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:
(E) "Covered personCovered person"Covered person" has the same meaning as in section 3922.01 of the Revised Code.Ohio Rev. Code § 3902.50(E)," "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)," "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)," and "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)" have the same meanings as in section 3922.01 of the Revised Code.
(K) "Prior authorization requirementPrior authorization requirement"Prior authorization requirement" means any practice implemented by a health plan issuer in which coverage of a health care service, device, or drug is dependent upon a covered person or a provider obtaining approval from the health plan issuer prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authorization requirement" includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug.Ohio Rev. Code § 3902.50(K)" means any practice implemented by 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) in which coverage of a health care service, device, or drug is dependent upon 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) or a providerProvider"Provider" has the same meaning as in section 1751.01 of the Revised Code.Ohio Rev. Code § 3902.80(A) obtaining approval from 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) prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authorization requirementPrior authorization requirement"Prior authorization requirement" means any practice implemented by a health plan issuer in which coverage of a health care service, device, or drug is dependent upon a covered person or a provider obtaining approval from the health plan issuer prior to the service, device, or drug being performed, received, or prescribed, as applicable. "Prior authorization requirement" includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug.Ohio Rev. Code § 3902.50(K)" includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug.
Section 3902.50 is the existing definitions section for Ohio's health plan issuer regulatory provisions (sections 3902.50 through 3902.72). This bill amends it to extend its scope through the new section 3902.80, so that all existing defined terms — including health plan issuer, covered person, health benefit plan, health care services, prior authorization requirement, and others — apply to the new AI provisions.
(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) 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) 7 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 bill's operative section, imposing four distinct categories of obligation on health plan issuers that use AI in utilization review. First, subsection (B) requires annual filing of a detailed report with the Superintendent of Insurance covering each issuer's network providers, enrollment numbers, and — critically — detailed information about any AI-based algorithms used in utilization review, including the algorithm criteria, training data, the algorithm itself, outcomes, and the time human reviewers spend on adverse determinations. Reports must be published on both the Department of Insurance website and the issuer's own website.
Second, subsection (C)(1) prohibits health plan issuers from basing care decisions solely on AI-derived results. Subsections (C)(2)–(3) impose affirmative requirements for medical necessity determinations: they must be made by qualified clinicians who consider the requesting provider's recommendation and the individual patient's clinical history. Third, subsection (C)(4) requires a plain-language explanation to accompany any AI-involved denial, delay, or modification decision. Fourth, subsection (D) authorizes the Superintendent to audit AI algorithm use at any time, including through third-party contractors.