If you are on Medicare, there is a big change coming that you should know about. Starting January 1, 2026, a new model called WISeR will roll out in six states, and it is going to affect how some services are approved and paid for. This may sound complicated, but do not worry—we will break it down for you.
What is the wiser model in medicare?
The WISeR model stands for Wasted and Inappropriate Services Reduction. It is a new approach from the Centers for Medicare & Medicaid Services (CMS) that focuses on cutting back on fraud, waste, and unnecessary treatments.
- This model will require certain medical services to get pre-approval before they are given to patients
- It only applies to traditional Medicare (also called Original Medicare), not Medicare Advantage plans
- The idea is to improve oversight and ensure only medically necessary services are approved
Before now, most people with traditional Medicare were not used to needing prior authorization. That is something Medicare Advantage plans usually require. But now, that is changing for some of you—depending on where you live and what services you need.
Which states are affected by the 2026 medicare rule change?
The WISeR model will begin January 1, 2026, and it will only apply to providers in six states during its first phase:
- New Jersey
- Ohio
- Oklahoma
- Texas
- Arizona
- Washington
If you live in one of these states, your doctors or healthcare providers may need to ask for authorization ahead of time before giving you certain services.
It is important to note: Providers in these areas can voluntarily submit requests for pre-approval. But if they do not, the claim may be reviewed after the service is done—and they might not get paid for it.
What types of services will need pre-approval?
Not all Medicare-covered treatments are included in this change. CMS has listed 17 specific services that will be affected. These were chosen because they are often overused or linked to fraud.
Some of the services that will need prior approval include:
- Electrical nerve stimulators
- Sacral nerve stimulation (used for urinary incontinence)
- Phrenic nerve stimulators
- Deep brain stimulation (for Parkinson’s and tremors)
- Vagus nerve stimulation
- Induced lesions of nerve tracts
- Epidural steroid injections for pain (except for certain joint injections)
- Incontinence control devices
- Leather and tissue substitutes (limited to certain jurisdictions)
- Diagnosis and treatment of impotence
Basically, if you need any of these services in one of the affected states, your provider might need to get it pre-approved before you can get it.
How will this affect your medicare experience?
This change is not meant to make things harder for you, but it could lead to delays if your provider is not familiar with the new system.
- It may add more paperwork for providers
- You might experience slower service approvals
- If a provider forgets to ask for pre-approval, Medicare might deny the payment, and that could lead to billing issues
According to CMS, “Generally, this model will require the same clinical information and documentation already required to support Medicare FFS payment, but at an earlier stage in the process.”
So the good news is—you will not be asked for anything new. It is your provider who has to adjust.
Why is medicare doing this now?
The government wants to cut costs, reduce waste, and catch fraud before it happens. That is the big reason behind WISeR.
This new system will also test out better technology for managing Medicare billing and approvals, which could lead to smoother processes in the future.
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