Major changes are coming to Original Medicare in 2026 for residents of six states. The federal government will launch a new pilot program. It introduces prior authorization for certain medical services. The goal is to reduce wasteful spending. However, some health experts worry it could harm patients by delaying or denying necessary care.
Which States Are Affected?
The Centers for Medicare and Medicaid Services (CMS) selected the six states for this test. The program, called the WISeR model, will begin on January 1, 2026. The affected states are:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington
What Is the New “WISeR” Model?
The “Wasteful and Inappropriate Service Reduction” (WISeR) model is a big shift. It requires doctors in the six test states to get approval from Medicare before performing some services. CMS says this will cut down on treatments that offer little to no clinical benefit. The agency reports that wasteful care accounts for up to 25% of all healthcare spending. The new model will also use artificial intelligence to help speed up the approval process.
The Big Concern: Denials of Needed Care
Health experts have voiced serious concerns about the new model. They fear it will bring some of the problems of private Medicare Advantage plans into Original Medicare. This could lead to delays in treatment. It might also cause denials of appropriate care for seniors. Critics point out that the contractors reviewing claims may be paid for each service they deny. This creates a financial incentive to reject claims, even if the care is necessary.
What This Means for Patients
Patients in the six selected states will see a new process for certain services. They may have to wait for Medicare to approve a procedure. If a service is denied, their doctor must notify them. Patients will still have the right to appeal any denial. This new model is a major test. CMS is already considering expanding it to more states if it is deemed a success.
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