S2010
Insurance -- The Transparency and Accountability in Artificial Intelligence Use by Health Insurers to Manage Coverage and Claims Act
This bill requires human doctors to review insurance denials made by AI and mandates reporting on AI usage by insurers.
Introduced
01/09/2026
Healthcare: Health Insurance
Bill Sponsors
Ujifusa, Gu, Ciccone, Lawson, Tikoian, DiMario, Valverde, DiPalma, Zurier, McKenney, and Burke
Committee
Senate Artificial Intelligence & Emerging Tech
Summary
Select
This legislation establishes the "Transparency and Accountability in Artificial Intelligence Use by Health Insurers to Manage Coverage and Claims Act." It regulates how health insurance companies use Artificial Intelligence (AI) to make decisions about patient coverage. The bill requires insurers to disclose their AI usage to state regulators and mandates that any decision to deny medically necessary care based on AI analysis must be reviewed and approved by a human provider with similar qualifications. It also requires annual reporting on AI accuracy and fairness to the Governor and Legislature.
Sponsor
Analysis
Pros for Progressives
- Ensures that critical healthcare coverage decisions are reviewed by human medical professionals rather than solely by algorithms, protecting patients from arbitrary automated denials of necessary care.
- Mandates transparency and data governance regarding AI models, which helps identify and mitigate algorithmic biases that can disproportionately affect marginalized communities in healthcare.
- Empowers state regulators to oversee insurance practices more strictly, ensuring that profit-driven corporations cannot hide behind "black box" technology to deny benefits to policyholders.
Cons for Progressives
- Does not ban the use of AI in healthcare denials entirely, leaving the door open for algorithms to still play a significant role in restricting access to care.
- The definition of "administrative adverse benefit determination" could allow insurers to categorize certain denials as administrative rather than medical, potentially bypassing the human review requirement.
- Relies on state regulators (OHIC/DBR) for enforcement rules and oversight, which could be weakened later depending on the political appointments and funding of those agencies.
Pros for Conservatives
- Protects the professional autonomy of doctors by ensuring that medical decisions are reviewed by licensed peers rather than being overridden by unaccountable software algorithms.
- Increases accountability for insurance companies, ensuring they cannot use technology to dodge their contractual obligations to pay for valid medical services.
- Explicitly requires insurers to bear the total cost of compliance, ensuring that these new regulatory expenses are not directly shifted to the taxpayer budget.
Cons for Conservatives
- Imposes heavy regulatory burdens and reporting requirements on private businesses, which interferes with the free market and operational efficiency.
- Forces private companies to disclose proprietary information regarding their technology and internal processes to government agencies, infringing on corporate privacy.
- Could stifle innovation and increase administrative costs for insurers, which may ultimately lead to higher premiums for consumers.
Constitutional Concerns
None Likely
Impact Overview
Groups Affected
- Health Insurers
- Medical Providers
- Health Insurance Enrollees
- Office of the Health Insurance Commissioner
- Department of Business Regulation
Towns Affected
All
Cost to Taxpayers
None
Revenue Generated
None
BillBuddy Impact Ratings
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Freedom Impact
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Public Services
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Regulatory
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Clarity of Bill Language
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Bill Status
Current Status
Held
Comm Passed
Floor Passed
Law
History
• 01/09/2026 Introduced, referred to Senate Artificial Intelligence & Emerging Technol
Bill Text
SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by adding thereto the following chapter: CHAPTER 84 THE TRANSPARENCY AND ACCOUNTABILITY IN ARTIFICIAL INTELLIGENCE USE BY HEALTH INSURERS TO MANAGE COVERAGE AND CLAIMS ACT
27-84-1. Short title and purpose.
(a) This chapter shall be known and may be cited as "The Transparency and Accountability in Artificial Intelligence Use by Health Insurers to Manage Coverage and Claims Act."
(b) The purpose of this chapter is to regulate the use of artificial intelligence ("AI") by health insurers to ensure transparency, accountability and compliance with state and federal requirements for non-administrative claims and coverage management.
27-84-2. Definitions.
As used in this chapter, the following terms shall have the following meanings, unless the context clearly indicates otherwise:
(1) "Adverse benefit determination" means a decision not to authorize coverage for a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes:
(i) "Administrative adverse benefit determination," meaning any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and
(ii) "Non-administrative adverse benefit determination," meaning any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.
(2) "Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to:
(i) Perceive real and virtual environments;
(ii) Abstract such perceptions into models through analysis in an automated manner; and
(iii) Use model inference to formulate options for information or action.
(3) "Enrollee" means an individual who has health insurance coverage through an insurer.
(4) "Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services including, but not limited to, pharmacy benefit managers.
(5) "Medically necessary care" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health-related condition including any such services that are necessary to prevent or slow a decremental change in either medical or mental health status.
(6) "Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.
27-84-3. Requirements. LC003250 - Page 2 of 5
(a) Transparency.
(1) Insurers subject to this chapter shall disclose to the office of the health insurance commissioner ("OHIC") and the department of business regulation ("DBR") how they use artificial intelligence to manage healthcare claims and coverage including, but not limited to, the types of artificial intelligence models used, the role of artificial intelligence in the decision-making process, training datasets, performance metrics, governance and risk management policies, and the decisions on healthcare claims and coverage where artificial intelligence made, or was a substantial factor in making, the decisions.
(2) Insurers shall submit to the office of the health insurance commissioner and the department of business regulation, upon request, all information, including documents and software, that permits enforcement of this chapter.
(3) Insurers shall maintain documentation of artificial intelligence decisions for at least five (5) years including adverse benefit determinations where artificial intelligence made, or was a substantial factor in making, the adverse benefit determination.
(b) DBR/OHIC reporting.
(1) DBR/OHIC shall provide an initial report to the governor, the senate president and the speaker of the house on the use of artificial intelligence by health insurers within eighteen (18) months of the effective date of this chapter and annually thereafter.
(2) The annual report shall state how health insurers use artificial intelligence to manage claims and coverage. The report shall state, for each insurer:
(i) The types of artificial intelligence models used;
(ii) The role of artificial intelligence in the decision-making process to approve or deny healthcare claims or coverage whenever artificial intelligence is used to make, or is a substantial factor in making, a decision on healthcare claims or coverage;
(iii) Information regarding training. testing, and risk management including data governance measures used to cover the training data sets and the measures used to examine the suitability of data sources, possible biases and appropriate mitigation; and
(iv) Performance metrics including: number of claims; percentage of claims accepted and denied; the average time claim reviewers and medical professional reviewers spend on each claim and on denials of claims; percentage of claims appealed; and percentage of denials reversed.
27-84-4. Non-administrative adverse benefit determination review.
(a) Any non-administrative adverse benefit determination where an artificial intelligence system made, or was a substantial factor in making, that determination regarding medically necessary care shall be reviewed and approved by a provider with the same license status of the LC003250 - Page 3 of 5 ordering professional provider before being finalized, with documentation of their rationale included in the enrollee’s case record. Failure to follow the requirements set forth in this subsection shall result in reversal of the non-administrative adverse determination.
(b) Appeals of non-administrative adverse benefit determinations made by an artificial intelligence system regarding medically necessary care that has been reviewed and approved by a provider with the same license status of the ordering professional provider shall comply with the appeals process set forth in chapter 18.9 of title 27.
27-84-5. Enforcement.
(a) OHIC, in collaboration with DBR, shall promulgate rules and regulations that may be necessary to effectuate the purposes and implementation of this chapter.
(b) The total cost of complying with the requirements of this chapter and the applicable rules and regulations shall be borne by the insurer.
27-84-6. Severability.
If any provision of this chapter is found unconstitutional, preempted, or otherwise invalid, that provision shall be severed, and such decision shall not affect the validity of the remaining provisions of this chapter.
SECTION 2. This act shall take effect upon passage.
27-84-1. Short title and purpose.
(a) This chapter shall be known and may be cited as "The Transparency and Accountability in Artificial Intelligence Use by Health Insurers to Manage Coverage and Claims Act."
(b) The purpose of this chapter is to regulate the use of artificial intelligence ("AI") by health insurers to ensure transparency, accountability and compliance with state and federal requirements for non-administrative claims and coverage management.
27-84-2. Definitions.
As used in this chapter, the following terms shall have the following meanings, unless the context clearly indicates otherwise:
(1) "Adverse benefit determination" means a decision not to authorize coverage for a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes:
(i) "Administrative adverse benefit determination," meaning any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and
(ii) "Non-administrative adverse benefit determination," meaning any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.
(2) "Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to:
(i) Perceive real and virtual environments;
(ii) Abstract such perceptions into models through analysis in an automated manner; and
(iii) Use model inference to formulate options for information or action.
(3) "Enrollee" means an individual who has health insurance coverage through an insurer.
(4) "Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services including, but not limited to, pharmacy benefit managers.
(5) "Medically necessary care" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health-related condition including any such services that are necessary to prevent or slow a decremental change in either medical or mental health status.
(6) "Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.
27-84-3. Requirements. LC003250 - Page 2 of 5
(a) Transparency.
(1) Insurers subject to this chapter shall disclose to the office of the health insurance commissioner ("OHIC") and the department of business regulation ("DBR") how they use artificial intelligence to manage healthcare claims and coverage including, but not limited to, the types of artificial intelligence models used, the role of artificial intelligence in the decision-making process, training datasets, performance metrics, governance and risk management policies, and the decisions on healthcare claims and coverage where artificial intelligence made, or was a substantial factor in making, the decisions.
(2) Insurers shall submit to the office of the health insurance commissioner and the department of business regulation, upon request, all information, including documents and software, that permits enforcement of this chapter.
(3) Insurers shall maintain documentation of artificial intelligence decisions for at least five (5) years including adverse benefit determinations where artificial intelligence made, or was a substantial factor in making, the adverse benefit determination.
(b) DBR/OHIC reporting.
(1) DBR/OHIC shall provide an initial report to the governor, the senate president and the speaker of the house on the use of artificial intelligence by health insurers within eighteen (18) months of the effective date of this chapter and annually thereafter.
(2) The annual report shall state how health insurers use artificial intelligence to manage claims and coverage. The report shall state, for each insurer:
(i) The types of artificial intelligence models used;
(ii) The role of artificial intelligence in the decision-making process to approve or deny healthcare claims or coverage whenever artificial intelligence is used to make, or is a substantial factor in making, a decision on healthcare claims or coverage;
(iii) Information regarding training. testing, and risk management including data governance measures used to cover the training data sets and the measures used to examine the suitability of data sources, possible biases and appropriate mitigation; and
(iv) Performance metrics including: number of claims; percentage of claims accepted and denied; the average time claim reviewers and medical professional reviewers spend on each claim and on denials of claims; percentage of claims appealed; and percentage of denials reversed.
27-84-4. Non-administrative adverse benefit determination review.
(a) Any non-administrative adverse benefit determination where an artificial intelligence system made, or was a substantial factor in making, that determination regarding medically necessary care shall be reviewed and approved by a provider with the same license status of the LC003250 - Page 3 of 5 ordering professional provider before being finalized, with documentation of their rationale included in the enrollee’s case record. Failure to follow the requirements set forth in this subsection shall result in reversal of the non-administrative adverse determination.
(b) Appeals of non-administrative adverse benefit determinations made by an artificial intelligence system regarding medically necessary care that has been reviewed and approved by a provider with the same license status of the ordering professional provider shall comply with the appeals process set forth in chapter 18.9 of title 27.
27-84-5. Enforcement.
(a) OHIC, in collaboration with DBR, shall promulgate rules and regulations that may be necessary to effectuate the purposes and implementation of this chapter.
(b) The total cost of complying with the requirements of this chapter and the applicable rules and regulations shall be borne by the insurer.
27-84-6. Severability.
If any provision of this chapter is found unconstitutional, preempted, or otherwise invalid, that provision shall be severed, and such decision shall not affect the validity of the remaining provisions of this chapter.
SECTION 2. This act shall take effect upon passage.