VT H0776

Health plans using AI, algorithms, or software tools for utilization review must base determinations on the individual insured's medical history, specific clinical circumstances, and relevant clinical records—not solely on group datasets.

AI tools must be applied consistently across all health plans and insureds, ensuring patients with similar clinical presentations receive the same decisions.

AI systems must be open to inspection by the Department of Financial Regulation and other state agencies, with quarterly performance reviews required to maximize accuracy and reliability.

Adverse coverage determinations (denials, delays, or modifications) cannot be made by AI and must be issued only by a licensed human health care provider competent to evaluate the specific clinical issues.

Effective date: July 1, 2026.