Reviewed Jul 11, 2026 · maintained by Erin Rose · general reference, not legal advice
Read this first: it probably doesn't apply to your patient
Every state gold-card law applies only to state-regulated insurers (and, in a few states, Medicaid). Federal ERISA preemption keeps them from reaching self-funded employer plans — roughly 63% of covered workers. So before you count on a gold card, confirm the plan is not self-funded.
Also don't confuse a gold card with three lookalikes that are not gold-card laws: general prior-authorization reform (deadlines, transparency), the voluntary insurer programs some payers run (e.g., UnitedHealthcare's), and the CMS interoperability rule (CMS-0057-F), which speeds electronic PA but does not mandate gold-carding.
The four states with a true gold card (in force)
These four have a fixed statutory threshold that automatically exempts a qualifying provider from PA on a service. The buy-and-bill detail that matters most: whether drugs are included.
| State | Statute (effective) | Threshold & scope | Plans reached | Drugs? |
|---|---|---|---|---|
| Texas | HB 3459 (2021), Ins. Code Ch. 4201 Subch. N; amended HB 3812 (eff. Sep 1, 2025) | ≥90% approvals on a service, ≥5 requests; per-service; lookback extended to 12 months. First gold-card law in the U.S. | TDI-regulated commercial, ACA marketplace, fully-insured employer, TX state (ERS/TRS). Not ERISA self-funded, Medicaid, or Medicare Advantage. | Excluded |
| West Virginia | SB 267 (2023), eff. Jan 1, 2024; amended SB 833 (2025) | Avg 30 procedures/yr + 90% approval over a 6-month window; per-procedure. Excludes experimental / non-covered / out-of-network. | Commercial insurers, HMOs, PEIA (state employees), Medicaid. Not ERISA self-funded. | Excluded (SB 833) |
| Arkansas | Act 575 (2023), Ark. Code 23-99-1120 et seq., eff. Jan 1, 2024; amended Act 511 (2025) | ≥90% on a service; 6-month window reassessed every 12 months; per-service. Same-TIN group extension on election. | Commercial fully-insured + non-federal governmental self-funded; also Medicaid managed care (PASSE), ARHOME, ACA QHPs. Not private ERISA. | Included (since Jan 1, 2025) |
| Wyoming | HB 14 (2024), Wyo. Stat. 26-55-112; gold-card section eff. Jan 1, 2026 | ≥90% (rounded down) over the most recent 12 months + ≥5 requests; per-service. 12-month exemption, retrospective revocation only. | Fully-insured commercial (individual / small / large group). Not ERISA self-funded. | Excluded |
Framework laws — a program is required, but no fixed threshold
Four more states require insurers to run a PA-reduction program based on provider performance, but leave the threshold, lookback, and covered services to the insurer's discretion — so there is no guaranteed 90%/6-month exemption to rely on. Louisiana (Act 432, 2022; R.S. 22:1020.61), Michigan (PA 60 of 2022; MCL 500.2212e), Georgia (SB 5, 2025), and Colorado (HB 24-1149, mandatory from Jan 1, 2026 but with the old fixed 80% removed). All exclude ERISA self-funded plans; Michigan and Georgia also exclude Medicaid.
Special structures
California (SB 306, 2025) is service-level, not provider-level: a service approved ≥90% statewide becomes PA-exempt — but the exemptions do not begin until January 1, 2028 (reporting 2026, published list 2027). Illinois (305 ILCS 5/5-30.18, eff. Jul 1, 2026) is Medicaid managed care only (≥90% over the prior calendar year, minimum 50 requests, hospital services).
Commonly miscounted — these are not gold cards
Other trackers inflate the count by including laws that don't actually exempt a provider based on approval rate. To be accurate:
Vermont exempts services ordered by a primary-care provider (a provider-type exemption, not a performance gold card); a true 90%/6-month bill died, and a 2023 study recommended against one. Iowa (§514F.8) is a carrier reporting metric on routinely-approved services, not a provider exemption. And a long list of states — Tennessee, Minnesota, New Jersey, Maryland, Indiana, Maine, Oklahoma, Virginia — passed general PA reform (deadlines, transparency, category bans) with no approval-rate exemption. Large states with no gold-card law at all include New York, Florida, Pennsylvania, and Ohio.
The federal picture
There is no federal gold-card mandate for Medicare Advantage: the 2024 CMS interoperability rule (CMS-0057-F) speeds electronic PA and encouraged gold-carding but did not require it, and the GOLD CARD Act has never passed (a similar MA provision sits in the 2025 Improving Seniors' Timely Access to Care Act, still in committee). The one place a federal gold card actually appears is a twist: the CMS WISeR pilot (2026–2031, six states) adds prior authorization / pre-payment review to traditional Medicare for select services — but builds in a gold-card-style exemption for providers who demonstrate compliance.
Frequently asked
- Which states have a gold-card prior-authorization law?
- About eight to ten depending on how strictly you count, but only four have a true fixed-threshold provider gold card in force (mid-2026): Texas (first, 2021), West Virginia, Arkansas, and Wyoming. Louisiana, Michigan, Georgia, and Colorado mandate a program but leave the threshold to the insurer; California and Illinois use special structures.
- Does a state gold-card law apply to a self-funded (ERISA) plan?
- No. Every state gold-card law reaches only state-regulated insurers and, in some states, Medicaid. ERISA preemption keeps them from reaching self-funded employer plans (~63% of covered workers). Confirm the plan type first.
- Are drugs (J-codes) included in gold-card laws?
- It varies. Arkansas includes prescription drugs as of Jan 1, 2025 (unless a drug is carved back); Texas, West Virginia, and Wyoming exclude pharmacy. For buy-and-bill practices this decides whether a drug can be gold-carded in a given state at all.
- How does a provider earn and keep gold-card status?
- The insurer evaluates your PA approval history automatically and grants the exemption — providers generally don't apply. Status ties to a threshold (commonly ~90% on a service over a 6-to-12-month window with a minimum request count) and is reviewed periodically; insurers can rescind it only through a defined retrospective review, usually with appeal rights.
Related references
From "can I skip PA?" to "what will it cost?"
Gold-carding is only part of the access picture. CareCost estimates the patient's out-of-pocket and your expected reimbursement for any specialty drug — in about 30 seconds.
Try the cost estimator →Sources & how this is maintained
- Primary sources
- Tex. Ins. Code Ch. 4201 Subch. N (HB 3459 / HB 3812), TDI FAQ; W. Va. SB 267 / SB 833 and OIC Bulletin 24-03; Ark. Code 23-99-1120 et seq. (Act 575 / Act 511); Wyo. Stat. 26-55-112 (HB 14); La. R.S. 22:1020.61; Mich. MCL 500.2212e; Ga. O.C.G.A. 33-46-20.1 (SB 5); Colo. HB 24-1149; Cal. SB 306 (2025); 305 ILCS 5/5-30.18; CMS-0057-F and the CMS WISeR Model.
- Maintained by
- Erin Rose, Founder, under CareCost's methodology and editorial policy. This area changes every legislative session; the page is dated and refreshed on that cadence. Corrections: Corrections page.
- Not legal advice
- General reference for billing and patient-access staff, not legal advice. Statutes and effective dates change; the state count is definition-dependent and approximate. Confirm the controlling statute and the patient's plan type for a specific situation.
- Spotted an error?
- Email editorial@carecostestimate.com.