Cutting the Medical Red Tape: How Gold Carding Impacts Patient Care

For some healthcare providers, gold carding acts as a VIP pass of sorts. This unique prior authorization reform enables clinicians with high prior authorization approval rates to skip certain paperwork requirements.

However, there’s no established standard for what gold carding is or who is eligible for it. Because existing programs vary, understanding gold carding requires a deeper look.

What is gold carding?

Gold carding broadly refers to programs that ease standard prior authorization requirements for providers or practices with a strong track record of prior authorization approvals.

Think of it as a provider prior authorization pre-check. If a prescriber or practice has a consistently high percentage of prior authorization approvals, they may no longer need to submit prior authorizations for that same service as they’ve already demonstrated they are prescribing judiciously.

Where gold carding legislation stands today

Generally speaking, gold carding is a practice with broad-based support: Both the American Medical Association and American Hospital Association stand behind it. It’s also becoming more common among commercial health plans. An AHIP survey found that the share of responding commercial health plans using gold carding rose from 32% to 58% for medical services between 2019 and 2022, and from 9% to 21% for prescription drugs.

Whether a specific healthcare procedure or treatment qualifies for gold carding today, however, depends on a long list of variables, including the location of the patient, the prescriber’s approval history, the treatment itself, and the insurer’s policies.

This means that even within the same health system, a specific therapy might be gold carded for one provider but not another. A procedure might qualify with one insurer but none of the others, or be covered in one state, but not a neighboring one.

Federal law: No national gold carding mandate

The reason so many gold carding variables exist today is that there is no overarching federal law requiring health plans to offer a standardized type of gold carding.

The Getting Over Lengthy Delays in Care As Required by Doctors Act of 2023, better known as the GOLD CARD Act, would have created a federal gold carding system for Medicare Advantage. However, the legislation didn’t advance before expiring, and hasn’t been reintroduced since. Meanwhile, lawmakers have introduced other proposals to make prior authorization less burdensome for providers

State laws: An uneven patchwork

In the absence of federal standards, a number of states have developed their own approaches, and more than 10 have enacted some form of gold carding legislation.

A major limitation of state gold carding laws, however, is that they generally apply only to state-regulated health plans, leaving out self-funded employer plans. Depending on the state, Medicaid, state employee coverage, and prescription drugs also may not be eligible for gold carding.

In fact, the state-level laws vary quite significantly, in terms of:

• types of health plans covered
• approval rate and minimum number of requests required to qualify
• length of the exemption period
• level of eligibility, whether for the individual provider, practice, or service
• process for obtaining eligibility, including automatic qualification or provider application
• inclusion or exclusion of prescription drugs
• treatment of previous determinations after a patient changes plans
• rules regarding audits, revocation, review, and appeals

Texas, for example, has one of the country’s strongest mandatory gold carding laws. In the state, a provider qualifies for a prior authorization exemption for a particular service or prescription drug if they have submitted at least five eligible authorization requests for that service and received approval for at least 90% of them during a 12-month period. Providers don’t have to do the math or apply, because it’s the insurers who are responsible for evaluating providers and granting exemptions automatically.

In contrast, Louisiana largely allows insurers themselves to set the rules for gold carding. Health insurers authorized to operate in the state are required to maintain a program that reduces some prior authorization requirements based on provider performance. But beyond that, the insurer has sole discretion over which providers qualify and which services are included. The law sets no statewide approval threshold, minimum request volume, or required exemption period. Pharmacy services are excluded from gold carding altogether.

The wide range of state gold carding laws can be a challenge to track, especially as these laws continue to evolve. More states are likely to introduce, revise, or expand gold-carding requirements as part of broader prior-authorization reform, and some of those will bring yet more variables into the mix. California’s approach, for example, is primarily service-based, instead of being tied to particular providers. Regulators will identify frequently requested services that plans approve at least 90% of the time and require insurers to stop imposing prior authorization on selected services no later than January 1, 2028. This is a fundamentally different approach from other states focusing on a provider-level scope. If this model gains traction, gold carding looks more like a PA exemption for specific services or procedures with comprehensive high rates of approval as opposed to a VIP pass for specific healthcare providers with high rates of PA approval. This broader approach would reduce burden among healthcare providers in a single sweep.

Insurance-led programs: Another layer of complexity

On top of the state-level gold carding laws, a number of payers have launched their individual programs. Some are state-specific, created to comply with legislation, while others are voluntary and involve a number of different states.

One of the best known among these is UnitedHealthcare’s Gold Card program. Launched in 2024, this program doesn’t do away with prior authorizations entirely, but allows providers with at least a 92% approval rate on 10 or more eligible requests annually for two consecutive years to skip the clinical documentation requirement. The program is offered across all of UnitedHealthcare’s products, including commercial, individual exchange, Medicare Advantage, and Medicaid, but does not include prescription medications.

Most individual payer programs are smaller in scale, with many limited to specific types of plans in just one to a few states. The bar to enter the programs can be higher, too. Highmark’s gold carding program, for example, generally recognizes clinicians with at least a 99% approval rate for selected services.

Beyond gold carding: Better workflows for every prior authorization

The biggest challenge with gold carding programs is that, while intended to reduce administrative burden for providers, the work required to stay abreast of the many different programs and their requirements can have the opposite effect.

Gold carding may reduce some prior authorizations over time, but a single nationwide rule that lets every provider with a strong approval record bypass prior authorization still seems a long way off. In the meantime, prior authorization is not going away. What started as a reasonable mechanism to help manage costs has snowballed into administrative overload that often leads to unnecessary delays in care.

Healthcare organizations need a practical way to make today’s process faster and easier to manage so patients can start therapy without delay and avoid undue harm. Cinnamon helps automate prior authorization workflows by bringing pharmacist-trained AI and clinical information together in a unified workflow and reducing the manual work required from care teams. Get in touch to see how Cinnamon can simplify every prior authorization for your organization.