State gold card laws are spreading, and few doctors qualify

State gold card laws are spreading, and few doctors qualify for them. The idea is simple. A physician whose prior authorization requests are almost always approved should not have to keep asking. At least 10 states now require insurers to offer some version of that exemption, and several more have studied or debated it. But in Texas, the state with the oldest automatic program, fewer than 4% of physicians qualified in its first years, and lawmakers rewrote the rules in 2025 to try again.

The gap between the idea and the results is not mainly about the approval threshold. It comes from how the laws count. They evaluate each service with each insurer separately, and only inside the slice of the market that state law can reach. A physician can have an excellent approval record overall and still fall short in every individual cell the law evaluates.

This analysis reviews the state laws as of February 2026 and what the Texas experience shows. It then compares insurer and federal programs and sketches a design that would actually reduce requests. It builds on our earlier pieces on reviewing less and on approvals that last as long as the treatment.

Key takeaways

• Gold card laws are common but narrow. The National Conference of State Legislatures counts at least 10 states with required programs. Most apply only to state-regulated plans and evaluate each service separately.
• Texas uptake was low. Texas Department of Insurance testimony put the share of providers who qualified at about 3%. The Texas Medical Association described it as fewer than 4%.
• The 2025 fixes target the counting. Texas lengthened its look-back to 12 months and began counting requests sent to insurer affiliates. It also added independent review and limited rescissions to January.
• Volume rules bind harder than thresholds. In a simple model, a physician with 120 requests a year would rarely send 5 requests for one service to one covered insurer within the old 6-month window.
• Approval rates are a weak test on their own. They reward practices with staff and volume, and they measure agreement with an insurer rather than the quality of care.
• Scope reduction does more. Removing prior authorization for services that nearly everyone gets approved helps every physician, not only the few who clear a threshold.

How the state laws work

A gold card law requires an insurer to look back at a provider’s prior authorization history for a service. If the share of approved requests meets the state’s threshold, the insurer must exempt the provider from prior authorization for that service for a set period. In most states, the exemption is specific to one insurer and one service. The insurer can still deny payment later if it finds a service was not medically necessary, and it can rescind the exemption under conditions the law sets.

Thresholds cluster at 90%. Look-back periods run from 6 to 12 months. Most laws require a minimum number of requests before a provider can be evaluated, and most exclude Medicaid and the Children’s Health Insurance Program. Some cover prescription drugs and some do not.

Compiled from the Aimed Alliance gold card law analysis (2025) and the NAIC prior authorization white paper (December 2025), with updates from MultiState (August 2025) and NCSL. Illinois and New Mexico also appear on NCSL’s list.

Counts vary with the definition. NCSL lists at least 10 states with required programs. A December 2025 NAIC white paper on prior authorization lists more than 20 jurisdictions with gold carding provisions of some kind, including laws that encourage or permit programs without requiring them.

An exemption is also narrower in practice than the word suggests. The physician’s office usually still checks eligibility and coverage, and in some programs still sends a notification. The insurer keeps the right to review claims after the service and deny payment for services it finds were not medically necessary. Patients typically have no way to know whether their physician holds an exemption for the service they need.

Almost every law shares 2 structural limits. First, state insurance law does not reach self-funded employer plans, which ERISA governs, or Medicare Advantage plans, for which federal standards largely preempt state rules. In Texas, the plans covered by the gold card law make up about one-fifth of the state’s market. Second, the evaluation is usually per insurer. A physician who works with 10 insurers has 10 separate records, each with only a fraction of the physician’s requests.

Low uptake and a rewrite in Texas

Texas passed HB 3459 in 2021, and the first exemptions followed in 2022. The law required insurers to exempt a physician from prior authorization for a service if the insurer had approved at least 90% of the physician’s requests for that service over a 6-month evaluation period. Exemptions were automatic, and insurers had to notify physicians when they qualified.

The results disappointed the law’s supporters. According to testimony from the Texas Department of Insurance reported in The Hospitalist, only about 3% of providers statewide met the bar. The Texas Medical Association described the outcome as fewer than 4% of physicians qualifying. As a physician interviewed by The Hospitalist put it, “Gold cards aren’t really fixing that problem.”

Several features of the original law help explain the numbers. A 6-month window gave many physicians too few requests for any single service to be evaluated, especially since requests sent to an insurer’s affiliated companies did not count toward the same record. Physicians also had limited recourse when an insurer denied or withdrew an exemption.

HB 3812, which took effect in September 2025, addressed each of those points. According to a Texas Department of Insurance FAQ dated September 2025 and the Texas Medical Association’s summary, the law makes 6 changes.

• It extends the evaluation period from 6 to 12 months, with an evaluation at least once a year.
• It sets a minimum of 5 requests for a service during the evaluation period.
• It counts requests sent to the insurer’s affiliates.
• It lets a physician whose exemption is denied or rescinded request an independent review, without first completing the insurer’s internal appeal. A request counts as approved if the reviewer disagrees with the insurer’s denial.
• It allows rescission only during January of a qualifying year, and it requires that a Texas-licensed physician make the rescission decision.
• It requires insurers to file annual reports on gold card data with the department.

These are sensible repairs. Each one widens the set of physicians who can be evaluated or makes the result harder to take away. The January-only rescission window also gives physicians a predictable period of protection, which the NAIC paper notes is the kind of limit insurers say can slow their response to real problems. None of the changes alters the basic structure of an exemption earned service by service and insurer by insurer.

Other states amended their laws in 2025 as well. According to MultiState, Arkansas removed an insurer’s ability to withdraw gold card status when a provider increased the number of gold-carded procedures by 25%, and extended the privilege to the provider’s group practice. West Virginia removed the prescribing of medication from its program, while Iowa considered a gold card pilot but dropped it before passage.

Why approval rates are a weak test

The approval-rate test has 3 problems that no threshold can fix.

It rewards capacity as much as judgment. A practice with dedicated authorization staff learns what each insurer wants and submits complete requests. A small practice without that staff may have the same clinical judgment and a lower approval rate. The physician quoted above raised this concern directly, noting that large groups and hospital systems have more resources to navigate the process than small practices do. A test that measures approvals partly measures administrative capacity.

It can reward avoidance. A physician who submits only the requests most likely to be approved will have a high approval rate. A physician who takes on harder cases, and asks for authorization when the evidence is less settled, may fall below the line. The test cannot tell those 2 physicians apart.

It measures agreement, not quality. An approval means the insurer agreed with the request. It says nothing directly about outcomes. The American College of Gastroenterology made this point about UnitedHealthcare’s national program in 2024, arguing that eligibility rested on past approval rates rather than evidence of better outcomes.

Insurers raise concerns from the other direction. The NAIC white paper notes arguments that gold card programs may increase use of services and put upward pressure on costs. Insurers also argue that thresholds set too low can pose risks to patient safety. The paper observes that state gold carding laws are relatively new, and that their long-term effects remain uncertain.

There is a quieter point in the numbers. KFF found that Medicare Advantage insurers denied 7.7% of prior authorization requests in 2024, which means they approved roughly 92%. Medicare Advantage is outside state gold card laws, but the figure suggests that a 90% threshold is not, by itself, a high bar. The binding constraints are the minimum volumes and the per-service, per-insurer counting.

A simple model shows how hard those constraints bind. Consider a physician who sends 120 prior authorization requests a year. If her patients mirror the Texas market, about 24 of those go to plans the law covers. Spread them across 3 covered insurers and 4 services, and the busiest insurer-service pairing averages only a few requests per window.

A Redlake illustration, not Texas data. The model assumes 120 requests a year that arrive at random, with 20% going to covered plans. Covered requests split across 3 insurers in shares of 50/30/20 and across 4 services in shares of 40/30/20/10.

Even if every one of her requests were approved, this physician would usually have had no service eligible for evaluation under the old 6-month window. The 12-month window helps, but she would still expect to be evaluated for about one service with one insurer. A threshold of 80% or 95% would not change that result. Counting would.

A physician can clear a 90% approval rate easily and still never send enough requests to any one insurer for any one service to be counted.

Insurer and federal programs

Insurers have built their own programs, partly in response to state laws and partly to head off more of them. The largest is UnitedHealthcare’s national gold card program, whose details the company released in September 2024. According to the American College of Gastroenterology, practices qualified by completing at least 10 prior authorizations a year over a 2-year review window with an approval rate of at least 92% across eligible codes. The program evaluates practices at the tax identification number level, across lines of business, which avoids some of the fragmentation of insurer-by-service counting. Qualifying practices still had to submit an advance notification for gold card services, which led the college to question how much burden the program would actually remove.

In June 2025, health plans signed onto an industry pledge that included reducing the scope of claims subject to prior authorization by January 2026. Scope reduction and gold carding attack the same problem from different ends. Scope reduction removes requirements for everyone. Gold carding removes them for selected providers.

On the federal side, CMS has signaled interest in exemptions for its own prior authorization model in traditional Medicare. As described in a January 2026 analysis by DLA Piper, CMS is exploring a gold carding program for the WISeR model that would exempt providers who meet thresholds for affirmed requests. CMS had not published the details as of this writing.

A better design

If the goal is fewer unnecessary requests, the evidence from Texas suggests a different order of operations.

• Start with scope. Services that almost every physician gets approved almost every time should not require prior authorization at all. That helps every physician at once, and it shrinks the set of services where an exemption even matters.
• Count across services, not just within them. Evaluating a physician on a related group of services, such as all advanced imaging, would let many more physicians reach a minimum volume while still keeping the evaluation clinically coherent.
• Use rolling evaluation. A rolling 12-month record, updated as decisions come in, avoids the cliff edges of fixed windows and lets a physician qualify as soon as the record supports it.
• Pair exemptions with sampling. Instead of choosing between full review and none, an insurer can review a small random sample of an exempt physician’s services after the fact. That keeps a real check in place without returning to case-by-case requests.
• Publish the results. Texas now requires insurers to report gold card data to the state. Public counts of exemptions granted and rescinded, by insurer, would let regulators and physicians see whether the program works.
• Measure what matters. Approval rates can be one input. Adherence to evidence-based criteria and appeal outcomes would bring the test closer to what it is supposed to measure.

A more ambitious option is broad-based gold carding, in which a state evaluates a physician’s record across all covered insurers and grants an exemption that each of them must honor. It would solve the fragmentation problem directly. It would also require insurers to share decision data with a central evaluator and to agree on common criteria for each service. Each insurer would then have to accept exemptions based partly on other insurers’ decisions. Those are hard problems, but they are data problems more than clinical ones.

Where Redlake stands

We build tools health plans use in utilization review. Our view is that the strongest form of gold carding is not an exemption at all. It is a review process that approves what should be approved quickly and automatically, for every physician, and saves clinical attention for the requests that need it. A machine can say yes. Only a person can say no.

Gold card programs fit inside that view as a second layer. When a physician’s record shows that their requests for a service consistently meet the criteria, routing those requests straight to approval is exactly the kind of decision software should make. The record should still show which criteria were met, so the exemption can be audited and defended.

We also think plans should be able to answer the questions a gold card law asks at any time. A plan should know which physicians would qualify for which services, and which services are approved so often that the requirement serves no purpose. If every decision can be reconstructed, those answers come from a query. Plans that can produce them will be better placed whether the next change comes from a legislature or from their own medical directors.

What to watch in 2026

• The first Texas reports. Annual insurer reports to the Texas Department of Insurance under HB 3812, and any rules the department adopts to implement the law.
• Wyoming’s program. How many providers qualify under a law that took effect in January, with a 12-month look-back and a 5-request minimum.
• New state bills. Whether 2026 sessions copy the Texas repairs, such as affiliate counting and independent review, or move toward broad-based exemptions that apply across insurers.
• WISeR exemptions. Whether CMS publishes thresholds and timing for a gold carding program in traditional Medicare.
• Scope reductions. Whether the pledge to reduce prior authorization requirements removes enough services to make gold cards less necessary.

About this analysis

Basis. We reviewed state gold card laws as summarized by NCSL and the NAIC, along with the Aimed Alliance and MultiState analyses. For Texas, we used the Department of Insurance guidance on HB 3812, along with reporting by The Hospitalist and the Texas Medical Association. Published descriptions of UnitedHealthcare’s program and of CMS’s plans for WISeR cover the insurer and federal side.

Data notes. State details change often, and the table reflects the sources listed as of February 2026. Each table entry is as described in those sources. The Texas uptake figures come from testimony and advocacy summaries rather than a published state report. The volume model is ours and uses stated assumptions with requests arriving at random. The observation about Medicare Advantage approval rates uses KFF’s 2024 figures and is meant only to show that a 90% threshold is close to typical approval rates.

Sources. NCSL, state prior authorization reforms. Aimed Alliance, Gold Card Law Analysis (2025). NAIC, Prior Authorization White Paper (December 2025). MultiState (August 2025). Texas Department of Insurance, gold carding FAQ (September 2025). Texas Medical Association, 2025 legislative wrap-up. The Hospitalist (July 2025). American College of Gastroenterology (September 2024). AHIP (June 2025). DLA Piper (January 2026). KFF (January 2026).

Frequently asked questions

What is a gold card exemption from prior authorization?

It is an exemption that lets a provider skip prior authorization for a service when the provider’s past requests for that service were approved at or above a set rate, usually 90%. The exemption typically applies to one insurer and one service for a set period.

Which states have gold card laws?

NCSL lists at least 10 states with required programs, including Texas, the first state with an automatic program. The table above covers 8 of them, and Illinois and New Mexico complete NCSL’s list. Broader counts that include voluntary or permissive provisions are higher.

Do gold card laws apply to Medicare Advantage or employer plans?

Generally not. State insurance laws do not reach self-funded employer plans governed by ERISA, and federal standards largely preempt state rules for Medicare Advantage. Many state laws also exclude Medicaid.

Can an insurer take a gold card away?

Yes, under conditions set by each law. In Texas, an insurer may rescind an exemption only during January of a qualifying year, and a Texas-licensed physician must make the decision. The physician can then ask for an independent review. Other states set their own rules, and some leave more to the insurer.