PRINTER'S NO. 1965
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1663
Session of
2023
INTRODUCED BY VENKAT, HOGAN, KHAN, KOSIEROWSKI, MERCURI,
PISCIOTTANO, DELLOSO, PARKER, PROBST, HILL-EVANS, MADDEN,
HANBIDGE, SANCHEZ, FREEMAN, DONAHUE, MALAGARI, HOWARD,
HADDOCK, MAYES, CEPEDA-FREYTIZ, SHUSTERMAN, BOROWSKI, MADSEN
AND BURGOS, SEPTEMBER 7, 2023
REFERRED TO COMMITTEE ON INSURANCE, SEPTEMBER 7, 2023
AN ACT
Providing for disclosure by health insurers of the use of
artificial intelligence-based algorithms in the utilization
review process.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Artificial
Intelligence Utilization Review (AURA) Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Artificial intelligence-based algorithms." Any artificial
system that performs tasks under varying and unpredictable
circumstances without significant human oversight or that can
learn from experience and improve performance when exposed to
data sets.
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"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Covered person." A policyholder, subscriber or other
individual who is entitled to receive health care services under
a health insurance policy.
"Department." The Insurance Department of the Commonwealth.
"Health care provider." A licensed hospital or health care
facility, medical equipment supplier or person who is licensed,
certified or otherwise regulated to provide health care services
under the laws of this Commonwealth.
"Health care service." Any covered treatment, admission,
procedure, medical supplies and equipment or other services,
including behavioral health, prescribed or otherwise provided or
proposed to be provided by a health care provider to a covered
person for the diagnosis, prevention, treatment, cure or relief
of a health condition, illness, injury or disease under the
terms of a health insurance policy.
"Health insurance policy." A policy, subscriber contract,
certificate or plan issued by an insurer that provides medical
or health care coverage. The term does not include:
(1) An accident only policy.
(2) A credit only policy.
(3) A long-term care or disability income policy.
(4) A specified disease policy.
(5) A Medicare supplement policy.
(6) A TRICARE policy, including a Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS)
supplement policy.
(7) A fixed indemnity policy.
(8) A hospital indemnity policy.
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(9) A dental only policy.
(10) A vision only policy.
(11) A workers' compensation policy.
(12) An automobile medical payment policy under 75
Pa.C.S. (relating to vehicles).
(13) A homeowner's insurance policy.
(14) Any other similar policies providing for limited
benefits.
"Insurer." The following:
(1) An entity licensed by the department that offers,
issues or renews an individual or group health insurance
policy that is offered or governed under:
(i) The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921, including section
630 and Article XXIV thereof.
(ii) The act of December 29, 1972 (P.L.1701,
No.364), known as the Health Maintenance Organization
Act.
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or 63 (relating to professional health
services plan corporations).
(2) The term does not include an entity operating as a
Medical Assistance or CHIP Managed Care Plan.
"Medical Assistance or CHIP Managed Care Plan." A health
care plan that uses a gatekeeper to manage the utilization of
health care services by medical assistance or children's health
insurance program enrollees and integrates the financing and
delivery of health care services.
"Specialist." A health care provider whose practice is not
limited to primary health care services and who has additional
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postgraduate or specialized training, has board certification or
practices in a licensed specialized area of health care.
"Utilization review." The term shall mean the same as
defined under section 2102 of The Insurance Company Law of 1921.
Section 3. Insurer requirements.
(a) Duty to disclose.--An insurer shall disclose to a health
care provider, all covered persons and the general public if
artificial intelligence-based algorithms are used, not used or
will be used in the insurer's utilization review process. An
insurer shall disclose information about the use or lack of use
of artificial intelligence-based algorithms in the utilization
review process on the insurer's publicly accessible Internet
website.
(b) Transparency.--An insurer shall submit the artificial
intelligence-based algorithms and training data sets that are
being used or will be used in the utilization review process to
the department for transparency. The department shall implement
a process that allows the department to certify that these
artificial intelligence-based algorithms and training data sets
have minimized the risk of bias based on the covered person's
race, color, religious creed, ancestry, age, sex, gender,
national origin, handicap or disability and adhere to evidence-
based clinical guidelines.
Section 4. Specialist requirements.
A specialist who participates in a utilization review process
for an insurer that initially uses artificial intelligence-based
algorithms for a utilization review shall open and document the
utilization review of the individual clinical records or data
prior to the individualized documented decision of a denial.
Section 5. Enforcement.
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(a) Penalties.--
(1) A violation of this act shall be deemed to be an
unfair method of competition and an unfair or deceptive act
or practice under the act of July 22, 1974 (P.L.589, No.205),
known as the Unfair Insurance Practices Act.
(2) Upon satisfactory evidence of a violation of this
act by an insurer or other person, one or more of the
following penalties may be imposed at the commissioner's
discretion:
(i) Suspension or revocation of license of the
insurer or other person.
(ii) Refusal, for a period not to exceed one year,
to issue a new license to the insurer or other person.
(iii) A fine of not more than $5,000 for each
violation of this act.
(iv) A fine of not more than $10,000 for each
willful violation of this act.
(b) Limitations on fines.--
(1) Fines imposed against an insurer under subsection
(a) may not exceed $500,000 in the aggregate during a single
calendar year.
(2) Fines imposed against any other person under
subsection (a) may not exceed $100,000 in the aggregate
during a single calendar year.
(c) Additional remedies.--The enforcement remedies imposed
under this subsection are in addition to any other remedies or
penalties that may be imposed under any other applicable law of
this Commonwealth, including:
(1) The Unfair Insurance Practices Act.
(2) The act of December 18, 1996 (P.L.1066, No.159),
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known as the Accident and Health Filing Reform Act.
(3) The act of June 25, 1997 (P.L.295, No.29), known as
the Pennsylvania Health Care Insurance Portability Act.
(d) Administrative procedure.--This section shall be subject
to 2 Pa.C.S. Ch. 5 Subch. A (relating to practice and procedure
of Commonwealth agencies). A party against whom penalties are
assessed in an administrative action may appeal to Commonwealth
Court as provided in 2 Pa.C.S. Ch. 7 Subch. A (relating to
judicial review of Commonwealth agency action).
Section 6. Effective date.
This act shall take effect in 60 days.
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