Building on years of Texas Medical Association advocacy, two House committees cleared a pair of bills that would strengthen existing state laws and regulations by further easing health plans’ onerous prior authorization requirements and strengthening network adequacy protections.
Both efforts, championed by physician lawmakers, now head to the full House.
Polishing the “gold-card” law
Texas took a huge step toward meaningful prior authorization reform with the passage of the 2021 “gold-card” law, with other states already advancing their own copycat legislation. But TMA lobbyist Ben Wright says there’s still work to be done to ensure eligible health plans are held accountable under the new law.
House Bill 4343 by Rep. Greg Bonnen, MD (R-Friendswood), a neurosurgeon, would help by cutting through unnecessary red tape preventing physicians from receiving gold cards exempting them from prior authorization requirements for a given service or medication. It also would strengthen oversight by requiring insurers to report their gold card results to the Texas Department of Insurance (TDI) and by granting the Texas Medical Board more authority when dealing with prior authorization denials made “in an arbitrary manner or without a medical basis.”
Christine Kean, chief operating officer of TSAOG Orthopaedics & Spine in San Antonio, recently testified on behalf of TMA and the Texas Orthopaedic Association in support of the bill.
“While we should be very proud of what we have accomplished to date, we are not done,” she told the House Public Health Committee on April 17. “The implementation of [the gold-card law] was complicated, and the rule-making process to implement the intent of the bill has not produced the results expected.”
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, an MRI of a knee – within the six-month review period.
TMA advocated during rulemaking for no minimum, as none was set forth in the law and many physicians won’t meet the current threshold given the time constraints. The association also continues to meet regularly with insurance companies, including to discuss prior authorization requirements and the implementation of the gold-card law.
Physicians continue to lament the patient and financial harm caused by health plans’ overzealous use of prior authorizations. A recent survey by the American Medical Association found 86% of physician respondents reported such requirements led to higher use of health care resources, driving up costs, and 89% said they had a negative impact on patient outcomes, in part because they delayed care.
For these reasons, Ms. Kean urged lawmakers to intervene.
The gold-card law “was a trailblazing event for Texas, but without the corrective actions contained in HB 4343 that we are discussing today, I’m afraid the path on our trail will end without accomplishing its objective,” she said.
As of this writing, the bill was still pending in committee.
Strengthening physician networks
Meanwhile, the House Insurance Committee unanimously cleared House Bill 3359, also by Representative Bonnen, which would promote adherence to the state’s network adequacy rules by putting them into statute and strengthening enforcement by TDI. It now heads to the House floor. Sen. Charles Schwertner, MD (R-Georgetown), filed the companion bill, Senate Bill 1765, which is still pending in the Senate Health and Human Services Committee as of press time.
Austin plastic surgeon Elisabeth Potter, MD, was one of three physicians who recently testified on behalf of TMA in support of the bill.
“Our responsibility to our patients is sacred, and our priority is to put the health and safety of our patients above all,” she told the House Insurance Committee. “[HB] 3359 does exactly that by delivering a number of critical patient protections and enhancing transparency.”
Despite Texas’ network adequacy regulations being among the strongest in the country, TMA continues to receive reports of health plans taking advantage of waiver processes and offering plans that don’t provide patients with a sufficient panel of in-network physicians.
More than 90% of the commercial health plan networks filed with TDI in 2022 didn’t meet state network adequacy standards and instead operate under a waiver, or “access plan,” detailing how the plan would cover such gaps, according to state agency data.
San Antonio radiologist Zeke Silva, MD, testified about the consequences of these waivers.
“Network adequacy standards are meant to hold health insurers accountable to employers and to patients by ensuring the health plan they pay for provides access to health care,” he said during the same hearing. “However, under the current waiver process that exempts insurers from those standards, there is neither accountability to the patient nor an incentive to contract with physicians and providers in good faith.”
Fort Worth radiologist Tilden Childs, MD, said in his testimony that HB 3359 would help improve the waiver process by codifying requirements that health plans monitor network adequacy compliance and by erecting guardrails, including new transparency measures and renewal limits.
Other bills to watch
TMA also is tracking House Bill 3414 by Rep. Tom Oliverson, MD (R-Cypress), an anesthesiologist, and its companion, Senate Bill 2045 by Sen. Kelly Hancock (R-North Richland Hills), which would enhance security of the new statewide all-payer claims database and prevent misuse of its data. The House Insurance Committee unanimously voted in favor of HB 3414, sending it to the House floor.
The database – established by the Texas Legislature in 2021 with TMA’s support – collects health care claims from public and private health plans with the stated goals of improving price transparency and supporting a more competitive marketplace.
Find all the testimonies by TMA physician advocates during the current session in TMA’s advocacy center.