“Gold Card” Final Rules Heed Some, But Not All, TMA Recommendations on Prior Auth Exemption Process
By Emma Freer

Texas physicians have anxiously awaited – and advocated for – relief from onerous prior authorizations, which is now closer than ever. 

By Oct. 1, state-regulated insurers and HMOs must issue the first so-called “gold cards” to comply with Texas’ 2021 law, which the Texas Medical Association championed.  

This deadline stems from the Texas Department of Insurance’s (TDI’s) recently released final rules for implementing House Bill 3459 by Rep. Greg Bonnen, MD (R-Friendswood), and Sen. Dawn Buckingham, MD (R-Lakeway). The law exempts physicians from prior authorization if they earn approvals on at least 90% of their requests for a given service or medication during the relevant six-month evaluation period.  

With the final rules released, insurers and HMOs now can review physicians’ approval records during the first six-month evaluation period, which ran from Jan. 1 through June 30.  

TMA experts say the final rules heed some of TMA’s recommendations for implementing the law as written. But, they caution, TDI has incorporated some new stipulations that could delay patients’ access to care and contribute to physicians’ administrative burden.  

In positive news, the final rules apply to prior authorization requests for prescription drugs, despite health plans’ attempts to omit them from the list of health care services eligible for exemption. TMA repeatedly advocated for prescription drug requests to be included in accordance with the law, such as in a May 9 comment letter sent to TDI with seven state specialty societies.  

“Anything less than an expansive application of the term ‘health care services’ [to include prescription drugs] would thwart the [Texas] Legislature’s goal of removing unnecessary barriers to patient access to care,” TMA and the other signatories wrote.  

The rules also lower the number of prior authorization requests necessary to earn a gold card to five. Although TMA lobbied for no minimum number of requests to prove eligibility, the change represents a significant improvement over TDI’s proposed rules, under which physicians would have had to earn approvals on at least 90% of at least 20 prior authorization requests on a given service over a six-month period.   

The final rules accord with TMA’s advocacy in other areas, including: 

• Requiring health plans to describe in denial notices how to appeal the decision and file a TDI complaint; and 
• Allowing physicians to specify a particular email or mailing address for notices regarding prior authorization exemptions, denials, and recissions.  

Despite these gains, TMA experts say the final rules also raise some concerns. 

For instance, per the law, the peer-to-peer calls that occur before an exemption request is denied must be conducted by a Texas-licensed physician in the same or similar specialty as the physician who requested the service. The final rules, however, allow physicians with a more limited administrative license from the Texas Medical Board to fill this role.  

TMA and the state specialty societies argued in their comment letter that, for such calls to be peer to peer as intended by state lawmakers, the reviewing physician must have the full authority to practice medicine in Texas, so as not to risk inappropriate rejections and further delays in necessary patient care.  

“For a reviewing physician on a peer-to-peer call to recommend denying coverage to an enrollee/patient based upon a determination that a drug being prescribed is medically necessary when that physician has no authority to prescribe that drug himself or herself makes little sense from either a clinical or a public policy perspective,” the signatories wrote. “If an adverse determination is issued due to this disconnect in clinical authority, it is likely to cause unnecessary delay in the patient’s care, as the ordering physician would then have to appeal the determination.” 

TMA continues to analyze the various regulations, which pertain to health plans and independent review organizations, and is developing a summary with more information. Read Texas Medicine Today for updates.