The Centers for Medicare & Medicaid Services (CMS) has announced a new pilot program that could change how older adults in Ohio access care. The Wasteful and Inappropriate Service Reduction (WISeR) Model is scheduled to begin January 1, 2026, in six states, including Ohio.
For the first time, traditional Medicare beneficiaries will face broad prior authorization requirements. About a dozen procedures—such as epidural steroid injections, knee arthroscopy, and cervical fusion—will require pre-approval. Historically, traditional Medicare has been free of these hurdles, which were more common in Medicare Advantage plans.
For Ohio’s nonprofit aging service providers, the implications are significant. Providers may see longer stays or delayed discharges if residents cannot access pain management or surgery in a timely way. Skilled nursing facilities, hospice programs, and home health agencies may need to devote more staff time to helping residents and families navigate new requirements and appeals.
CMS states that WISeR is designed to reduce waste and ensure services are medically necessary, with all denials reviewed by a licensed clinician. Critics, however, worry that artificial intelligence tools could worsen disparities for underserved communities. Others raise concerns that contractors’ financial incentives to deny claims could limit access to needed care.
Nonprofit providers should begin preparing now by identifying residents most likely to be affected, updating care planning protocols, and connecting with organizations that support appeals, such as the Ohio Senior Health Insurance Information Program (OSHIIP) and the Medicare Rights Center. Documenting cases of delays or denials will also be key for advocacy efforts.