WHAT THIS BILL REGULATES · 2 REQUIREMENT TYPES
How Is This Bill Enforced
Verbatim statutory text on the left; plain-language analysis and a per-section checklist on the right. Numbered markers cross-link to the matching checklist row.
As used in sections 3902.50 to 3902.80 of the Revised Code:
Section 3902.50 is the existing definitions section for Ohio's health insurance utilization review and prior authorization statutes (§§ 3902.50–3902.72). HB 579 amends this section solely to extend its scope to the new § 3902.80 by changing the cross-reference from "sections 3902.50 to 3902.72" to "sections 3902.50 to 3902.80." No new definitions are added; all existing definitions now apply to the new AI regulation section.
(A) As used in this section, "providerProvider"Provider" has the same meaning as in section 1751.01 of the Revised Code.Ohio Rev. Code § 3902.80(A)" has the same meaning as in section 1751.01 of the Revised Code.
(B)(1)(a)–(c) 1 Each health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E), annually, on or before the first day of March, shall file a report with the superintendent of insurance covering all of the following information: (a) Each providerProvider"Provider" has the same meaning as in section 1751.01 of the Revised Code.Ohio Rev. Code § 3902.80(A) in the health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E)'s network; (b) The number of covered personsCovered person"Covered person" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) enrolled in health benefit plansHealth benefit plan"Health benefit plan" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) issued by the health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) in this state in the preceding calendar year; (c) Whether the health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) used, is using, or will use artificial intelligence-based algorithms in utilization review processes for those health benefit plansHealth benefit plan"Health benefit plan" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) and, if so, all of the following information: (i) The algorithm criteria; (ii) Data sets used to train the algorithm; (iii) The algorithm itself; (iv) Outcomes of the software in which the algorithm is used; (v) Data on the amount of time a human reviewer spends examining an adverse determination prior to signing off on each such determination.
(B)(2) 1 The health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) shall submit the report in a form prescribed by the superintendent. An officer of the health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) shall verify the contents of the report.
(B)(3) 2 The superintendent shall publish a copy of the report on the web site of the department of insurance. The health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) shall publish a copy of the report on the health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E)'s publicly accessible web site.
(C)(1) 3 No health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) shall make a decision regarding the care of a covered personCovered person"Covered person" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E), including the decision to deny, delay, or modify health care servicesHealth care services"Health care services" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) based on medical necessity, based solely on results derived from the use or application of artificial intelligence.
(C)(2)(a)–(b) 4 A determination of medical necessity under a health benefit planHealth benefit plan"Health benefit plan" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) must meet both of the following requirements: (a) The determination is made by a licensed physician or a providerProvider"Provider" has the same meaning as in section 1751.01 of the Revised Code.Ohio Rev. Code § 3902.80(A) that is qualified to evaluate the specific clinical issues involved in the requested health care servicesHealth care services"Health care services" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E). (b) The determination takes into consideration the requesting providerProvider"Provider" has the same meaning as in section 1751.01 of the Revised Code.Ohio Rev. Code § 3902.80(A)'s recommendation, the covered personCovered person"Covered person" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E)'s medical or other clinical history, and individual clinical circumstances.
(C)(3) 5 Any physician who participates in a determination of medical necessity or a utilization review process on behalf of a health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) shall open and document the review of the individual clinical records or data prior to making an individualized documented decision.
(C)(4) 6 Any decision to deny, delay, or modify health care servicesHealth care services"Health care services" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) covered under a health benefit planHealth benefit plan"Health benefit plan" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) in which an artificial intelligence-based algorithm is used shall be accompanied by a plain language explanation of the rationale used in making the decision.
(D) The superintendent may audit a health plan issuerHealth plan issuer"Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E)'s use of an artificial intelligence-based algorithm at any time and may contract with a third party for the purposes of conducting such an audit.
(E) This section applies to health benefit plansHealth benefit plan"Health benefit plan" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E) issued, amended, or renewed on or after the effective date of this section.
Section 3902.80 is the operative section of HB 579, imposing four distinct compliance obligations on health plan issuers. First, it requires annual reporting to the Superintendent of Insurance on AI use in utilization review, including detailed disclosures about algorithm criteria, training data, algorithm design, outcomes, and human reviewer engagement time. Reports must be published on both the Department of Insurance and the issuer's own website.
Second, it categorically prohibits health plan issuers from making care decisions — including denials, delays, or modifications based on medical necessity — solely on AI-derived results. Third, it mandates that medical necessity determinations be made by a licensed physician or qualified provider who considers the treating provider's recommendation and the individual's clinical history. Fourth, it requires any physician participating in a medical necessity or utilization review determination to open and document review of individual clinical records before making a decision.
Enforcement: The Superintendent of Insurance may audit an issuer's AI algorithm use at any time, including through third-party auditors. The section applies to plans issued, amended, or renewed on or after the effective date.