Medicare Prior Authorization Changes for Beneficiaries

Prior authorization has long been a sticking point in health care, often delaying treatment and creating extra headaches for policyholders, providers, and insurance agents.

Fussy Faye with MA wondering why she can’t get that important test the same day? Not so fast… you know her insurance company needs to approve it. You also know they might take one week… or two weeks… or longer.

Now, major reforms are underway from health plans, and the Centers for Medicare & Medicaid Services (CMS) have launched a new pilot program to reshape how prior authorization works across the Medicare industry.

It’s important you’re aware of the Medicare prior authorization changes for 2026 and 2027, so you’re prepared to best help your clients.

What Is Prior Authorization?

Before we dive into those changes, let’s start at the beginning. Maybe your client doesn’t know what prior authorization is.

Prior authorization in insurance is an approval that a specific health care provider needs to receive from the health insurer before they can give care. In Medicare, prior authorization is the Medicare program confirming that they’ll provide coverage of the services given by the health care provider.

Any denial of care based on medical necessity must be reviewed by a qualified clinician. This ensures that decisions are backed by medical expertise rather than just administrative processes!

CMS uses this system to monitor payments and prevent improper billing by ensuring that the services given are medically necessary. These efforts are part of an overall Medicare insurance fraud and abuse prevention strategy by CMS.

Medicare Advantage Plans Simplify Prior Authorization Process

After a meeting with the Department of Health and Human Services (HHS), several Medicare Advantage insurers have committed to simplifying the prior authorization process. Here’s what prior authorization changes will be rolled out over the next two years.

Note: Health plans are voluntarily making these changes. See a list of the participating health plans here.

Starting in 2026

As of January 1, 2026, Medicare Advantage insurers will:

• Require fewer medical services to need approval
• Honor any existing prior authorizations new enrollees had with their old plan for up to 90 days, as long as the service is in-network and covered under the new plan.
• Provide plain-language explanations for decisions and easy-to-follow instructions for appeals

Starting in 2027

As of January 1, 2026, Medicare Advantage insurers will:

• Begin using a standardized electronic system
• Provide real-time approvals for at least 80 percent of requests that include all necessary documentation

This shift toward a single digital framework should streamline the process for everyone involved, reducing confusion and frustration for your clients!

Original Medicare Adds WISeR Prior Authorization Requirements

CMS has launched the Wasteful and Inappropriate Service Reduction (WISeR) Model targeting Original Medicare.

Starting January 1, 2026, and running through December 31, 2031, WISeR will test a new, tech-enabled prior authorization process for select services vulnerable to overuse such as skin substitutes, nerve stimulator implants, and knee arthroscopy.

This voluntary program will leverage AI and machine learning to sort requests more efficiently. However, licensed clinicians will still make the final decisions to ensure accuracy and protect patient safety.

Who’s Affected by These Changes?

About 99 percent of Medicare Advantage enrollees are in plans that require prior authorization for services like:

• Skilled nursing facility stays
• Part B drugs
• Inpatient hospital stays
• Outpatient psychiatric services

The WISeR program will only operate in six states to start: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

Once the WISeR Model launches in 2026, your clients will see prior authorization apply to the 17 services where there is already evidence of fraud, waste, and abuse.

For years, prior authorization has been one of the most frustrating parts of health care for patients, providers, and even agents who often step in to help clients navigate the process.

The Medicare prior authorization changes may be fantastic news for Fussy Faye with MA, but those affected by WISeR? They may be venting to their advisor.

Want to learn more about helping your clients navigate Medicare updates? Register with Ritter for free and get the tools and resources you need!