Medicare 2026

WISeR Explained: What the New Prior Authorization Test in Original Medicare Means for You

Starting January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) is running a new experiment in Original Medicare called the Wasteful and Inappropriate Service Reduction Model, or WISeR for short. It's a six-year test, scheduled to end on December 31, 2031, operating in six states. If you've only ever associated "prior authorization" with Medicare Advantage or private insurance, this is a meaningful shift worth understanding — even if you don't live in a test area, because results from the model could shape future national policy.

Here's a plain-English look at what WISeR is, what it isn't, and how it could affect your care.

What WISeR actually does

Traditionally, Original Medicare has paid claims after the fact, using medical review to flag problems. WISeR tests a different approach for a narrow set of items and services that have raised concerns about overuse or inappropriate use. Examples CMS has highlighted include skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis.

In the six participating states, providers and suppliers have two options when they want to furnish one of the selected services:

1. Submit a prior authorization request before performing the service, or 2. Perform the service and let the claim go through medical review before payment.

Either way, review happens. The difference is timing.

Participating technology companies — vendors chosen by CMS — handle the reviews. They are expected to issue a decision within three days of receiving a request, and within two days for an expedited request when a delay could seriously jeopardize a patient's life or health. Importantly, CMS states that any recommendation to deny payment must be made by an appropriately licensed clinician, not by software alone.

What WISeR does not change

A few points are worth underlining, because they often cause confusion:

• Coverage rules are the same. WISeR does not change what Medicare covers or how it pays. The underlying coverage policy is unchanged; the model only tests how review is done.
• It doesn't touch Medicare Advantage. WISeR applies to Original Medicare only. People in Medicare Advantage plans already deal with their plan's own prior authorization rules, which are separate.
• You keep provider choice. Under Original Medicare, you can still see any doctor or supplier who accepts Medicare, including in WISeR areas.
• Emergencies and inpatient-only services are excluded, as are services that would pose a substantial risk to patients if delayed.

What happens if a service isn't approved

If a prior authorization request is "not affirmed," the physician must give you an Advance Beneficiary Notice of Non-coverage (ABN) before going ahead. An ABN tells you, in writing, that Medicare is unlikely to pay and lays out your options and potential financial responsibility. You can decide whether to proceed, pursue an alternative, or wait.

Both you and your provider retain the right to appeal any denied claim through the standard Medicare appeals process. In other words, a "no" from a WISeR reviewer isn't the final word.

CMS has also said that providers and suppliers with strong records of compliance may eventually qualify for a "gold card" exemption, meaning their requests wouldn't need to go through WISeR review. The details of that program will come later.

Why CMS is doing this — and the debate

CMS designed WISeR to target services where evidence suggests Medicare dollars are being spent on care that isn't necessary or appropriate. The participating technology companies are paid a percentage of the spending on wasteful or inappropriate care their reviews avert, which is meant to align their incentives with program savings.

Supporters say this could reduce low-value procedures and protect the Medicare trust fund. Critics worry about delays and administrative burden on providers. That tension — speed and access versus oversight and stewardship — is part of why CMS is running this as a time-limited model rather than a permanent rule.

A quick note on Original Medicare vs. Medicare Advantage

Because WISeR brings a touch of prior authorization into Original Medicare, some readers may wonder how the two paths compare. Both have trade-offs. Original Medicare offers broad provider access nationwide and the option to pair with a Medigap policy and a stand-alone Part D plan; Medicare Advantage plans often include extra benefits and an out-of-pocket maximum but typically use networks and prior authorization across a wider range of services. Neither is universally better — the right fit depends on your health, your providers, and your preferences.

A few 2027 facts worth knowing

While you're thinking about Medicare, keep these national dates and figures handy:

• Annual Enrollment for 2027 coverage runs October 15 – December 7, 2026, with changes effective January 1, 2027.
• The Part D out-of-pocket cap rises to $2,400 in 2027 (up from $2,100 in 2026).
• The maximum Part D deductible any plan may charge in 2027 is $700.
• The Part D base beneficiary premium for 2027 is $41.33 — a national figure used to calculate the late-enrollment penalty; actual plan premiums vary.
• Social Security announced a 3.6% COLA for benefits payable beginning January 2027.
• The 2027 Part B standard premium and deductible, and the IRMAA income brackets, have not yet been announced; CMS typically releases them in the fall.

If you have Medicaid or Extra Help, remember that since 2025 you have a monthly Special Enrollment Period to move to Original Medicare with a stand-alone Part D plan or to switch stand-alone plans, and full-benefit dual-eligible individuals can join an integrated D-SNP in any month.

Where to learn more

For official details on WISeR, the services it covers, and the states involved — plus general questions about enrollment, appeals, and coverage — go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), available 24/7.