Seniors often need much more medical care than the younger population. This, in part, is why Medicare programs exist -- to ensure that retirees have access to affordable healthcare coverage that pays for critical services.
Unfortunately, some new limits are being put in place for Medicare plans in 2026. The new rules have advocates extremely concerned about how access to care for retirees will be affected.
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Medicare is imposing strict new rules
The rule change that has many people concerned about Medicare coverage is occurring as a result of a program called the Wasteful and Inappropriate Service Reduction (WISeR) model. Under this model, so-called "wasteful" care that Medicare pays for is being targeted. The WISeR program will be operating in six states -- New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington -- and will affect access to care for around 6.4 million Medicare enrollees within those states.
Based on the rules established by the WISeR model, retirees are going to need pre-approval for care that the government has deemed wasteful. While this is common with Medicare Advantage plans, prior authorization like this has almost never been required under traditional Medicare. In fact, the lack of prior authorization is one reason people opt for traditional Medicare during their retirement planning process instead of signing up for an Advantage Plan.
However, because the government has deemed that 17 common medical procedures are wasteful, access to those services will now be limited without getting approval first.
Advocates are concerned about the effect on care
While it could, in theory, make sense to restrict coverage of services that are wasteful, retirees who were previously obtaining these services as covered benefits under Medicare probably don't consider them to be a waste. They're now going to have to hope that they get approved for their treatments. Otherwise, they may have to pay for this care out of their retirement plans. And if they don't have the money in their 401(k)s or IRAs to do so, they may not get the care at all.
This issue has advocates very worried about how the new prior-authorization rules will affect vulnerable seniors. Senator Patty Murray of Washington released a statement saying:
We already know that prior authorization creates major burdens and delays for patients and providers, and expanding it to Traditional Medicare will just force seniors to wait longer and navigate mountains of paperwork to get the care their doctor says they need. Make no mistake: this is a backdoor effort to privatize Medicare and cut benefits.
Despite these concerns, the prior-authorization requirement is in effect. Retirees need to be aware of it because they may very well have to deal with some major obstacles this year if they want one of the covered services.
