Retirees in These 6 States Face New Limits on Medicare Coverage

Retirees who are 65 and over can choose between traditional Medicare and Medicare Advantage programs.

Traditionally, one big benefit of traditional Medicare has been that prior authorizations are very rarely required. This makes it easier for patients to get the care they need, since their insurance company does not have to approve it first.

Now, however, a new pilot program is launching in six states that will necessitate prior approval for 17 covered services. This program could make it harder for retirees in these six states to get the medical help they want.

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Medicare recipients in these six states face new obstacles before getting care

The new preapproval requirements will affect Medicare beneficiaries in the following six states:

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

There are around 6.4 million Americans enrolled in traditional Medicare in these locations. They are now part of a pilot program that uses artificial intelligence to determine if they can get certain kinds of care paid for.

The program is called the Wasteful and Inappropriate Service Reduction (WISeR) model. It is a major change that makes traditional Medicare much more like Medicare Advantage, which is a private alternative that relies much more on pre-authorizations.

What medical services does Medicare now need to pre-authorize?

The pilot program specifically requires pre-authorization for 17 different medical procedures. The services that are now subject to pre-authorization requirements include:

• Arthroscopic lavage and arthroscopic debridement for the knees of osteoarthritis
• Bioengineered skin substitutes applied to chronic non-healing wounds on the lower limbs
• Cervical fusion surgery
• Deep brain stimulation to treat essential tremor and Parkinson's disease
• Electrical nerve stimulators
• Epidural steroid injections, except facet joint injections, which are used for pain management
• Hypoglossal nerve stimulation to treat obstructive sleep apnea
• Incontinence control devices
• Impotence diagnosis and treatment
• Percutaneous vertebral augmentation
• Percutaneous image-guided lumbar decompression for spinal stenosis
• 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

The new pre-authorization requirements have caused concerns among advocates about access to care. Multiple Democratic senators tried to block the program from being implemented, with Senator Patty Murray of Washington stating: "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."

Despite these concerns, the pre-authorization requirement begins this January, and retirees must be aware of the new restrictions. If they cannot get the services approved by insurance, they may need to rely on their retirement plans to cover the cost.

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