The Academy has again strongly endorsed legislation that would give certain Medicare Advantage providers an exemption from some prior authorization requirements. It’s part of our ongoing efforts to reform prior authorization usage in Medicare Advantage plans.
The so-called “gold card” exemption would apply to specific items, services or groups of similar services on which a provider has a prior authorization approval rate of 90% or better during the preceding plan year.
The bill was introduced on Friday by obstetrician and House Rep. Michael C. Burgess, MD, R-Texas, and Vicente Gonzalez, D-Texas.
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They modeled the federal bill on Texas’ HB 3459, which ophthalmologist Dawn Buckingham, MD, co-introduced and helped shepherd into state law. Dr. Buckingham is a former Texas state senator and current Texas land commissioner.
In addition to giving the exemptions, HR 4968, if enacted, would:
- Require Medicare Advantage plans to notify each provider who qualifies no later than 30 days before the first day of each plan year.
- Limit reviews for gold card status to no more than once every 12 months.
- Allow physicians to appeal gold card revocations they believe were wrongly decided.
- Require the U.S. Department of Health and Human Services secretary to issue a rule on the use of prior authorization by Medicare Advantage plans. The rule would ensure continuity of care for individuals transitioning to or between coverage to minimize disruption of ongoing treatments covered by previous plans.
A previous version of this bill was introduced by the lawmakers in the last Congress.
At the start of the 2023 legislative session, five states had enacted laws on gold card exemptions: Texas, Michigan, Louisiana, West Virginia and Vermont. In May, Alaska introduced a similar bill at the Academy's encouragement.
“The Gold Card Act is a necessary response to the over utilization of prior authorization in Medicare Advantage plans that have created needless barriers between patients and the care they need,” Michael X. Repka, MD, Academy medical director for Governmental Affairs, said in the official news release on the bill’s introduction.
“Ophthalmology’s patients come to us to save their sight and preserve their quality of life — in some cases, putting off a procedure will lead to further complications,” Dr. Repka said. “It is unfair to make those same patients get preapproval for procedures that are widely approved anyway and further delay that sight-saving care. The Gold Card Act will remove this barrier and allow patients to get the care they need when they need it, not later. The American Academy of Ophthalmology is proud to support this commonsense solution.”