“Gold carding” may sound like a luxe way to take advantage of credit card rewards, but it’s actually a new advance in managing prior authorizations. Prior authorizations are a long-standing utilization management tool used by health plans requiring pre-approval from the plan before a specific treatment or medication will qualify for coverage. An American Medical Association (AMA) survey of over 1,000 physicians found that physician practices completed an average of forty-five prior authorization requests per physician, per week. While a well-designed prior authorization program should work to limit the burden on patients and prescribers, they may still result in significant time spent by physicians and staff completing the requests.

State Legislation

In recent years, many states have passed prior authorization legislation with varying mandates. One recent solution to eliminating the physician burden of prior authorizations is a process called “gold carding.” Gold carding is a type of prior authorization reform that requires plans to exempt providers with high prior authorization approval rates. As of November 2024, eight states, as listed below, have passed “gold card” legislation, though not all legislation has gone into effect:

• Arkansas
• Louisiana
• Michigan
• New Mexico
• Texas
• Vermont
• West Virginia
• Wyoming

Prior authorizations for prescription medications are not included in the gold card program legislation in Louisiana, West Virginia, and Wyoming. Gold card programs in these states are limited to procedures such as medical and imaging services. In Arkansas, gold card legislation will include prescription medications beginning January 1, 2025. Arkansas House Bill 1271, Section 5 addresses this change, stating “Prescription drugs, medicines, biological products, pharmaceuticals, or pharmaceutical services are exempt as a healthcare service for purposes of §§ 23-99-1120 – 23-99-1126 until December 31, 2024.” Each state has set different requirements and criteria that should be evaluated by health plans when implementing gold card programs. One constant across all legislation is that the gold card is specific to one provider for each healthcare service, procedure, or prescription product and does not provide a blanket exemption for all prior authorizations submitted by a physician.

State requirements for gold card exemptions vary from needing five prior authorization requests for a healthcare service during a six-month period with a 90% or greater approval rate (Texas) to requiring an average of thirty procedures per year with a 90% or greater prior authorization approval rate over a six-month period (West Virginia). Prior authorization approval rate requirements may reach as high as 95-100% to qualify for the gold card program. Exemptions typically last from six to twelve months and may be at the discretion of the health plan. Additionally, some states allow for plan discretion as it relates to the criteria and services to be included.

Federal Legislation

In 2023, federal legislation was introduced to create a gold card program for Medicare Advantage plans, but the proposed legislation has not progressed over the past year. Alternatively, the Centers for Medicare & Medicaid Services (CMS) have implemented other changes to prior authorization requirements in 2024 through the CMS Interoperability and Prior Authorization Final Rule. This rule, which applies to Medicare Advantage plans, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans offered on the Federally-Facilitated Exchanges, aims “to improve the electronic exchange of health information and prior authorization processes for medical items and services.”

National Health Plan Gold Card Programs

Outside of legislative requirements, individual health plans have begun to launch their own gold card programs. In 2024, UnitedHealthcare (UHC) announced their National Gold Card program to simplify prior authorizations for qualifying providers. The program, which went into effect on October 1, 2024, includes the following requirements for provider groups and will be evaluated on a yearly basis.

• Be in network for at least one UnitedHealthcare health plan
• Have a minimum annual volume of at least 10 eligible prior authorizations each year for 2 consecutive years across Gold Card-eligible codes
• Have a prior authorization approval rate of 92.0% or greater across all Gold Card-eligible codes for each of the review years

A review of UHC’s Gold Card-eligible procedure code list found that no prescription medications requiring prior authorizations were included as part of the program. One notable difference for the UHC program compared to state gold card programs is that the UHC exemption covers all health care providers associated with a provider care group tax ID number (TIN), such as a physician group practice, not just the individual provider.

Highmark has also implemented their own Gold Carding Program applicable to providers in Delaware, New York, and Pennsylvania. The program assesses practice and provider performance twice yearly to determine eligibility of prior authorization exemptions for eighteen different treatment modalities. Eligibility requirements are as follows:

• Practices and individual providers with a minimum submission history of five cases per gold carded modality are eligible.
• Practices and individual providers must have a 99% or higher approval rating for the specified gold carded Current Procedural Terminology (CPT) codes and modalities.
• Plans must be one of the following: Commercial, Affordable Care Act, Medicare Advantage.

Highmark includes a list of over 20,000 providers that are “Gold Carded Clinicians” and identifies the procedure(s) for which they have received gold card exemptions.

Other plans have implemented their own processes to improve the prior authorization burden. For example, Cigna announced in 2023 that they would be removing approximately 25% of their medical prior authorization requirements.

Healthcare Industry Stance

In January 2018, the American Medical Association, American Health Insurance Plans, American Hospital Association, American Pharmacists Association, BCBS Association, and Medical Group Management Association published a joint consensus statement recommending Gold Card programs to improve the prior authorization process. The AMA continues to advocate for prior authorization reform at the state and federal levels. However, not all organizations are in favor of removing prior authorization requirements. Health plans and pharmacy benefit managers continue to rely on prior authorizations as a tool to limit coverage to ensure appropriate use of a procedure or medication.

Going Forward

More than 10 states were reported as having introduced gold carding bills in 2024, with additional prior authorization reform also being considered. However, not all these bills are expected to be passed into law as the year comes to a close. Based on current legislation, gold card programs may have a limited impact on pharmacy, with many states and plans excluding or limiting prescription medications within these programs. All parties involved in the healthcare decision process should continue working together to ensure that patient care is at the forefront of implemented utilization management tools and refine their use in the best interest of all participants.

 

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