Prior Authorization Coming to Traditional Medicare Starting in 2026

[lostincalifornia]

"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