Physician-Led Results: Insurance
By Emma Freer

TMA Priority: Build on the success of last session’s gold-card law by advancing further prior authorization reform. 

Recap: Carrying the torch from last session, the Texas Medical Association followed up on its 2021 gold-card success with a new prior authorization reform for vulnerable patients and other insurance-related policy wins this session.  

In keeping with TMA’s top legislative priorities, medicine also laid the groundwork for gold-card fixes during the interim with the introduction of a bill that, although it did not pass, built some early support for adjustments likely to be handled by the Texas Department of Insurance (TDI) via rulemaking.  

TMA threw its support behind House Bill 755 by Rep. Julie Johnson (D-Farmers Branch), which Gov. Greg Abbott signed into law to restrict insurers from requiring more than one prior authorization request annually for patients with autoimmune and certain blood disorders. 

Tilden Childs, MD, a radiologist in Fort Worth and chair of TMA’s Council on Legislation, says HB 755 is “a big step in reducing the hassle [for] people on chronic medications [who] have to get a prior authorization every time they need treatment or a refill for their prescription.”  

TMA also secured the passage of other patient and physician protections penned into law, including: 

• House Bill 1647 by Rep. Cody Harris (R-Palestine), which prohibits the practice of white-bagging – insurers requiring physicians to purchase drugs through the health plan’s specialty pharmacy – known to cause dosage discrepancies and patient safety concerns; and 
• House Bill 999 by Rep. Four Price (R-Amarillo), which bans “co-pay accumulators,” meaning health plans cannot effectively pocket drug manufacturer coupons by refusing to apply them to patients’ deductibles or out-of-pocket maximums. 

“To us, it was pretty clear that this was a necessary patient protection,” Zeke Silva, MD, a radiologist in San Antonio and member of TMA’s Council on Legislation said of HB 999, explaining that co-pay accumulators benefit health plans at patients’ expense by adding to their out-of-pocket costs.  He  testified in support of the bill. 

In addition, TMA helped mitigate the impact of Senate Bill 490 by Sen. Bryan Hughes (R-Tyler), which otherwise could have required physician-owned facilities to give patients an itemized billing statement before collecting any payment when it takes effect Sept. 1.  

On the defensive front, TMA killed several bills that would have advanced questionable health plan practices: 

• House Bill 2414 by Rep. James Frank (R-Wichita Falls), would have allowed health plans to steer patients to physicians and other health care professionals of their choosing, regardless of quality; 
• House Bill 3351 by Rep. Caroline Harris (R-Round Rock), would have undone physician protections, such as notification and appeal processes, in health plans’ ranking-and-tiering programs; 
• Senate Bill 1581 by Sen. Paul Bettencourt (R-Houston), would have favored health plans at the expense of patients and physicians by establishing a Texas Health Insurance Mandate Advisory Committee to analyze bills imposing new regulations on health plans; and  
• House Bill 1001 by Rep. Giovanni Capriglione (R-Southlake) and its companion, Senate Bill 605 by Sen. Drew Springer (R-Muenster), would have reduced the value of health care coverage and gutted certain consumer protections, including mandated benefits.  

In the interim, TMA is focused on burnishing the gold-card law to ensure it holds health plans accountable. 

Under the law, which took effect in October 2022, physicians who earn approvals on at least 90% of prior authorization requests for a given service or medication can earn a “gold card” exempting them from onerous preapproval requirements for that service or medication. 

But TDI reports only 3% of physicians and other health care professionals have received gold cards due to the current eligibility threshold, which requires physicians to submit a minimum of five prior authorization requests for each service code – say, and MRI of a knee – within the six-month review period.  

Dr. Silva says these problems represent “a future opportunity for TMA,” which will work with TDI on revisiting its rules and prepare for legislative fixes in the next session. 

For more information, check out TMA’s state advocacy webpage.