6.4 Million Medicare Recipients Face New Hurdles in Getting Care

Seniors tend to use more medical care than most, which is why access to Medicare is so important for retirees.

While Medicare definitely doesn't cover everything, it provides an affordable solution for seniors so they can get most of the care they need at least partially paid for.

Unfortunately, life will soon get harder for around 6.4 million Medicare beneficiaries as coverage rules change this year. These seniors will find it harder to get some services they may depend on to help maintain their health.

Here's why.

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Medicare introduces new barriers to care for 6.4 million seniors

Millions of seniors will have a harder time getting Medicare to pay for care this year, thanks to a pilot program that now requires prior approval for 17 healthcare services.

While Medicare Advantage plans have routinely required pre-approval for certain healthcare services, pre-approval is not usually required for seniors with traditional Medicare coverage. However, a new pilot program called the Wasteful and Inappropriate Service Reduction (WISeR) model is launching in six states that changes that.

The purpose is to limit access to "wasteful" care, but the Medicare retirees who use the affected services may not agree with the government that their care is a waste.

Medicare makes it harder to get access to 17 medical services

Under the WISeR model, the 17 different services that seniors will now need to get pre-approval for include:

• Arthroscopic lavage and arthroscopic debridement to treat osteoarthritis sufferers
• Bioengineered skin substitutes applied to chronic non-healing wounds affecting the lower limbs
• Cervical fusion surgery
• Deep brain stimulation that treats Parkinson's and essential tremor
• Electrical nerve stimulators
• Epidural steroid injections (except for facet joint injections) for pain management
• Hypoglossal nerve stimulation that treats obstructive sleep apnea
• Impotence treatment
• Incontinence control devices
• Percutaneous image-guided lumbar decompression to treat spinal stenosis
• Percutaneous vertebral augmentation
• Phrenic nerve stimulator
• Sacral nerve stimulation to treat urinary incontinence
• Skin and tissue substitutes
• Surgically induced lesions of nerve tracts
• Vagus nerve stimulation
• Wound application of cellular/tissue-based products for lower limbs

Seniors who were using these services and are in a state implementing the WISeR pilot program may lose access to this care entirely if they can't get pre-approved. This could mean they have to pay for the costs out of their retirement plans.

Which retirees are affected by Medicare's new restrictions?

The six states that are participating in the pilot program include:

• Arizona
• New Jersey
• Ohio
• Oklahoma
• Texas
• Washington

Around 6.4 million retirees have traditional Medicare in these states, so the new rules will begin impacting them immediately as they went into effect on Jan. 1, 2026. Retirees should be aware of these restrictions so they can understand the impact on their healthcare needs.

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