State Legislatures Work to Address Prior Authorization
Prior authorization (PA), identified as a top advocacy priority by the ACS, is generating significant momentum in state legislatures. The ACS State Affairs team is tracking 190 PA-related bills nationwide. Several common themes are emerging in this proposed legislation.
Artificial Intelligence in Prior Authorization
The dominant legislative theme is focusing on health insurers’ use of artificial intelligence (AI) in processing PA requests and claims. Legislators are interested in establishing guardrails to ensure clinical decision making remains patient centered and physician driven, and some common themes are emerging.
Human review mandate. The most consistent provision across states is a prohibition on “autonomous” denials. Health insurers may use AI initial review and sorting of requests or claims, but AI cannot be the sole basis for denying, delaying, or modifying care. Adverse decisions must be reviewed and affirmed by a licensed human professional, and many states require the reviewer to be a physician in the same or similar specialty as the requesting physician. In addition, AI cannot be used to override the clinical judgment of a health care provider.
Individualized care vs. group data. Another legislative focus is ensuring coverage decisions are based on the individual's unique medical history and clinical circumstances rather than "group data." The treating physician’s recommendations must be treated as a primary data point in the review process.
Decision timelines. Many bills address how quickly an insurer must respond to initial requests for care and appeals. Urgent requests typically must be addressed within 24 hours, while non-urgent requests must generally be addressed within 3 business days. Appeal decisions must be decided in 48 hours for an urgent request and up to 30 days for a non-urgent request.
In addition, several bills contain a “failure to act” provision wherein if the insurer fails to meet a deadline, the healthcare professional is automatically authorized to proceed with the treatment.
Transparency and disclosure. Legislatures require that complex decision-making processes are fully visible. Insurers must notify both the physician and patient when AI is used, and some bills go further, requiring insurers to disclose the specific models used, training datasets, and performance metrics to regulators.
When a denial occurs, the insurer must provide a detailed explanation of how AI influenced that specific outcome.
Accountability and oversight. Many bills require reporting to a state agency and define legal consequences for insurers. Insurers must submit periodic reports to state agencies with denial rates, appeal rates, and potential "disparity indicators," such as bias or discrimination. In addition, records of AI-influenced decisions must be maintained for up to 5 years.
Penalties for violations vary, ranging from fines up to $50,000 in one bill, to another bill providing patients the right to pursue private legal action against the health insurer.
Gold Carding and the Texas Experience
Gold carding is another notable legislative strategy. Under these programs, physicians with high PA approval rates—typically between 85% and 95% over a defined timeframe or 3 to 12 months—are exempted from future PA requirements for specific billing codes.
Ten states have implemented some form of a gold carding program, including Arkansas, Colorado, Illinois, Louisiana, Michigan, New Mexico, Texas, Vermont, West Virginia, and Wyoming.
Texas was the first state to enact gold carding legislation. However, after 3 years of implementation, the Texas Department of Insurance (TDI) reported only 3% of state physicians had actually achieved gold card status.
While the law represented meaningful progress, the results have been described as “disappointing” by both legislators and medical associations. In a 2024 data summary, TDI reported the reason only 3% of physicians qualified for gold card status is not because of low approval rates, but because they didn’t meet the minimum threshold of five requests for a specific service code within a 6-month period. Because service codes are so granular, a physician might do 50 PAs a month but not enough of any one specific code to trigger the gold carding eligibility.
As a result, Texas enacted several adjustments to the statute:
- Extended the evaluation period from 6 months to 12 months
- Extended the exemption period for a PA request from 6 months to 12 months, or the duration of a chronic condition
- Created a centralized database within TDI to track exemptions
- An independent review organization can now review and overturn gold card denials
Many states advancing PA legislation in 2026 are incorporating these improvements into their own gold carding bills.
Looking Ahead
In 2026, PA is undergoing its most significant transformation in decades, and this is reflected in a growing legislative consensus: technology may assist, but it cannot replace medical expertise. State lawmakers are signaling efficiency cannot come at the expense of individualized patient care. Decision timelines in legislation aim to reduce harmful delays and transparency measures bring greater accountability to an increasingly complex process.
To stay informed on what legislation is tracked in your state, review the ACS State Affairs Updates or visit the legislative tracking map. Contact the ACS State Affairs team at stateaffairs@facs.org for more information.
Arkansas Surgeons Secure Mandated Insurance Coverage for Bariatric Surgery
Kenneth Bruce Jones, MD, FACS, FASMBS, ACS Arkansas Governor-at-Large
Arkansas surgeons recently played a major role in achieving a significant legislative victory—and a victory for public health in the state.
Arkansas Act 628, which went into effect in January, mandates that bariatric surgery coverage must be included in all commercial insurance plans in Arkansas. This legislative success was the result of work done by a group of ACS Fellows recognizing a need and committing the energy, time, and resources required to address it.
Arkansas has consistently been in the top five states with the highest rates of obesity in the US. Consequently, the state has a high incidence of obesity comorbidities including diabetes mellitus, renal failure, hypertension, strokes, and death. Despite this, bariatric surgery coverage was spotty at best.
The state’s major insurance company, Blue Cross, offered plans that covered bariatric surgery, but also offered other lower cost and consequently popular options without bariatric coverage. Other insurance providers frequently offered no bariatric surgery coverage or made the requirements for coverage so onerous that few patients would ever achieve approval for surgery.
The coverage situation led many patients to travel outside the country for a lower cost self-pay surgery option. Any surgical complication discovered and treated before the patient returned to Arkansas or, more likely, found days, months, or years later could lead to financial ruin as insurance carriers would also deny coverage for complications.
Work began in 2022 when the Arkansas Legislature evaluated the State Employee Health Plan, and an independent, out-of-state consulting group was hired to help with the evaluation. They produced a report that confirmed the potential for bariatric surgery coverage to offer significant long-term savings for Arkansas taxpayers through plan member comorbidity reduction.
Along with the report, direct phone calls to legislators and testimony before legislature committees led to passage in 2024 of Arkansas Act 109, which mandated bariatric coverage for all state employees.
Building off this success, Arkansas surgeons worked to expand bariatric coverage to all commercial plans in Arkansas. Enthusiasm grew upon passage of similar legislation in Louisiana, another state with a high obesity rate. Surgeon leaders sought guidance from Louisiana experts, made phone calls, and sent messages to Arkansas Fellows and organized a stakeholder meeting with surgeons, hospital administrators, industry partners, and potential lobbyists to determine interest and financial feasibility of advancing these efforts.
Enough capital was raised through grants from the ACS, the American Society of Metabolic and Bariatric Surgery, and other stakeholders to have dinner with the state house and senate insurance committee, where surgeons testified to the benefits of bariatric surgery. Legislative champions in the senate and house also were identified, and lobbyists also were hired as part of the push for legislation, which is almost a necessity for major legislative endeavors in today’s political climate.
These coordinated efforts resulted in the passage and the Governor signing into law Arkansas Act 628 in 2025, which requires all commercial insurance plans in Arkansas to cover bariatric surgery beginning in 2026. As part of the law, any complication resulting from that surgery, from the early postoperative phase to years later, will be covered. The bill also addresses what insurance companies may require of patients and surgeons for bariatric surgery coverage.
The ACS Fellows in Arkansas are immensely proud of the grassroots advocacy effort for the patients and people of their state, and they feel their efforts could serve as an outline and an energizer for surgeons in other states on similar issues or others, including helmet laws, cancer screening funding, and so on.
Arkansas ACS Fellows thank Sam Bledsoe, MD, FACS, FASMBS, and Eric Paul, MD, FACS, FASMBS, for their roles as surgeon champions on this issue.
Dr. Patricia Turner Describes How the ACS Supports State Advocacy
As Fellows and surgeons on the front line work to advance surgery-related health policy in their states, ACS leadership continues to promote and value their critical work. Read the Executive Director’s Update from Patricia L. Turner, MD, MBA, FACS, ACS Executive Director & CEO, in the February Bulletin to learn more about state issues, ways to engage, and how the ACS supports these invaluable local and regional efforts.
