and "artificial intelligence system" are also defined (§ 4201.002(1-a)-(1-c))
3. 3"Adverse determination" now covers a utilization review agent's determination that services are not medically necessary or appropriate (previously: not medically necessary) or are experimental or investigational (§ 4201.002(1))
4. 4Algorithms, AI systems and automated decision systems may still be used for administrative support or fraud-detection functions (§ 4201.156(c))
5. 5The commissioner may audit and inspect a utilization review agent's use of an automated decision system for utilization review at any time (§ 4201.156(b))
6. 6Notice of an adverse determination must include a description of and the source of the screening criteria and review procedures used as guidelines (§ 4201.303(a)(3))
7. 7Signed by the Governor June 20, 2025 (Chapter 989); effective September 1, 2025; applies only to utilization review for health benefit plans delivered, issued for delivery or renewed on or after January 1, 2026 (earlier plans stay under prior law)

Latest legislative action

Jun 20, 2025. Signed by the Governor; effective on 9/1/25

Sponsors (showing 5 of 16)

Roll call votes (showing 3 of 4)