HB3812

HB3812 changes Texas’s service-specific preauthorization exemptions, often called “gold cards,” and tightens physician qualifications for directing insurance medical reviews. It applies to utilization review conducted on or after September 1, 2025. It does not abolish prior authorization for every provider, service or health plan. Final law.

Qualifying for an exemption: Evaluation changes from six months to one year, with evaluation generally once a year. For a particular service, the insurer/HMO and its affiliates must have approved—or would have approved—at least 90% of the provider’s preauthorization requests, and the provider must have provided that service at least five times during the period. Existing law still says providers need not request an exemption to qualify, and an insurer may continue one without reevaluating it for a particular period. Qualification rules.

The evaluation must include requests across all policies and plans issued or administered by the insurer/HMO and its affiliates, even when a particular plan is not itself subject to the exemption law. An affiliate includes entities under common control. Including those requests in the calculation does not itself expand which plans must honor the exemption.

Plan limits remain: The exemption subchapter covers the specified Texas HMO, preferred-provider and exclusive-provider plans and their contracted preauthorization decision-makers. It excludes Medicaid, Medicaid managed care and the listed children’s programs. Do not assume every employer plan or government program is covered. Scope.

Taking an exemption away becomes less frequent. Rescission is allowed only during January of a year beginning on or after the first anniversary of the last day of the most recent exemption evaluation period, instead of the former January-or-June windows. The existing medical-necessity threshold and other requirements still apply. Normally the insurer reviews a random sample of 5–20 claims; the new exception requires review of all claims if fewer than five were submitted for that service during the evaluation period. Rescission requirements.

Existing notice and review protections remain, including at least 25 days’ advance notice of proposed rescission with sample information and a plain-language explanation of review rights. Separate existing duration rules govern when the exemption actually ends, including when review is requested. The law also protects exemptions granted before September 1 from rescission before the first anniversary of the last day of their most recent evaluation period. Duration rules.

Independent review now expressly includes a denial of an exemption, not only a dispute over taking one away. Insurers cannot require an internal appeal first. Existing provisions requiring the insurer to pay for the review and providing an expedited review remain. After a finalized denial or rescission, eligibility for another exemption is considered after the following one-year evaluation period rather than six months. Independent review and later eligibility.

An exemption cannot simply be bypassed with a differently named review. The revised law restricts utilization review or another review similar to preauthorization for an exempt service, even if the exemption is rescinded after the service was provided. Exceptions remain for checking continued exemption eligibility or reasonable suspicion of the specified payment-denial grounds: intentional material misrepresentation to obtain unlawful payment, or failure to substantially perform the service. It is not unconditional coverage of every claim or permission to practice outside a provider’s license. Payment and review protections.

Physician qualifications: A physician directing utilization review, or making the specified medical-necessity determination to rescind an exemption, cannot hold the limited administrative-medicine license described in Occupations Code Section 155.009. Texas medical licensure remains required; for a physician’s rescission review, the same-or-similar-specialty requirement remains. The law concerns the limited license, not a blanket ban on physicians doing administrative work. Administrative-medicine license.

Reporting: Insurers and HMOs must submit annual reports to the Texas Department of Insurance covering exemptions, denials/rescissions and independent review requests and outcomes by service. Reports are public information, but the department must remove identifying information before disclosure. Reporting requirement.