🟡Relating to the use of certain automated systems in, and certain adverse determinations made in connection with, the health benefit claims process.

🟡 SB 815: Stops Robots from Denying Your Care

What it says it does:
SB 815 bans health insurance companies from using artificial intelligence or automated systems to decide if medical care is “medically necessary.” It requires a human reviewer to make that call and allows the Texas Department of Insurance to audit insurers.

What it actually changes:
The bill adds new rules for how utilization review agents make adverse determinations and what must appear in denial notices. It also gives the Insurance Commissioner the power to inspect and audit automated systems used in the claims process. The law takes effect September 1, 2025, and applies to plans renewed on or after January 1, 2026.

Who is pushing for it:
Physician groups, hospitals, and patient advocacy organizations that want people—not algorithms—to decide whether treatment should be covered.

Who benefits:
Patients and doctors gain stronger footing when contesting denials. Hospitals and healthcare providers benefit from more human oversight in medical necessity decisions.

Who gets left out or exposed:
Insurers and third-party review companies that rely on automated decision tools lose flexibility. Patients may still be exposed if oversight is weak, since the law does not include penalties for violations or clear disclosure when automation is used behind the scenes.

Why this matters long term:
SB 815 recognizes that healthcare decisions affect lives, not just balance sheets. But if regulators lack staff or authority to enforce the new rules, AI-driven denials could quietly continue under the label of “administrative support.”

What to watch next:
Watch how the Texas Department of Insurance defines “automated decision system” in its rules, and whether lawmakers add penalties or funding in future sessions. Also watch if insurers attempt to stretch the “fraud detection” exception to keep AI in the mix.

Bottom line:
SB 815 is an important step toward keeping medical decisions in human hands, but without real enforcement or transparency, it may be more symbolic than transformative. Patients deserve proof that care decisions are being made by people, not code.

#SB815 #TexasPolicy #HealthCareRights #InsuranceReform #WatchTheRules