Policy & oversight
Traditional Medicare Required Prior Authorization for Certain Services in Six States for the First Time Starting January 2026, KFF Finds
A KFF examination of the WISeR Model, active in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, found it targets services whose spending grew about 400 percent between 2019 and 2024.
By the Goodsurance editorial teamSeptember 21, 2026
A KFF analysis published in February 2026 examined the WISeR Model, a Center for Medicare and Medicaid Innovation program that introduced prior authorization requirements into traditional Medicare for the first time.
The model, whose full name is Wasteful and Inappropriate Service Reduction, launched January 1, 2026 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Traditional Medicare has historically not required prior authorization for covered services, a structural difference from Medicare Advantage plans, which have used advance approval as a cost-management tool for many years. WISeR represents the first large-scale use of prior authorization in the traditional Medicare fee-for-service program.
Traditional Medicare now requires prior authorization for certain procedures in 6 states for the first time, under a federal model active since January 2026, KFF reports.
Services subject to prior authorization under WISeR include skin substitute wound care products, several orthopedic pain management procedures such as epidural steroid injections and cervical fusion, electrical nerve stimulator implants, incontinence control devices, and services related to impotence diagnosis and treatment.
KFF found that these services collectively accounted for about 12.3 billion dollars, or 5.3 percent of all Medicare Part B spending in 2024. Spending on WISeR-targeted services had grown about 400 percent between 2019 and 2024. Skin substitutes alone represented 83 percent of that category's spending. KFF estimated that about 207,500 beneficiaries in the six WISeR states would be subject to the new requirement.
The analysis also noted that a concurrent nationwide Medicare payment reform for skin substitutes, separate from WISeR, was projected to reduce Medicare spending on those products by nearly 90 percent in 2026, a change that may exceed WISeR's own fiscal impact. Providers in WISeR states had already reported implementation difficulties in the early months of the model.
In plain words
Starting January 1, 2026, some Medicare patients in six states need to get approval before they can receive certain medical treatments. This is called prior authorization.
The six states are Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
This is new for traditional Medicare. In the past, traditional Medicare did not usually require pre-approval for covered services. Medicare Advantage plans have had this type of requirement for many years, but not traditional Medicare.
The treatments that now need approval in these states include wound care patches, some back pain injections, spinal procedures, nerve stimulators, and a few others.
A study group called KFF looked at this new rule. They found spending on these services grew very fast, about 400 percent in just five years. About 207,500 people in those six states may need to go through the new approval process.
If you live in one of these states and need one of these treatments, ask your doctor about getting prior authorization before your appointment.
Understand the basics first
Source: KFF
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