Starting January 1, 2026, Medicare beneficiaries in New Jersey will experience a significant shift in how certain medical services are approved and delivered. For the first time, Original Medicare—not just Medicare Advantage—will require prior authorization for a select group of services as part of a new federal pilot called the WISeR Model (Wasteful and Inappropriate Service Reduction).
What Is Changing?
- Prior Authorization Requirement:
Certain medical procedures and services identified as high-risk for fraud, waste, or abuse, will now require pre-approval before Medicare will cover them. This is a departure from Original Medicare’s traditional approach, which rarely required such authorizations. - Scope and Duration:
The WISeR Model will run from January 1, 2026, through December 31, 2031, and is limited to six states, including New Jersey. - Technology-Driven Oversight:
The program will use advanced technologies, including artificial intelligence, to help flag potentially unnecessary or inappropriate treatments. However, all final decisions will be made by licensed clinicians, not machines.
Affected Procedures
Services requiring prior authorization include:
- Electrical and nerve stimulators
- Deep brain stimulation for Parkinson’s disease
- Epidural steroid injections (excluding facet joint injections)
- Arthroscopic knee procedures for osteoarthritis
- Cervical fusion
- Incontinence control devices
- Skin and tissue substitutes for chronic wounds
- Treatments for impotence, among others
What Stays the Same?
- Emergency and Inpatient Services:
Emergency care, hospitalizations, and services where delays would pose substantial risk are exempt from prior authorization. - Medicare Advantage Unaffected:
These changes do not impact those enrolled in Medicare Advantage plans, which already use prior authorization.
Implications for New Jersey Beneficiaries
- Administrative Impact:
Providers and patients will need to navigate new paperwork and approval steps before receiving certain treatments, potentially leading to delays. - Goal:
The aim is to reduce unnecessary procedures, curb fraud, and ensure appropriate care while maintaining patient safety and access.
Medicare beneficiaries in New Jersey should stay informed and work closely with their healthcare providers to understand how these changes may affect their care in 2026 and beyond.
For more information, please visit the Medicare website.
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