FIJISHI EPL

Fijishi Jurisdiction Index 2026 · Entry US-TX · Published 12 October 2026

At a glance

Jurisdiction tier	Tier A - Specified and enforced. A binding instrument that applies to insurers' own use of AI, or an issued regulator document addressed to this insurance market, addresses AI - by name or by an unambiguous description such as "predictive models" or "automated decision system" - and sets out rules or expectations that apply to it; and the regulator has a live mechanism to check or sanction them.
Case examined	Evolent Health - AI in utilization review
Band for this case	Elevated
Rules reach	Insurers: not stated · Reinsurers: not stated · Intermediaries: not stated
Last verified	[actual date of the launch-window check]

1. The rules in United States (Texas)

Texas Insurance Code §4201.156(a), added by SB 815 with effect from September 1, 2025, bars a utilization review agent from using an automated decision system to make an adverse determination wholly or partly. The commissioner may audit that use.

The change applies to plans delivered, issued or renewed on or after 1 January 2026.

Who these rules reach

• Insurers: not stated. The rule applies to utilization review agents, not to insurers as such: §4201.156(a) binds "a utilization review agent", which the chapter defines as "an entity that conducts utilization review for: (A) an employer with employees in this state who are covered under a health benefit plan or health insurance policy; (B) a payor; or (C) an administrator holding a certificate of authority under Chapter 4151" (§4201.002(14)). Read on a secondary host. The same section defines an automated decision system as "an algorithm, including an algorithm incorporating an artificial intelligence system, that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions" (§4201.002(1-c), as added by SB 815; read on LegiScan).
• Reinsurers: not stated.
• Intermediaries: not stated.

2. The case examined: Evolent Health - Elevated

This band describes how clearly the rules meet the AI use that Evolent Health has itself published. It is not a finding that Evolent Health has breached any rule.

Why Evolent Health: Evolent's own annual report says it uses AI to automate authorization approvals only, with requests it cannot approve going to clinical review.

The question

Evolent's 10-K says it uses AI "to automate authorization approvals only", that it is against company policy to use AI to deny care, and that requests the application cannot approve go to manual clinical review - where its Machinify-derived Auth Intelligence tool "aid[s] nurses and physicians in completing clinical review". Texas Insurance Code §4201.156(a), added by SB 815, bars a utilization review agent from using an automated decision system to make an adverse determination "wholly or partly". When Evolent's AI declines to auto-approve a Texas request and routes it to a human reviewer, supported by Auth Intelligence, who then denies it, does Evolent treat that denial as one an automated decision system has "partly" made - and how has it documented that position for the Texas commissioner, who may audit that use at any time?

In brief

Evolent says its AI only ever approves and every denial is human - but Texas now bars an automated decision system from making a denial even "partly", and Evolent has not publicly said how it treats cases its AI declined to approve and routed, with AI-assisted review, to a human who then denied them.

Why this band: The question points to one firm and one statutory bar, but the bar applies only to plans issued or renewed from 1 January 2026 and reaches Medicaid plans by implication.

3. The same question for other firms in United States (Texas)

Any utilization review agent in Texas whose AI declines to auto-approve a request and routes it to a human reviewer faces the same point: whether a resulting denial is one an automated decision system has partly made. This entry gives no band to any firm other than Evolent Health.

4. What this entry does not establish

• The enrolled text of SB 815 was read on LegiScan; the state's own site served an incomplete page.
• The current section number of the Medicaid provision after its 2025 recodification was not verified.
• Whether a Medicaid managed-care plan is "delivered, issued or renewed" within SB 815 is a point of interpretation.
• The annual report's filing date was not captured from the filing itself.

5. Dates ahead

• No dated item is recorded for this entry.

See the Regulatory Deadline Calendar: fijishi.com/viewforum.php?f=9.

Sources

1. Evolent Health, Form 10-K for the year ended 31 December 2025 (Filing Date 2026-02-25, per the filing index). Company's own. sec.gov
2. Evolent Health, release on the Machinify acquisition, Jun 4, 2024 (printed). Company's own. ir.evolent.com
3. SB 815 (enrolled): "This Act takes effect September 1, 2025" (printed). Statute. LegiScan
4. Texas Insurance Code, chapter 4201. Statute. statutes.capitol.texas.gov

Related entries

None share a law or regulator with this entry.

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