2026 Medicare Changes: What Prior Authorization Means for Your Doctor’s Visit
Medicare has long been a reliable health insurance program for Americans aged 65 and older. For decades, Original Medicare operated with a simple promise: if your doctor ordered a covered procedure, Medicare would pay—no extra steps required.
But starting January 1, 2026, that process is changing for millions of people. A new pilot program called the WISeR Model introduces prior authorization for certain medical services in six states. The goal? To reduce waste and ensure Medicare funds are used for care that’s truly necessary.
3 Key Points to Know First
The WISeR Model affects Original Medicare—not Medicare Advantage.
It starts in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
17 specific procedures will now require prior approval before Medicare pays.
What Is “Prior Authorization”?
Prior authorization (also called pre-approval) means Medicare must approve a procedure before your doctor performs it. Without this approval, Medicare may not cover the cost—even if the service is normally covered.
While Medicare Advantage plans already use prior authorization, this is a new step for Original Medicare under the WISeR pilot.
Where and When Does It Start?
The WISeR Model launches January 1, 2026 in:
Arizona
New Jersey
Ohio
Oklahoma
Texas
Washington
About 6.4 million Americans will be affected. The program will run for six years to test its effectiveness before any nationwide expansion.
What Services Require Approval?
Medicare isn’t changing what it covers—but it is adding an extra step for 17 procedures, including:
Electrical nerve stimulators
Deep brain stimulation for Parkinson’s
Devices for bladder control or sleep apnea
Epidural steroid injections
Knee procedures for osteoarthritis
Skin and tissue substitutes for chronic wounds
These were chosen because they’re often used in cases where medical necessity is unclear.
How the Process Works
Doctors must submit a request to Medicare before performing any of the 17 listed procedures. AI will help screen these requests for speed—but licensed clinicians will make the final decision to ensure human oversight.
The goal is faster answers and less paperwork for your doctor.
Why Medicare Is Making This Change
Medicare officials say the WISeR Model aims to:
Reduce waste by avoiding unnecessary procedures
Protect taxpayers by using funds more responsibly
Standardize approvals to ensure fairness and consistency
What Seniors and Doctors Are Saying
While the goals are clear, some concerns remain:
Delays in care: Doctors worry that waiting for approval could slow down treatment.
AI involvement: Some fear that automation may lead to more denials or confusion.
Limited rollout: For now, it’s only in six states—but expansion is possible.
Importantly, Medicare coverage isn’t changing—just the approval process behind it.
4 Things to Remember
If you’re on Original Medicare:
Check your state: See if you live in one of the six pilot states.
Know the 17 services: This doesn’t apply to routine care or emergencies.
Ask questions: Confirm with your doctor whether prior authorization is needed.
Stay proactive: This is the new normal—be informed before agreeing to treatment.
Conclusion: Same Care, New Step
Medicare is adding a safety check—not removing benefits. If your doctor recommends a procedure, make sure it’s approved before moving forward. This change is designed to protect your health and your wallet—but it requires a little more awareness from you and your care team.
Senior Help And You, LLC is your trusted partner in navigating these changes. We simplify Medicare, explain new rules, and help you avoid costly surprises. Whether you're reviewing your plan, preparing for a procedure, or just want peace of mind—we’re here to guide you every step of the way.
3 Takeaways to Remember
Prior authorization starts in 2026 for select services in six states.
It applies only to Original Medicare—not Medicare Advantage.
Senior Help And You offers expert, bilingual support to help you stay informed and protected.
References
·Centers for Medicare & Medicaid Services. WISER (Wasteful and Inappropriate Service Reduction) Model. Goldman, M. (2025). Medicare's prior authorization has doctors on edge. Hall, J. (2025). Over 6 million Americans on Medicare will now need to get prior authorization for these 17 procedures. Medicare Resource Center. (2025). New Medicare Changes in 2026: Prior Approval Required for These 17 Services.
Authored by:
Albert Ferrin, RSSA® — Registered Social Security Analyst
Founder - Senior Help And You , LLC
