Representatives unveil Medicare Advantage gold-card legislation

Two U.S. representatives have introduced gold-card legislation that would exempt qualifying providers from prior authorization requirements for Medicare Advantage plans. 

The bill is sponsored by Reps. Michael Burgess, MD, and Vicente Gonzalez, both of Texas, a state that has implemented its own gold-card law, according to a July 31 news release from Dr. Burgess' office. 

If enacted, the legislation would exempt providers from needing prior authorization for a Medicare Advantage plan year if the provider had at least 90 percent of requests approved the preceding year, according to the release. The 90 percent threshold includes approvals granted after appeal. 

Medicare Advantage organizations would be required to notify each provider who qualifies no later than 30 days prior to the first day of each plan year. 

Reviews for a gold card would be limited to no more than once per year. 

Medicare Advantage plans would be allowed to revoke a providers' gold card during a plan year if less than 90 percent of claims submitted would have been approved for prior authorization — or in the case of less than 10 claims being submitted, if less than 90 percent of the last 10 claims submitted would have been approved for prior authorization. Physicians would be allowed to appeal gold-card revocations they believe were wrongly decided.

The HHS secretary would be required to issue a rule on the use of prior authorization by Medicare Advantage plans to ensure continuity of care for individuals transitioning to, or between, coverage to minimize disruption of ongoing treatments in previous plans.

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