Welcome to DU! The truly grassroots left-of-center political community where regular people, not algorithms, drive the discussions and set the standards. Join the community: Create a free account Support DU (and get rid of ads!): Become a Star Member Latest Breaking News Editorials & Other Articles General Discussion The DU Lounge All Forums Issue Forums Culture Forums Alliance Forums Region Forums Support Forums Help & Search

lostincalifornia

(3,908 posts)
Thu Jul 17, 2025, 02:36 PM Thursday

Prior Authorization Coming to Traditional Medicare Starting in 2026

"The Centers for Medicare and Medicaid Services (CMS) will implement prior authorization requirements for certain traditional fee-for-service Medicare services in six states starting next year.

Traditional Medicare, also known as Original Medicare, has historically required little in the way of pre-authorization for beneficiaries seeking services; pre-authorization was typically the domain of Medicare Advantage. But that's about to change, as the Centers for Medicare and Medicaid Services (CMS) announced that it will implement prior authorization requirements for certain traditional fee-for-service Medicare services in six states starting next year.

This change will go into effect on January 1, 2026, when the CMS starts to "test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars," per a CMS press release. The model being implemented in 2026 builds on a change to prior authorizations rolled out by the Department of Health and Human Services (HHS) and CMS on June 23, 2025.

Six states — New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — will begin using the Wasteful and Inappropriate Service Reduction (WISeR) Model to perform prior authorization evaluations, CMS announced in a Federal Register notice. This will apply to 17 services that CMS says "are vulnerable to fraud, waste and abuse."


https://www.kiplinger.com/retirement/medicare/prior-authorization-coming-to-traditional-medicare?lrh=787ccbf689a2babdb90b9d6ae676fe0e081553b5c9477a5458b5b2a0630c0052

10 replies = new reply since forum marked as read
Highlight: NoneDon't highlight anything 5 newestHighlight 5 most recent replies

Silent Type

(10,526 posts)
5. It's a demonstration project in 6 states, not all states. It was also proposed during Biden admin although they
Thu Jul 17, 2025, 02:47 PM
Thursday

didn't specify the services to be subjected to priorauthorization.

17 services to be subject to prior authorization
Here is the list of services that will go through a prior authorization process in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, between January 1, 2026, and December 31, 2031.

These are the services subject to prior authorization:
Electrical nerve stimulators
Sacral nerve stimulation for urinary incontinence
Phrenic nerve stimulator
Deep brain stimulation for essential tremor and Parkinson’s disease
Vagus nerve stimulation
Induced lesions of nerve tracts
Epidural steroid injections for pain management excluding facet joint injections
Percutaneous vertebral augmentation (PVA) for vertebral compression fracture
Cervical fusion
Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee
Hypoglossal nerve stimulation for obstructive sleep apnea
Incontinence control devices
Diagnosis and treatment of impotence
Percutaneous image-guided lumbar decompression for spinal stenosis
Skin and Tissue Substitutes
Application of bioengineered skin substitutes to lower extremity chronic non-healing wounds
Wound Application of cellular and/or tissue based products (CTPs), lower extremities

https://www.kiplinger.com/retirement/medicare/prior-authorization-coming-to-traditional-medicare

ck4829

(37,019 posts)
6. Even people who work in healthcare get snagged up in this
Thu Jul 17, 2025, 02:47 PM
Thursday

My mother needed surgery done and insurance said “you needed to get this checked off”, some procedure before the surgery, one of two they tried to say, after the surgery was done. She works in X-rays in a major practice.

The insurance companies have people looking for a single i not being dotted and that is pretty much all it takes to get thousands added to your bill.

S/V Loner

(9,410 posts)
7. While, at the same time, they are firing...
Thu Jul 17, 2025, 03:12 PM
Thursday

those that deal with customer service.
What could go wrong?

Hugin

(36,653 posts)
10. In order to make the so-called advantage plans the norm original Medicare has to be broken.
Fri Jul 18, 2025, 03:37 AM
Friday

This is one of the first stages of that.

Latest Discussions»General Discussion»Prior Authorization Comin...