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2023 TEXAS LEGISLATIVE
SESSION WRAP-UP

protections, such as network adequacy protections, prompt pay and solidation would have increased costs and compromised healthcare
claims administration procedures. quality, while the bill also lacked adequate patient protections.
• Prior Authorization/Gold Carding (HB 4343): Unfortunately,
this favorable bill also failed to advance, despite its objective to Gold Carding:
strengthen Texas’ gold carding law and mitigate excessive prior au- A significant victory in the 2021 legislative session was Texas’ gold
thorization. Political reasons, rather than the content of the bill, carding law (HB 3459). This act allows physicians who achieve a 90%
hindered its progress. This issue remains a continuous battle for prior authorization approval rate for specific healthcare services to earn
BCMS and the TMA. Gold Card status, granting them exemption from prior authorization
requirements for those healthcare services such as drugs, procedures,
Want to take a deeper dive? pathology and diagnostic imaging.
General Comments about the process: The law has been implemented for only a short period of time. How-
The Texas Legislature convenes only once every two years for a 140- ever, it is disappointing to note that according to the Texas Department
day period. Thus, time sensitivity is crucial in advancing legislation due of Insurance (TDI), only 3% of Texas physicians have attained Gold
to the numerous steps involved, such as bill submission, hearings, votes, Card status. This may, in part, stem from TDI rules that imposed a
conference committees and the Governor's approval. At any point in minimum number of eligible services to qualify for Gold Card status.
this process, a bill can stall. The TMA possesses a robust lobbying team, HB 4343 aimed to strengthen Texas’ gold carding law by reducing the
a dedicated Council on Legislation and widespread physician engage- minimum number of eligible services, enhancing health plan account-
ment across the state. BCMS physicians actively participate in various ability regarding initial denials through stronger enforcement and
ways, including Capitol visits on First Tuesdays, sharing patient care physician appeals, and increasing the Texas Medical Board's oversight
experiences with the TMA, and providing online and live testimony. of medical decisions made by health plans during utilization review.
It's important to note that state laws primarily affect state-regulated Unfortunately, HB 4343 failed to advance, primarily due to political
health plans, excluding federally administered ones like self-funded reasons rather than shortcomings in the bill's content. Although re-
ERISA plans. Nevertheless, achievements at the state level often influ- grettable, both BCMS and the TMA understand the burdens of prior
ence policies in other states and at the federal level. authorization and the resulting harm to patients. This issue will con-
tinue to be an ongoing battle.
Network Adequacy:
Despite Texas already having robust network adequacy requirements, Going forward:
only 3% of health plans in the state meet these standards. The remaining Drafting and passing meaningful legislation is crucial for supporting
97% receive waivers. This situation has multiple consequences, including physicians, but it represents just the first step. Once laws are enacted, the
unfair negotiation practices by health plans during contract negotiations regulatory phase commences, where various state agencies, typically the
with physicians, leading to challenges in sustaining practices and provid- Texas Department of Insurance for health insurance, must implement these
ing high-quality care. Additionally, patients are unaware that their plans laws. Implementation typically involves a rule-making process that includes
may not meet their primary care and specialty needs (limiting patient soliciting comments from medical societies such as BCMS and the TMA.
choice of in-network physicians and providers and reducing the value of This process may also involve hearings before state agencies or interim hear-
the health plan product purchased). HB 3359 addresses this issue by ings before legislative committees. Therefore, the vital role of physicians in
holding health plans accountable for their networks. The bill ensures the legislative process remains continuous and ever-important.
greater oversight and transparency in the waiver process, requires valid
reasons for exemptions, and establishes clearer network standards based Ezequiel “Zeke” Silva III, MD, FACR, FSIR, FRBMA,
on federal Medicare Advantage guidelines, including factors like time, RCC, is the Medical Director of Radiology at the Methodist
distance, appointment wait times and required physician specialties. Texsan Hospital and an adjunct professor at the UT Health-
San Antonio. He is a member of the TMA Delegation to the American
Insurance Steerage: Medical Association and TMA Council on Legislation as well as Chair
The healthcare marketplace is experiencing increased vertical and of the AMA/Specialty Society RVS Update Committee and immediate
horizontal integration, leading to a greater likelihood of health plans past Co-Chair of the AMA Digital Medicine Payment Advisory Group.
directing patients towards entities in which they have a financial stake. Dr. Silva is the President-Elect of the Bexar County Medical Society, Past
HB 2414, which failed to pass, aimed to allow health plans to selec- President of the Texas Radiological Society and currently serves on the
tively steer patients covered by their insurance. Enabling further con- board of directors for the South Texas Radiology Group.

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