HB 26-1139

HB 26-1139, titled "Use of Artificial Intelligence in Health Care," is a bill that sets rules for how artificial intelligence (AI) can be used by health insurance companies and other healthcare providers when deciding whether to cover medical services. It ensures that AI systems must consider individual patient circumstances rather than just group data and requires human review if the AI denies coverage. The bill also defines mental health chatbots as AI tools that interact with users like a therapist would, but it prohibits these bots from pretending to be real therapists or handling sensitive user information without proper safeguards. This means insurance companies can't pay for therapy provided by an AI system unless it's just giving general advice and not claiming to offer professional treatment. The bill has been signed into law, so its rules are now in effect and must be followed by healthcare entities in Colorado.

Official Summary

On and after January 1, 2027, when determining coverage for health-care services, the act requires entities that use an artificial intelligence system (AI system) for the purpose of conducting utilization review of health-care services, including health insurance companies (carriers), pharmacy benefit managers, private utilization review organizations, behavioral health administrative services organizations, and managed care entities (entities), ensure that the AI system complies with certain requirements specified in the act. Specifically, an entity shall ensure that the AI system:Makes determinations based on medical or clinical history, the patient's individual clinical circumstances, and other relevant clinical factors specified in the act, with denial of coverage reviewed by a licensed clinician or physician or other competent regulated professional who is competent to evaluate the specific clinical issues and review the health benefit plan's terms of coverage (competent regulated professional);Does not base its determination solely on group data without reference to the individual's data;Is not used in any way that discriminates against individuals in violation of other state or federal laws and is fairly and equitably applied, including in accordance with regulations and guidance issued by the federal department of health and human services; andIs periodically reviewed to ensure the AI systems outcomes are accurate and reliable and that an individual's health data is not used beyond its intended or stated purpose.     Entities that use AI systems shall disclose to the division of insurance, the department of human services, or the department of health care policy and financing, as applicable, the utilization review functions for which the AI system will be used and the points in the utilization review process when it will be used, the process for human oversight of adverse coverage determinations, and the process for maintaining audit information to ensure that the use of the AI system complies with the requirements in the act.     The AI system may be used to assist in utilization review, including expedited approvals. A carrier's denial of coverage for a service based in whole or in part on medical necessity shall not be issued solely on the output of an AI system without human review by a licensed clinician or physician or other competent regulated professional.     Further, the act prohibits a carrier and a payer of services under the 'Colorado Medical Assistance Act' and the 'Children's Basic Health Plan Act' from paying for psychotherapy services that are provided directly to a client and that are conducted by an AI system.(Note: This summary applies to this bill as enacted.)

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