Medicare's New Prior Authorization Program: What Seniors Need to Know

If you're on traditional Medicare, you may have chosen it specifically to avoid the hassles of prior authorization – those time-consuming approval processes that Medicare Advantage plans often require before covering medical procedures. Unfortunately, that advantage may be changing.

A Major Shift Coming to Traditional Medicare

According to a recent New York Times report, the Centers for Medicare and Medicaid Services (CMS) is launching a pilot program that will bring prior authorization requirements to traditional Medicare for the first time. Starting in January 2026, beneficiaries in six states – Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington – will be part of this six-year experiment called the "Wasteful and Inappropriate Service Reduction Model."

What This Means for You

The program will use artificial intelligence to review about a dozen specific procedures before approving coverage, including:

• Certain spine surgeries and steroid injections
• Devices for incontinence control
• Cervical fusion procedures
• Select nerve stimulators
• Diagnosis and treatment of impotence
• Expensive "skin substitutes"

If you live in one of the pilot states and need any of these procedures, you'll now face the same type of pre-approval process that has made Medicare Advantage plans frustrating for many seniors.

The Concerning Details

What's particularly troubling is how this system will work. Private companies hired by Medicare will use AI algorithms to make coverage decisions, and these companies will be paid a share of the money they save by denying claims. This creates a direct financial incentive to reject coverage requests.

As Dr. Vinay Rathi, an Ohio surgeon and Medicare payment expert, told the Times: "It's basically the same set of financial incentives that has created issues in Medicare Advantage and drawn so much scrutiny."

Why This Matters to Seniors

For years, one of traditional Medicare's biggest selling points has been its straightforward coverage without the bureaucratic hurdles of private insurance plans. Many seniors, like 74-year-old Frances Ayres quoted in the Times article, specifically chose traditional Medicare to avoid these hassles.

The American Medical Association has called prior authorization "one of the most burdensome and disruptive administrative requirements" doctors face. While most patients who appeal denials are successful, the vast majority never appeal in the first place – meaning they simply go without needed care.

What You Can Do

If you live in a pilot state:

• Stay informed about which procedures will require prior authorization
• Work closely with your healthcare providers to understand the new requirements
• Don't hesitate to appeal if a claim is denied – success rates for appeals are high
• Consider whether Medicare Advantage might now offer comparable benefits without additional hassles

Regardless of where you live:

• Contact your representatives in Congress – both Democrats and Republicans have supported legislation to curb problematic prior authorization practices
• Stay engaged with healthcare advocacy groups
• Keep detailed medical records to support any future authorization requests

The Bigger Picture

While CMS says this program targets wasteful spending and could save billions of dollars, critics worry it's the beginning of a broader shift toward privatizing traditional Medicare. Representative Alexandria Ocasio-Cortez and other House Democrats have warned that giving for-profit companies a "veto" over care could lead to "further erosion of our Medicare system."

Navigating Healthcare Changes

Healthcare policy changes like this can feel overwhelming, especially when they affect essential services you depend on. At Butterfly Guides, we understand how challenging it can be to navigate these evolving systems while managing your health and wellbeing.

The key is staying informed and advocating for yourself. Don't let bureaucratic processes prevent you from getting the care you need – whether that means working with your doctor to meet authorization requirements, filing appeals when necessary, or exploring alternative coverage options.

Looking Ahead

This pilot program is scheduled to run for six years, but its future depends on the results and public response. If the AI-driven system proves to save money without harming patient care, it could expand to all states and potentially to many more procedures.

The Medicare landscape is changing, and seniors need to stay informed about how these changes might affect their care. While the goal of reducing wasteful spending is admirable, the methods matter – and the voices of Medicare beneficiaries must be heard in this process.

Stay informed about Medicare changes and other issues affecting seniors by following our blog at butterflyguides.com/blog. For more detailed information about this program, read the full New York Times investigation: "Medicare Will Require Prior Approval for Certain Procedures"