State ‘Gold Card’ Laws Sound Good — But Are They Working?

Have you wished you could be exempt from prior authorizations, especially because your procedures or prescriptions are almost always approved?

That’s the idea behind “gold card” laws some states have implemented, but the laws have not always worked out quite the way supporters have envisioned.

Take Texas, for example. Under that state’s gold card law, passed in 2021, “a health maintenance organization or an insurer that uses a preauthorization process for healthcare services may not require a physician or provider to obtain preauthorization for a particular healthcare service if, in the most recent 6-month evaluation period, the health maintenance organization or insurer has approved or would have approved not less than 90% of the preauthorization requests submitted by the physician or provider for the particular healthcare service.” As with other gold card laws, the privilege is supposed to be automatically granted, without the provider having to do anything.

Although that 90% figure may sound like an easy bar to clear, only 3% of the state’s healthcare providers have so far received a gold card, according to a January 2023 survey from the Texas Department of Insurance. “We do not have any data to indicate that the percentage will increase,” a spokesperson for the department said in an email.

Granular CPT Codes

Zeke Silva, MD, chair of the Council on Legislation at the Texas Medical Association (TMA), said that in getting the law passed, “we had hoped if a physician did a procedure that was common for them, that was in their sphere of expertise, and for which they almost always received prior authorization approval, going forward, they would no longer have to go through the process. So the goal was very logical.”

However, “it’s become difficult for physicians in that circumstance to satisfy the threshold to earn a gold card,” he continued, noting that a physician must have a particular service approved a minimum of five times during the 6-month period being considered. “While that sounds like it wouldn’t be hard to achieve, CPT [Current Procedural Terminology] coding is very granular.”

For example, in radiology — Silva’s specialty — “there’s a different CPT code for a chest CT without contrast, with contrast, and then with and without contrast, which is good because it allows you to report what you’re doing in a fairly granular fashion,” he said. “The downside is, if you’re a pulmonologist and you’re trying to get prior authorization for a chest CT, some of your patients might need contrast, some may not, and some may need both,” so getting five approvals for a particular CPT code suddenly becomes more complicated. The same is true for accumulating prior authorizations for the same medication with different dosages and different therapeutic regimens.

He added that there’s another problem, and that’s lack of transparency from the insurers about how they’re awarding the gold cards. “There’s no transparency on the data for anyone to specifically know” why so few providers are receiving them, he noted. “We thought the plans were going to be forthright in how they’re evaluating physicians … Without seeing the data, we certainly can’t correct [the problem].”

Hoping for Change

The TMA is hoping to persuade the state legislature to make several changes to the law, Silva said. One change would be to do away with the five-case minimum. “We take a position even as few as one, if they’re approved, that number should be sufficient.”

The TMA also would like to see the duration of the gold card exemption — currently lasting for 6 months — to change to 1 year, “so that physicians aren’t constantly having to engage or think about this process,” he said. And finally, the TMA would like more transparency from health insurers regarding what services are being reviewed and how decisions are being made.

The association has had some other successes regarding prior authorization, he added, including getting the legislature to exempt treatment of autoimmune conditions from prior authorization requirements. “We had always focused on relieving the physician burden, but that bill was interesting because it was patient-focused,” he said. “We’re thinking about going into the next [legislative] session expanding on that mindset,” and getting the legislature to exempt patients undergoing cancer treatment or treatment for a chronic disease.

In addition to Texas, other states with gold card laws include Arkansas, Colorado, Louisiana, Montana, and West Virginia, according to the National Conference of State Legislatures. Louisiana’s law applies only to prior authorization for drugs to treat mental health conditions.

Colorado’s law, which was passed this year, is a little different from the others, requiring health insurers and pharmacy benefit managers to “adopt a program, developed in consultation with providers participating with the carrier, to eliminate or substantially modify prior authorization requirements in a manner that removes the administrative burden for qualified providers as defined under the program, and their patients for certain prescription drugs and related drug benefits based on certain criteria.” The deadline for implementing the program is Jan. 1, 2026.

Gold Card Laws’ Evolution

Gold card laws have been undergoing an evolution, said Emily Donaldson, principal at the consulting firm Avalere in Washington, D.C. “When we first saw gold carding legislation being discussed, it was more on the medical services side, and as the legislation has evolved, we have now seen states also apply gold carding to prior authorization for medicines, or subsets of medicines,” she said during an interview with a public relations person present. “I think those of us who follow health policy understand that there is no silver bullet or one solution to a problem, and that includes some of the challenges patients and providers face with prior authorization.”

Donaldson said she wasn’t surprised at how few providers in Texas have gotten gold cards. “If you look at the legislative text itself, there is fairly broad discretion given to the health plans and how they design their gold card programs,” she said. “And so that may be a factor in why you see these differences between programs, when maybe some plans have more providers receiving a gold card than others, and why maybe it’s not working the way that providers thought it might work when the legislation was initially passed.”

She said she has seen an uptick in states looking at gold card laws — “even if states haven’t passed something, they may have proposed something that hasn’t made it through the legislative process.” She said she thought states would learn from the experience of states like Texas and use that information when they’re developing their own legislation.

An insurer organization did not respond by press time to a request for comment on the gold card issue.

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