Traditional Medicare Gets Medicare Advantage’s Most Controversial Feature
Starting January 1, 2026, traditional Medicare beneficiaries in six states will face a dramatic change that could fundamentally alter their healthcare experience. For the first time, Original Medicare will require prior authorization for certain medical services—bringing the bureaucratic hurdle that has long plagued Medicare Advantage plans directly into traditional Medicare.
The Centers for Medicare and Medicaid Services (CMS) announced the Wasteful and Inappropriate Service Reduction (WISeR) Model, a six-year pilot program affecting residents of Washington, Texas, Arizona, New Jersey, Ohio, and Oklahoma. This represents the most significant structural change to traditional Medicare in decades, and it’s got seniors, healthcare providers, and policy experts on both sides of the political aisle deeply concerned.
What’s Changing and Why It Matters
Traditional Medicare has historically operated with minimal red tape. Unlike Medicare Advantage plans, which require prior authorization for 99% of their enrollees, Original Medicare typically lets doctors and patients make medical decisions without insurance company interference.
That’s about to change. The WISeR Model will require preapproval for 17 specific medical services that CMS says are “vulnerable to fraud, waste and abuse.” The program runs from January 1, 2026, through December 31, 2031.
The 17 Services Requiring Prior Authorization
The targeted procedures include:
• Nerve stimulation devices (electrical, sacral, phrenic, vagus)
• Brain and spinal procedures (deep brain stimulation, cervical fusion, epidural injections)
• Surgical interventions (vertebral augmentation, arthroscopic knee procedures)
• Sleep apnea treatments (hypoglossal nerve stimulation)
• Wound care products (skin substitutes and tissue-based products)
• Incontinence treatments and impotence diagnosis
CMS Administrator Dr. Mehmet Oz stated, “CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare.”
The Technology Behind the Changes
The WISeR Model promises to use artificial intelligence and machine learning to streamline the authorization process. However, CMS emphasizes that final decisions will be made by licensed clinicians, not machines.
Healthcare providers will have two options:
- Submit a prior authorization request before providing services
- Go through post-service/pre-payment medical review
The program explicitly excludes emergency services, inpatient-only procedures, and treatments that would pose substantial risk if delayed.
Following the Money Trail
The timing isn’t coincidental. The Justice Department’s 2025 National Health Care Fraud Takedown charged over 300 defendants with healthcare fraud schemes. One case particularly influenced the WISeR service list: three Arizona defendants allegedly bilked Medicare for over $1 billion by providing unnecessary skin grafts to elderly patients, many in hospice care.
Skin substitutes represent a massive expense for Medicare, with spending exceeding $10 billion in 2024—more than double the previous year’s cost.
The Profit Motive Concern
Critics worry about the financial incentives built into the system. Companies contracted to perform prior authorizations will receive a percentage of the savings from denied or reduced services. As former CMS Administrator Donald Berwick and health policy expert Andrea Ducas wrote, “the more care they deny, the more money contracting companies make.”
Political Pushback from All Sides
The WISeR Model faces rare bipartisan criticism, though for similar reasons.
From the Left: Rep. Suzan DelBene (D-Wash.) told MedPage Today, “It’s baffling how in one breath the administration is trying to take a victory lap on insurers streamlining prior authorization in Medicare Advantage, and in the other instituting the same delay tactics in traditional Medicare.”
From the Right: Michael Baker, director of healthcare policy at the American Action Forum, expressed skepticism about AI’s role and warned of increased administrative burden that could “delay beneficiary care.”
The Medicare Advantage Connection
The irony isn’t lost on healthcare watchers. While the Trump administration simultaneously pressured private insurers to reduce prior authorizations, it’s introducing the same system to traditional Medicare.
Medicare Advantage plans currently make 50 million prior authorization determinations annually. When patients appeal MA denials, they succeed 82% of the time—compared to just 29% in traditional Medicare.
What Seniors Need to Know
Who’s Affected
The pilot affects only beneficiaries receiving care from providers in the six test states: Washington, Texas, Arizona, New Jersey, Ohio, and Oklahoma. If you live elsewhere or receive care outside these states, you won’t be impacted initially.
Services Protected
The model excludes:
• Emergency services
• Inpatient hospital stays
• Services posing substantial risk if delayed
• Most preventive care
Your Options
If you’re in an affected state and concerned about access:
- Stay informed about which specific procedures require authorization
- Work closely with your healthcare provider on timing for elective procedures
- Consider Medicare Advantage alternatives if traditional Medicare becomes too restrictive
- Understand the appeals process for denied authorizations
The Broader Healthcare Landscape
This change reflects larger tensions in American healthcare between cost control and access. Healthcare waste does represent up to 25% of total spending, but most waste comes from administrative complexity, pricing issues, and care coordination failures—not overuse.
The WISeR Model addresses only overuse, which accounts for less than 3% of total healthcare spending. Critics argue that adding more administrative layers may increase costs rather than reduce them.
Looking Ahead: What to Expect
The six-year timeline suggests this isn’t a temporary experiment. If deemed successful, prior authorization requirements could expand to additional services and states, fundamentally changing traditional Medicare’s character.
Healthcare advocates worry this represents a step toward full Medicare privatization—a concern given CMS Administrator Oz’s stated goal of privatizing Medicare.
Your Next Steps
Whether you support or oppose these changes, staying engaged is crucial. The WISeR Model represents a significant shift in Medicare philosophy—from trusting healthcare providers and patients to make decisions together, to requiring insurance-style approval processes.
Contact your representatives if you have concerns about these changes. Medicare policy affects over 65 million Americans, and your voice matters in shaping its future.
The question facing Medicare beneficiaries is stark: Will these changes genuinely reduce waste and improve care, or will they import the delays, denials, and frustrations that have made Medicare Advantage controversial? The answer may determine the future of American healthcare for seniors.
Stay informed, stay engaged, and make your voice heard. The Medicare you save may be your own.
