Advisors serving Medicare clients in six states should prepare for a major policy change starting next year: For the first time, the Centers for Medicare and Medicaid Services will require prior authorization for certain procedures under Original Medicare.
The new CMS pilot program introduces a utilization review process similar to those already used in the Medicare Advantage program, creating new considerations for advisors during client enrollment and plan evaluation.
The Question:
What should advisors know about the new CMS prior authorization pilot in traditional Medicare?
The Answer:
CMS will require prior authorization for select procedures under a six-year pilot program beginning Jan. 1, 2026.
The model, called the Wasteful and Inappropriate Service Reduction (WISeR) model, will operate in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
The program applies to a defined list of outpatient services, with the goal of reducing unnecessary or low-value procedures.
CMS has said reviews will be conducted by contractors using technology, including artificial intelligence tools, with final coverage determinations made by licensed clinicians.
The WISeR Program Timeline
The WISeR model marks the first time prior authorization will be applied in Original Medicare on this scale.
The WISeR model will begin in January 2026 and is scheduled to run through December 2031.
CMS has described it as a test of whether utilization review in Original Medicare can reduce costs while maintaining access to necessary care.
Depending on the results, the program could expand or be revised in future years.
How WISeR Will Work
Initially, 17 services will be subject to review, including:
♦ Cervical spinal fusions
♦ Select steroid injections
♦ Nerve stimulation devices
♦ Skin substitute products
♦ Devices related to incontinence and erectile dysfunction
Emergency services and inpatient hospital stays will not be included.
CMS has said the list of services may be updated over time based on utilization and outcomes.
The agency has published a fact sheet and a set of answers to frequently asked questions as additional resources.
Implications for Clients
♦ Plan comparisons may shift. Historically, one distinction between Medicare Advantage and Original Medicare has been the absence of prior authorization in the latter.
The new pilot may influence client preferences when comparing coverage options.
♦ New steps for clients. Beneficiaries in the pilot states may need prior approval for certain services, which could be an adjustment for those used to Medicare's current structure.
♦ Technology in reviews. While AI will be used in screening, CMS has emphasized that clinicians will make the final determinations.
♦ Appeals processes remain in place. As with other CMS programs, beneficiaries will have the right to appeal denials.
Advisors may need to guide clients through these steps if needed.
For Medicare beneficiaries, the introduction of prior authorization may feel like a change to a program they have known as straightforward and predictable.
A client who once scheduled an outpatient procedure without delay could now need to wait for approval.
While most services will remain unaffected, even a short delay could cause concern for individuals accustomed to immediate access to care.
Understanding the process will be key.
Clients will have questions about why a service requires prior authorization, how long the review process will take, and what steps they should follow if coverage is denied.
Advisors can help translate program requirements into clear next steps, ensuring beneficiaries know what to expect and how to respond if they face added paperwork or delays.
What Advisors Can Do
♦ Monitor CMS updates on the WISeR model, especially if you serve clients in the six pilot states.
♦ Prepare to explain prior authorization steps to clients unfamiliar with the process.
♦ Reassess plan comparisons for clients who previously preferred Original Medicare because of its administrative simplicity.
♦ Support clients by providing guidance if they encounter documentation or appeal requirements.
The Takeaway
The WISeR model marks a new step in how Original Medicare approaches certain high-cost services.
Though the pilot is limited to six states and a narrow list of procedures, it introduces prior authorization into a program that historically has not required it.
By helping beneficiaries understand what the pilot means for their care, advisors can play a central role in reducing confusion and ensuring that clients feel prepared to handle the new requirements with confidence.
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