Health plans have begun implementing Texas’ new prior authorization exemption process requiring them to issue the first so-called “gold cards” by Oct. 1.
Following the release of the Texas Department of Insurance’s final rules, state-regulated insurers and HMOs now must review physicians’ preauthorization approval records during the first six-month evaluation period – which ran from Jan. 1 through June 30 – and notify physicians of an initial exemption, or denial of an exemption, no later than Oct. 1.
Thanks in large part to Texas Medical Association advocacy during rulemaking, state-regulated insurers and HMOs must analyze those approval rates for a threshold of at least five preauthorization requests for a particular service or prescription drug during the relevant evaluation period (as opposed to a 20 minimum threshold as originally proposed under the rules); physicians with an approval rate of 90% or greater are exempt from having to request prior authorizations for the particular service or medication.
The gold card law applies to state-regulated insurers and HMOs, as well as the Employees Retirement System of Texas, and the Teacher Retirement System of Texas, which collectively represent about 20% of Texas’ health insurance market.
TMA is monitoring the process and health plans’ activity, with several issuing their own website notices about the process, including Blue Cross and Blue Shield of Texas and UnitedHealthcare.
TMA also has learned that insurers and HMOs plan to use various processes for notifying physicians of their status, such as via letters or Availity, although state regulations allow physicians to specify their preferred method of notification and outlines ways for physicians to communicate that preference to insurers and HMOs. Aetna, for instance, has indicated it began sending letters this week.
For more information on this notification process and for answers to other frequently asked questions about the new law, check out TMA's new white paper on the topic.
You also can get a full overview of the gold-carding measure in recording of a TDI-hosted webinar on the rules, where agency experts discussed processes for granting, denying, and rescinding preauthorization exemptions as permitted under House Bill 3459.
If you have questions or concerns about your experiences with the process, contact the TMA Knowledge Center by calling (800) 880-7955, emailing, or submitting a request. And continue to read Texas Medicine Today for future TMA analyses of the rules and their implementation.