If you’re on Medicare—or helping a loved one who is—you’ve probably heard that Medicare prior authorization changes in 2026 are coming. For the first time, traditional Medicare (also called Original Medicare) will begin requiring prior authorization for certain services in select states starting January 1, 2026.
At Skyline Benefit, we help Medicare beneficiaries navigate policy changes, enrollments, and plan options with expert, personalized support. Here’s what you need to know about the upcoming prior authorization changes and how they may impact your coverage.
Why Is Medicare Adding Prior Authorization in 2026?
The Centers for Medicare & Medicaid Services (CMS) is rolling out a new initiative called the Wasteful and Inappropriate Service Reduction (WISeR) Model.
The goal?
- Reduce fraud, waste, and abuse in Medicare
- Improve oversight of high-risk or low-value services
- Protect federal funds and ensure care is medically necessary
The WISeR Model builds on technology like AI and machine learning to streamline approvals, but licensed healthcare providers will still make final decisions.
Which States Are Affected by the 2026 Prior Authorization Rollout?
If you live in any of these states, the new prior authorization process will apply to select Medicare services:
- New Jersey
- Ohio
- Oklahoma
- Texas
- Arizona
- Washington
The program begins January 1, 2026, and runs through December 31, 2031, in these states as part of a CMS pilot program.
What Services Will Require Prior Authorization?
CMS has identified seventeen services as high risk for fraud or inappropriate use. These include:
- Electrical nerve stimulators
- Deep brain stimulation for Parkinson’s and tremors
- Epidural steroid injections for pain
- Cervical spinal fusions
- Arthroscopic knee lavage and debridement
- Hypoglossal nerve stimulation for sleep apnea
- Incontinence control devices
- Skin substitutes and wound care treatments
- Vertebral compression fracture repairs
Providers in affected states will submit authorization requests before services are performed or undergo post-service claim reviews.
Will AI or Machines Decide My Authorization?
No. While CMS will use technology to assist with reviews, all final decisions will be made by licensed healthcare professionals.
This ensures that human judgment—not automated systems—will guide approvals, with patient safety and care standards as top priorities.
How Does Prior Authorization in Medicare Compare to Medicare Advantage?
Historically, Original Medicare required little to no prior authorization for most services, unlike Medicare Advantage, where nearly all members face prior authorization for certain procedures.
This change narrows that gap, introducing more oversight into Original Medicare while still maintaining access to necessary care.
What Should You Expect with This Change?
- Prior authorization will only apply to the 17 listed services—other Medicare coverage rules stay the same.
- Emergency services, inpatient-only procedures, and time-sensitive care are excluded.
- Your provider may seek pre-approval or submit for post-service review.
What Is the Government Doing About Medicare Fraud and Abuse?
The WISeR Model is part of the federal government’s intensified efforts to crack down on Medicare fraud, waste, and abuse.
In 2025, the National Health Care Fraud Takedown charged over 300 defendants in fraud cases totaling billions of dollars.
CMS’s approach:
- Use technology to detect waste
- Enforce stricter rules on high-risk services
- Increase accountability for providers and suppliers
Will This Affect California or My Medicare Plan?
Right now, California is not part of the initial rollout. But CMS may expand the program based on results from the six pilot states.
If you’re enrolled in a Medicare Advantage plan, keep in mind that prior authorization is already a standard part of your coverage—and this change will not directly impact you.
How Skyline Benefit Can Help You
We know Medicare changes can be overwhelming. At Skyline Benefit, we:
- Help you understand Medicare prior authorization changes in 2026
- Provide expert guidance on Medicare Advantage, Medigap, and Part D plans
- Assist with enrollment, renewals, and coverage reviews — at no extra cost
Need Help Understanding Medicare Prior Authorization Changes in 2026?
Skyline Benefit is an independent health insurance broker in Fullerton, CA, offering affordable and flexible Medicare options. Whether you have questions about prior authorization changes, Medicare Advantage enrollment, or staying compliant with new Medicare rules, we’re here for you.
Schedule a consultation today. Call us at: (714) 888-5112