Decades of insurance advocacy overturned. Undermined patient and clinician protections. Unwarranted criminal and civil penalties. These would-be detriments were just a few the Texas Medical Association defeated as part of its mission to preserve physicians’ practice viability, striking down a slew of bad insurance bills during the 2025 state legislative session.
TMA also made some progress on the prior authorization front, with a bill directed at closing gaps in the implementation of 2021’s gold-card law with greater health plan accountability.
The stakes were high, with more insurance bills filed this session than in the recent past, and more for medicine to oppose, many of which sought novel and drastic changes to the health insurance industry. Health plan advocates made a strong – albeit flawed – push for pro-payer bills they argued were needed to curb health care costs due to rising premiums, insurance mandates, or fraud, waste, and abuse.
Medicine countered those and other arguments in a series of largely defensive victories, thanks to more than a dozen testimonies and 1,600-plus physicians who bolstered TMA’s advocacy against two majorly harmful bills alone by contacting their elected officials directly – both of which were defeated on the House floor in the same week.
The association also had help from a coalition it built of more than 30 state and national medical, pharmacy, and patient advocacy organizations in killing its top target: House Bill 139. That bill sought to establish a new type of “employer choice of benefits” (ECOB) health plan exempt from a long list of TMA-backed patient and physician protections won over the years, including:
- Every state-level mandated benefit for health plans regulated by the Texas Department of Insurance (TDI);
- Network adequacy requirements;
- Texas’ utilization review laws and the 2021 gold-carding prior authorization law;
- Texas’ prompt-pay legislation;
- State law that sets baseline standards and transparency in health plan ranking and tiering of physicians;
- State law that sets baseline standards and transparency in how health plans can steer enrollees to certain physicians or providers; and
- State laws that require transparency and protect patients and pharmacies from anti-competitive pharmacy benefit manager (PBM) practices.
TMA Council on Legislation Chair Zeke Silva, MD, warned the consequences of the bill could have set a dangerous precedent and created a loophole in which ECOB plans would be exempt from vast swaths of future legislation.
“Imagine Texas passes a law that requires [TDI-regulated] health plans to cover a specific medication for a specific condition, for example,” Dr. Silva told Texas Medicine. “The new plans would have been exempted from doing so, leading to more work for physicians and a lack of necessary care for patients.”
Additionally, the bill would have allowed ECOB plans to be exempted from a litany of other state patient and physician protection laws – all despite the fact nothing in the bill required ECOB health plans be offered at a lower premium.
Similarly, TMA defeated legislation sought by commercial health plans that would have created a new criminal penalty and a new private cause of action for health care fraud committed against a private insurance company, despite the fact Texas already has laws and multiple enforcement vehicles in place against commercial insurance fraud.
House Bill 4012 would have created new criminal and civil penalties against physicians for potential good-faith billing disagreements, as well as a new False Claims Act-like “whistleblower” statute that would have applied to the commercial market.
“Fraud should be prosecuted – but this bill targets physicians broadly, not just bad actors. It expands authority without accountability … and oversight without insurer transparency,” Dr. Silva testified during the session.
Although HB 139 and HB 4012 died this session, they are likely to be pursued next legislative session, putting medicine on guard for yet another battle against aggressive insurer tactics.
In a proactive win, TMA succeeded in a multi-session effort to pass legislation addressing some of the shortfalls and inconsistencies among payers in the intended implementation of Texas’ landmark “gold-card” prior authorization exemption law, which have led to fewer than 4% of physicians qualifying.
Under the 2021 bill, physicians are eligible for an exemption from an insurer’s prior authorization requirements for a particular service if they receive approvals on at least 90% of their requests during the timeframe set forth in the law.
However, House Bill 3812 by Reps. Greg Bonnen, MD (R-Friendswood), Tom Oliverson, MD (R-Tomball), and Venton Jones (D-Dallas) brings to bear some of the fixes TMA sought during early rulemaking to streamline eligibility, improve transparency, and enhance state oversight by:
- Extending the evaluation period from six to 12 months;
- Codifying the minimum threshold of five services to qualify during that time;
- Expanding the data to be used in an exemption evaluation; and
- Requiring HMOs and insurers to submit annual written reports on certain gold-card data to the Texas Department of Insurance.
HB 3812 takes effect Sept. 1 but TDI rulemaking is also likely. TMA will monitor and weigh in on the rulemaking process and provide further member guidance in an updated whitepaper.
“The big frustration I’ve had as a surgeon is the weaponization of the prior auth process by the insurers against patients, resulting in delayed care and denied care,” Representative Bonnen told Texas Medicine. “We took a huge step forward when we asked for the first prior authorization bill, and as with so much of what we do, you inevitably come back to make improvements.”
Continue to read Texas Medicine Today for legislative updates and related TMA resources in development, and visit TMA's state advocacy webpage.
Editor's note: This story was updated to reflect legislative developments post-publication in Texas Medicine.
Related 2025 Legislature wrap-up stories:
‘A United Force’: Physicians Answered the Call for Patients, Medicine This Legislative Session
Inside the Capitol – Lessons from the 89th Legislative Session
Access to Care – Advanced
Scope Creep Defense Preserves Physician-Led Care, Patient Safety
Texas Physician Workforce Gets Budget Boost
Texas Medicaid Enrollment Could Benefit from Modernization Funding
Measles Outbreak and E-Cigarettes Shape Session Debates
Practice Viability – Supported
New Technology Laws Take Effect Sept. 1
Medical Liability Risks Fail to Find Foothold in Texas
Physician Autonomy – Preserved
Life of the Mother Act Provides Clarity Around Medical Emergency Exception for Pregnant Patients
TMA Helps Craft Balanced Noncompete Compromise
TMA Deflects Onerous Reporting Regs for Independent Practices