WHAT THIS BILL REGULATES · 3 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.
(a)–(b) This chapter shall be known and may be cited as "The Transparency and Accountability in Artificial IntelligenceArtificial intelligence"Artificial intelligence" or "AI" means a machine-based system that undertakes analysis, reasoning and problem-solving, and that can be used to generate predictions, recommendations, or other content.R.I. Gen. Laws § 27-83-2(2) Use by Health InsurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) to Manage Coverage and Claims Act." (b) The purpose of this chapter is to regulate the use of artificial intelligenceArtificial intelligence"Artificial intelligence" or "AI" means a machine-based system that undertakes analysis, reasoning and problem-solving, and that can be used to generate predictions, recommendations, or other content.R.I. Gen. Laws § 27-83-2(2) (AI) by health insurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) to ensure transparency, accountability and compliance with state and federal requirements for claims and coverage management including anti-discrimination and privacy laws.
This section establishes the short title and states the legislative purpose: to regulate the use of artificial intelligence by health insurers to ensure transparency, accountability, and compliance with state and federal requirements for claims and coverage management, including anti-discrimination and privacy laws. It creates no independent compliance obligation.
(1)–(6) As used in this chapter, the following terms shall have the following meanings, unless the context clearly indicates otherwise: (1) "Adverse determinationAdverse determination"Adverse determination" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual's eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided as a result of a determination that the item or service is experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.R.I. Gen. Laws § 27-83-2(1)" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual's eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided as a result of a determination that the item or service is experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination. (2) "Artificial intelligenceArtificial intelligence"Artificial intelligence" or "AI" means a machine-based system that undertakes analysis, reasoning and problem-solving, and that can be used to generate predictions, recommendations, or other content.R.I. Gen. Laws § 27-83-2(2)" or "AI" means a machine-based system that undertakes analysis, reasoning and problem-solving, and that can be used to generate predictions, recommendations, or other content. (3) "EnrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3)" means an individual who has health insurance coverage through an insurerInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4). (4) "InsurerInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4)" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2. (5) "Medically necessary careMedically necessary care"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.R.I. Gen. Laws § 27-83-2(5)" 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) "Third partyThird party"Third party" means an individual or entity, including independent contractors, pharmacy benefit managers and group purchasing organizations, that provides to an insurer services, including software development, data collection, analysis and administrative or other resources that manage or assist in managing enrollee healthcare coverage and claims.R.I. Gen. Laws § 27-83-2(6)" means an individual or entity, including independent contractors, pharmacy benefit managers and group purchasing organizations, that provides to an insurerInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) services, including software development, data collection, analysis and administrative or other resources that manage or assist in managing enrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) healthcare coverage and claims.
This section defines six key terms used throughout the chapter. The definition of Insurer is notably broad, encompassing all insurance companies licensed in Rhode Island, including HMOs and Medicaid managed care organizations. Third party extends the reach of the monitoring obligations to pharmacy benefit managers, independent contractors, and group purchasing organizations that assist insurers with AI-driven claims management.
(a)(1) 1 InsurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) shall publicly disclose how they use AI to manage claims and coverage, including underlying algorithms, data used, and resulting determinations.
(a)(2) 2 InsurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) shall submit to the office of the health insurance commissioner and the executive office of health and human services, upon request, all information, including documents and software, that permits enforcement of this chapter.
(a)(3) 3 InsurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) shall maintain documentation of AI decisions for at least five (5) years.
(a)(4) 4 InsurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) shall provide notice to enrolleesEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) and healthcare providers when AI has been used to issue an adverse determinationAdverse determination"Adverse determination" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual's eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided as a result of a determination that the item or service is experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.R.I. Gen. Laws § 27-83-2(1) and provide a clear and timely process for appealing the determination.
(b)(1) 5 InsurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) shall not rely exclusively on AI or automated decision tools to deny, reduce, or alter coverage or claims for medically necessary careMedically necessary care"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.R.I. Gen. Laws § 27-83-2(5).
(b)(2) 6 Adverse determinationsAdverse determination"Adverse determination" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual's eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided as a result of a determination that the item or service is experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.R.I. Gen. Laws § 27-83-2(1) shall be reviewed by physicians or other licensed healthcare professionals who are qualified in the appropriate specialties, without conflicts of interest or incentives to confirm adverse determinationsAdverse determination"Adverse determination" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual's eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided as a result of a determination that the item or service is experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.R.I. Gen. Laws § 27-83-2(1), and who have the authority to reverse adverse determinationsAdverse determination"Adverse determination" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual's eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided as a result of a determination that the item or service is experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.R.I. Gen. Laws § 27-83-2(1) based on their clinical judgment.
(b)(3) 7 InsurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) shall conduct on-going monitoring, audits and oversight of all employees and third parties using AI on their behalf to manage enrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) coverage or claims, including taking actions to ensure: (i) EnrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) medically necessary careMedically necessary care"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.R.I. Gen. Laws § 27-83-2(5) has not been delayed, denied or limited; (ii) Financial and administrative burdens on enrolleesEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) and healthcare providers are reasonable and minimized; (iii) Private enrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) health information is protected as required under state and federal privacy laws; and (iv) AI use does not violate enrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) rights under state and federal laws prohibiting discrimination, including those based on age, race, sex, sexual orientation, and pre-existing conditions.
This section imposes the bill's core operating requirements, organized under two headings. The Transparency subsection requires insurers to publicly disclose how they use AI in claims and coverage management, submit enforcement-related information to regulators on request, retain AI decision documentation for at least five years, and notify enrollees and providers when AI has been used to issue an adverse determination with a clear appeals process. The Accountability subsection prohibits exclusive reliance on AI for denying or altering medically necessary care, mandates clinical review of adverse determinations by qualified physicians free of conflicts, and requires ongoing monitoring of employees and third parties using AI — with specific attention to medically necessary care, administrative burden minimization, privacy compliance, and anti-discrimination compliance.
(a) The office of the health insurance commissioner and the executive office of health and human services, in collaboration with other state authorities including the department of business regulation, the secretary of state, and the attorney general, are authorized to promulgate such rules and regulations, and take such actions as may be necessary, to implement and enforce the provisions of this chapter.
(b) Nothing in this chapter shall limit them from taking independent actions permitted under any state or federal law, including, but not limited to, consumer protection laws related to antitrust, and deceptive trade practices as described in chapter 13.1 of title 6 ("deceptive trade practices").
(c) EnrolleesEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) have a private right of action to enforce the provisions of this chapter.
(d)(1)–(4) Violations of this chapter may result in: (1) Orders to change or limit how insurersInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4) use AI for management of enrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) coverage and claims; (2) Fines of up to fifty thousand dollars ($50,000) per violation; (3) Revocation or suspension of the insurerInsurer"Insurer" means all insurance companies licensed to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health insurance carrier subject to and organized pursuant to chapter 18 of title 27, a nonprofit hospital service corporation subject to and organized pursuant to chapter 19 of title 27, a nonprofit medical services corporation subject to and organized pursuant to chapter 20 of title 27, a qualified health maintenance organization subject to and organized pursuant to chapter 41 of title 27, and Medicaid managed care organizations as described in §42-7.4-2.R.I. Gen. Laws § 27-83-2(4)'s licenses in Rhode Island; and (4) Compensation and damages to affected enrolleesEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3) and health care providers, including pharmacies and hospitals.
This section establishes the enforcement framework. The OHIC and EOHHS, together with other state authorities including the Attorney General, are authorized to promulgate rules and take enforcement actions. The bill preserves independent enforcement authority under other state and federal laws, including deceptive trade practices. Enrollees receive an explicit private right of action. Remedies include orders to change AI use practices, fines up to $50,000 per violation, license revocation or suspension, and compensation and damages to affected enrollees and providers.
This chapter supplements requirements set forth in other general laws. To the extent there is any direct conflict, the provisions of this chapter shall control over any more general provisions.
This section clarifies the relationship between this chapter and other general laws. The chapter supplements existing requirements, and its provisions control over more general provisions in the event of a direct conflict.
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.
Standard severability clause providing that if any provision is found unconstitutional, preempted, or otherwise invalid, it shall be severed without affecting the remaining provisions.
(16) Enforce the provisions of title 27 as set forth in § 27-83-1 through § 27-83-6.
This provision amends the duties of the EOHHS Secretary to add enforcement responsibility for §§ 27-83-1 through 27-83-6. It assigns administrative authority rather than creating a new compliance obligation on regulated entities.
(v) To enforce the provisions of title 27 as set forth in § 27-83-1 through § 27-83-6.
This provision amends the powers and duties of the Health Insurance Commissioner to add enforcement responsibility for §§ 27-83-1 through 27-83-6, mirroring the parallel amendment to the EOHHS Secretary. It assigns administrative authority rather than creating a new compliance obligation on regulated entities.