Original Medicare Is Testing Prior Authorization in 2026

If you live in New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington, you may have heard that Original Medicare is changing.

Some people heard that and panicked. Others assumed it meant Medicare was “turning into Medicare Advantage.”

Neither is an accurate way to look at what’s happening.

So let’s separate the actual Medicare rule from the headlines and walk through what WISeR means for beneficiaries in plain English.

If you’re wondering how prior authorization works across Original Medicare, Medicare Advantage, and Part D—not just this six-state program—read my complete guide: Does Medicare Require Prior Authorization?

What Is the Medicare WISeR Model?

First, let’s name the thing properly.

Original Medicare—sometimes called Traditional Medicare—is Medicare Parts A and B.

Original Medicare has historically used much less prior authorization than Medicare Advantage plans. But that doesn’t mean Original Medicare has never used prior authorization or other pre-claim review programs.

In 2026, CMS began testing another targeted approach through the WISeR Model.

The model runs from January 1, 2026 through December 31, 2031.

And this is important: WISeR is not a nationwide change to all Original Medicare care.

Where Does WISeR Apply?

WISeR operates in six states:

• Arizona
• New Jersey
• Ohio
• Oklahoma
• Texas
• Washington

Why Is Medicare Testing WISeR?

Here’s the basic issue CMS is trying to address.

Original Medicare generally pays providers through a fee-for-service system. Providers are paid for the services they furnish, and CMS says that structure can create incentives for medically unnecessary treatments, tests, or other care.

WISeR focuses on a specific group of services that CMS says may have little or no clinical benefit for certain patients and have historically carried a higher risk of fraud, waste, or abuse.

One example is skin and tissue substitutes used in wound care. CMS has identified this area as one where inappropriate use can expose beneficiaries to unnecessary costs and potential complications.

That’s a much more accurate way to understand WISeR than saying Medicare suddenly doesn’t trust doctors or suddenly wants to deny care.

Think targeted checkpoint—not a new gate in front of every Medicare service.

What Services Are Affected?

WISeR applies to a selected group of items and services, not routine Medicare care.

CMS examples include:

• certain skin and tissue substitutes
• implantation of electrical nerve stimulators
• knee arthroscopy for knee osteoarthritis

The selected services have existing Medicare coverage criteria and may raise concerns about patient safety when delivered inappropriately or have a history of fraud, waste, or abuse.

How Does Prior Authorization Work Under WISeR?

If your provider is furnishing one of the selected WISeR services, there are two possible review paths.

That’s an important distinction because WISeR isn’t simply:

“Get prior authorization or you can’t receive the service.”

It’s a targeted review model with more than one pathway.

How Is AI Being Used in Medicare’s WISeR Model?

This is the part getting a lot more attention in 2026.

Yes, WISeR uses technology that can include artificial intelligence and machine learning.

But before the headline turns into “AI is deciding whether Grandma gets care,” here’s what CMS actually says.

Participating technology companies use enhanced technology to help review whether selected services meet Medicare’s existing documentation, coverage, payment, and coding requirements.

CMS also says WISeR uses that technology along with human clinical review.

That’s still a meaningful use of AI inside Original Medicare—and it’s worth watching carefully.

But we don’t need to exaggerate what the program does to understand why it matters.

What Does WISeR Not Change?

This may be the most important section of the article.

CMS says WISeR does not change Medicare coverage or payment policy.

In other words, the model changes when and how selected services are reviewed against Medicare’s existing requirements. It doesn’t create an entirely new set of Medicare benefits.

This is a review-process change for selected services—not a rewrite of Original Medicare.

What Should Beneficiaries Do?

For most people, WISeR won’t become something you need to manage yourself every time you use Medicare.

But if your doctor recommends a service that falls under the model, ask a few simple questions before scheduled care.

Your provider’s documentation matters because the review is based on Medicare’s existing coverage requirements.

But your state matters too. WISeR currently applies only in the six participating states.

So I wouldn’t make this more complicated than it needs to be: know whether the model applies to you, ask your provider whether your service is affected, and get the facts before assuming the worst.

So… Should You Be Worried?

If you don’t live in a WISeR state, this particular model doesn’t apply to you.

If you do live in one of the six states but aren’t receiving one of the selected services, WISeR may never directly affect your care.

And if you are receiving an affected service, expect more attention to documentation and whether Medicare’s existing coverage requirements are met.

That doesn’t mean denial by default.

It means review.

Know what’s changing. Know what isn’t. Then make your Medicare decisions from facts—not fear.

Bottom Line

The WISeR Model is a targeted Medicare experiment—not a wholesale change to Original Medicare.

It applies to:

• selected services
• in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington
• during a model period running from January 1, 2026 through December 31, 2031

CMS is testing whether technology—including AI and machine learning—combined with human clinical review can help identify inappropriate care earlier while applying Medicare’s existing coverage requirements.

That’s worth paying attention to.

But it isn’t a reason to panic, switch Medicare coverage, or assume a computer has taken over your healthcare decisions.

Clarity beats confusion. Every time.

If you’re trying to understand prior authorization beyond WISeR—including how the rules differ for Original Medicare, Medicare Advantage, and Part D—read my complete guide: Does Medicare Require Prior Authorization?

Reviewed for accuracy: August 17, 2026. WISeR currently applies to selected Original Medicare services in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. CMS states that the model does not change Medicare coverage or payment policy and uses enhanced technology alongside human clinical review.