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Gold Card Act Legislation

In an effort to alleviate some of the steps associated with prior authorizations to help prevent delays in care, some state and federal lawmakers have introduced legislation to help reform the practice.

The official names of these laws vary by state, but they are commonly referred to as “Gold Card Acts.” These laws allow certain services to be exempted—or “gold carded”—from prior authorization requirements. They allow health care providers who have consistently met prior authorization requirements and prior approval rates within a specific period to bypass the prior authorization process for certain procedures.1

The following is a quick reference guide to the status of state-specific and federal Gold Card Act legislation.2

Summaries of State-Specific
Legislation Status

Summaries of
State-Specific
Legislation Status

Texas

Statute or Bill Citation
TX Ins Code 4201.653*
Legislation Status†
Effective
Percentage Rate‡
90%
Time Frame§
6 months
Minimum Number of Claim Approvals||
20/6 months
Other Considerations
Evaluate every 6 months

W. Virginia

Statute or Bill Citation
WV Ins Code 33-25A-8s*
Legislation Status†
Effective
Percentage Rate‡
100%
Time Frame§
6 months
Minimum Number of Claim Approvals||
30/year
Other Considerations
May audit and rescind anytime

Vermont

Statute or Bill Citation
VT 18 Section 9377a
Legislation Status†
Pilot Program
Percentage Rate‡
TBD
Time Frame§
TBD
Minimum Number of Claim Approvals||
TBD
Other Considerations
TBD

Arkansas

Statute or Bill Citation
House Bill 1271
Legislation Status†
Pending
Percentage Rate‡
90%
Time Frame§
12 Months
Minimum Number of Claim Approvals||
5/20 max
Other Considerations
Evaluate only once per year

California#

Statute or Bill Citation
Senate Bill 598
Legislation Status†
Pending
Percentage Rate‡
90%
Time Frame§
12 Months
Minimum Number of Claim Approvals||
N/A
Other Considerations
Evaluate only once per year

Indiana**

Statute or Bill Citation
House Bill 1610
Legislation Status†
Pending
Percentage Rate‡
90%
Time Frame§
6 months
Minimum Number of Claim Approvals||
5/20 max
Other Considerations
Evaluate every 6 months

Kentucky**

Statute or Bill Citation
House Bill 134
Legislation Status†
Pending
Percentage Rate‡
90%
Time Frame§
6 months
Minimum Number of Claim Approvals||
5/20 max
Other Considerations
Evaluate every January and July

New York**

Statute or Bill Citation
Senate Bill 8299
Legislation Status†
Pending
Percentage Rate‡
90%
Time Frame§
6 months
Minimum Number of Claim Approvals||
20/6 months
Other Considerations
Evaluate every 6 months

Oklahoma#

Statute or Bill Citation
Senate Bill 756 (Medicaid)
Legislation Status†
Pending
Percentage Rate‡
90%
Time Frame§
6 months
Minimum Number of Claim Approvals||
5/20 max
Other Considerations
Evaluate every 6 months

Colorado

Statute or Bill Citation
Senate Bill 22-078
Legislation Status†
Failed
Percentage Rate‡
Failed
Time Frame§
Failed
Minimum Number of Claim Approvals||
Failed
Other Considerations
Failed

Oklahoma

Statute or Bill Citation
Senate Bill 1409
Legislation Status†
Failed
Percentage Rate‡
Failed
Time Frame§
Failed
Minimum Number of Claim Approvals||
Failed
Other Considerations
Failed

Mississippi

Statute or Bill Citation
Senate Bill 2449
Legislation Status†
Failed
Percentage Rate‡
Failed
Time Frame§
Failed
Minimum Number of Claim Approvals||
Failed
Other Considerations
Failed

Connecticut

Statute or Bill Citation
House Bill 5447
Legislation Status†
Failed
Percentage Rate‡
Failed
Time Frame§
Failed
Minimum Number of Claim Approvals||
Failed
Other Considerations
Failed

Federal Legislation

Medicare Part C

Statute or Bill Citation
House Resolution 7995
Legislation Status†
Failed
Percentage Rate‡
Failed
Time Frame§
Failed
Minimum Number of Claim Approvals||
Failed
Other Considerations
Failed

Note: The notice requirements imposed upon health plans vary from 24 hours to 5 days. Health plans are automatically obligated to provide notice of exemption to providers. Bills also vary regarding the consideration of claims in appeal. Minimums are presented.

* The full title of the effective Texas “Gold Card Act” statute is Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services. The full title of the effective West Virginia “Gold Card Act” statute is the Health Maintenance Organization Act. 2,3
† The status of the state or agency version of the Gold Card Act legislation (ie, effective, pending, pilot program, in committee, or failed).
‡ The prior authorization approval rate history for a particular service over a given period.
§ The past time frame from which prior authorization approval rates will be considered.
‖ The minimum number of claim approvals during the required time frame.
Any legislative requirements other than required percentage rate, required time frame, and minimum number of claims.
# New Gold Card Act legislation.
** Reintroduced Gold Card legislation.

References: 1. New physician “gold card” law will cut prior authorization delays. American Medical Association. Accessed March 10, 2023. https://www.ama-assn.org/practice-management/prior-authorization/new-physician-gold-card-law-will-cut-prior-authorization 2. Data on file. Regeneron Pharmaceuticals, Inc. 3. Insurance code: Title 14. Utilization review and independent review chapter 4201. Utilization review agents. Subchapter A. General provisions. Texas Constitution and Statutes. Accessed March 12, 2023. https://statutes.capitol.texas.gov/Docs/IN/htm/IN.4201.htm 4. West Virginia code: Chapter 33. Insurance. Article 25A. Health Maintenance Organization Act. Accessed March 12, 2023. https://www.wvlegislature.gov/wvcode/ChapterEntire.cfm?chap=33&art=25A&section=8S

This material is provided for informational purposes only, is subject to change, and should not be construed as legal or medical advice. Use of this information to challenge or appeal a coverage or reimbursement delay and/or denial by a payer is the responsibility of the provider.

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This material is provided for informational purposes only, is subject to change, and should not be construed as legal or medical advice. Use of this information to challenge or appeal a coverage or reimbursement delay and/or denial by a payer is the responsibility of the provider.