If you rely on Medicare, there are some major changes coming in 2026 that could affect how and when you receive care. These updates haven’t made big headlines, but they could have a serious impact—especially for people in certain states and those who depend on specific medical services.
The new rules introduce prior authorization requirements in Original Medicare for the first time and loosen them for Medicare Advantage. Understanding what’s happening can help you prepare.
What Is the WISeR Model?
The WISeR Model is a pilot program that Medicare is launching to reduce what officials call “waste, fraud, and abuse.” Under this model, certain medical services will require approval from Medicare before you can receive them—even if your doctor recommends them.
This process is called prior authorization. It’s something that people with private insurance or Medicare Advantage may already be familiar with, but it hasn’t typically applied to Original Medicare. That’s about to change.
Under the WISeR Model, pre-authorization requests will often be reviewed by artificial intelligence first. If the system flags an issue, a licensed medical professional—though not your personal doctor—will review the request. This extra step could lead to delays or even denials, depending on how the process works in real time.
Where It’s Happening
The WISeR Model begins on January 1, 2026, and will be tested in six states:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington
Initially, the program will target 17 medical services that Medicare considers “low value.” These services include treatments like nerve stimulation devices, deep brain stimulation, and some procedures for urinary incontinence. If you use one of these services, you could be directly affected.
Officials say these services offer minimal benefit in most cases, but that definition is broad—and not everyone agrees. What one person considers unnecessary may be crucial to someone else’s quality of life.
What’s especially concerning is how Medicare is paying the companies that manage these reviews. These companies may be rewarded based on how much money they save Medicare, which means there’s a financial incentive to deny care.
Changes in Medicare Advantage
While Original Medicare is adding new hurdles, Medicare Advantage is making things easier. Several major insurance providers have agreed to reduce the number of services that require prior authorization. They’re also streamlining the process with new electronic tools, ensuring that previously approved services remain in place during transitions, and improving communication around decisions and appeals.
By 2027, they aim to offer more real-time decisions—likely powered by AI—and will require a medical professional to review all clinical denials.
This means that starting in 2026, the two sides of Medicare will be moving in opposite directions. Original Medicare will have more restrictions, while Medicare Advantage will have fewer.
Why It Matters
These changes may not affect everyone right away, but they represent a significant shift in how Medicare operates. People in the six pilot states may feel the effects first, especially if they rely on one of the 17 targeted services.
The use of AI and the financial incentives tied to cost savings raise concerns about whether care decisions will truly be based on what’s best for the patient. Even though a licensed medical professional will review denials, they may not be familiar with the patient’s full medical history or specific needs.
This is just the beginning of what could become a broader national rollout. If the pilot is deemed successful, similar policies could eventually be applied across the country and to more services.
Relief Recap
If you live in one of the affected states or use one of the services listed in the pilot, it’s a good idea to talk to your healthcare provider about how these changes could impact you. Make sure your care team knows what’s coming and can help you navigate the new rules if they apply to your situation.
Even if these rules don’t apply to you today, they offer a clear signal of where Medicare policy is heading. Keeping an eye on these developments will help you stay ahead and protect your access to the care you need.
I am all in favor of them doing whatever is necessary to cut down the amount of fraud and abuse that is happening with Medicare.
I have been the subject of fraudulent charges made to my Medicare account – this creates a lot of stress, headaches and anxiety
If Medicare is to be able to continue the fraud, waste and abuse needs to be dealt with
Thank you for sharing your perspective and experience. We’re sorry you’ve had to deal with that—it’s completely understandable how frustrating and stressful that must be. We appreciate you being part of this important conversation.