01/15/2026

Ohio Included in Medicare Prior Authorization Pilot

On January 1, 2026, the Centers for Medicare and Medicaid Services began to require prior authorization for certain services under traditional Medicare in Ohio and five other states. The change is part of a six-year federal demonstration focused on reducing fraud, waste, and clinically unsupported care.

The pilot - known as the Wasteful and Inappropriate Services Reduction (WISeR) Model - applies only to fee-for-service Medicare and does not affect Medicare Advantage plans.

What You Need To Know

• Seventeen Medicare-covered procedures now require prior authorization in Ohio.
• The requirement applies to traditional Medicare, including beneficiaries with Medigap Plan G or Plan N.
• Providers must obtain CMS approval before delivering covered services, or claims may be denied.
• CMS estimates up to 25% of U.S. health care spending is tied to low-value or unnecessary care.
• Reviews will use technology-supported clinical screening, including artificial intelligence tools.
• CMS has stated reviewers are not paid based on denials, limiting financial incentives to restrict care.

What Happens Next

• Prior authorization applies to services delivered on or after January 1, 2026.
• CMS will track spending, utilization, access, and outcomes through December 31, 2031.
• If CMS deems the model effective, the agency may expand it nationally or make it permanent.
• Provider advocates have raised concerns about care delays, particularly for rural and resource-limited organizations.

What to Do

• Confirm whether your services are included in the WISeR procedure list.
• Adjust ordering and scheduling workflows to account for authorization timelines.
• Track delays and denials to identify access or operational concerns.
• Communicate clearly with individuals and families about potential timing impacts.
• Document and share real-world effects with state and federal policymakers if care is delayed or disrupted.

CMS maintains details and the full list of affected procedures on its WISeR model information page. LeadingAge Ohio will continue to monitor implementation and share Ohio-specific guidance as it becomes available.

Related: House lawmakers debate, sharply disagree with new AI-driven prior-authorization used with WISer.