In 2021, Texas enacted first-of-its-kind legislation requiring certain state-regulated payers to exempt providers from prior authorization requirements for which they consistently receive approvals. These exemptions, also known as “gold cards,” are designed to reduce the burden of prior authorization requirements that do not serve a meaningful role in controlling unnecessary utilization.
CSRO is excited that states across the country are considering innovative solutions to the administrative burden issues created by prior authorization. New approaches are needed to tackle this problem. Requiring use of gold cards by health plans certainly qualifies as such, but as with any innovative policy it also raises numerous questions regarding how it will work in practice.
The Texas Department of Insurance (TDI) recently issued proposed rules designed to help clarify some of these operational questions in anticipation of the law going into effect. CSRO took the opportunity to comment on some of the questions TDI answered in their proposal, and to raise questions that the proposal did not address.
Some highlights include requesting TDI to:
- finalize the clarification that prescription drugs are eligible for exemptions
- clarify how a preauthorization exemption interacts with other utilization management restrictions
- clarify how appeals and exception requests are counted when determining whether to issue an exemption
Once TDI finalizes its rules, CSRO will post content on its map tool to guide rheumatologists through the components of the new law.