4. Prior Authorization Pilot Program in Six States
Beginning January 1, 2026, a new prior authorization requirement affects certain medical procedures under Traditional Medicare in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. This pilot initiative, called WISeR (Wasteful and Inappropriate Services Reduction), requires healthcare providers to obtain Medicare approval before performing specific services.
Seventeen types of procedures now require prior authorization in these states, including inpatient hospital admissions, certain spinal injections, power mobility devices, non-emergency hyperbaric oxygen therapy, and various imaging and surgical procedures. These services were selected because they’re often flagged for being overused or not always medically necessary.
The pilot program aims to reduce waste, detect potential fraud, and improve patient safety. However, critics worry it could create delays in care and increase administrative burdens for both patients and healthcare providers. Beneficiaries in pilot states who require these services should expect their doctors to need additional time to secure approval before procedures can be scheduled.
This change also affects individuals with Medigap supplemental insurance plans such as Plan G or Plan N, as they use Traditional Medicare coverage. Medicare Advantage plans already typically require prior authorization for many services, so this change primarily impacts those enrolled in Original Medicare.
Beneficiaries living in the six pilot states should proactively discuss with their healthcare providers whether any planned treatments or equipment will require prior authorization in 2026. Keeping documentation and maintaining clear communication with both providers and Medicare can help minimize potential delays.
