Jacksonville-based agency tracks national Medicare changes that could impact care access and provider operations in 2026.

For the first time ever, Traditional Medicare will begin requiring prior authorizations for certain services — and while this change may not hit Florida first, it’s a sign of where things are headed.

📢 On June 26, 2024, the Centers for Medicare & Medicaid Services (CMS) announced the launch of the WISeR Model, short for Wasteful and Inappropriate Service Reduction. This pilot program will bring prior authorization requirements to Original Medicare beneficiaries in six states beginning January 1, 2026.

The WISeR Pilot States:

• Arizona

• New Jersey

• Ohio

• Oklahoma

• Texas

• Washington

(Source: Federal Register Notice – WISeR Model)

What’s the Goal?

The WISeR Model is designed to reduce unnecessary, overused, or fraudulent services within Traditional Medicare by introducing prior authorization for 17 high-risk outpatient services, including:

• Spinal and joint injections

• Advanced imaging like MRIs and CT scans

• Hyperbaric oxygen therapy

• Knee arthroscopies

• Spinal fusions

These procedures were flagged through CMS data reviews and audits as vulnerable to overuse, billing errors, or potential fraud.

Why This Matters for Jacksonville, Florida

While Florida isn’t part of the pilot program, we are a hub for retirees, snowbirds, and Medicare beneficiaries who could be affected in several ways:

1️⃣ Our Clients Span Across the U.S.

At Mere Benefits, we’re proud to be a Jacksonville-based insurance agency serving clients in Texas, Arizona, and New Jersey — three of the six states selected for the WISeR pilot.

Whether you live in Florida full-time or split your time between Florida and one of those states, this may affect your access to care in the future. And if the WISeR pilot is expanded, Florida could be next.

2️⃣ Jacksonville Providers Should Be Paying Attention

Even if your practice is based in Florida, changes like this often set a precedent for broader CMS rulemaking. If you’re a:

• Skilled nursing facility

• Imaging center

• Orthopedic provider

• Pain management clinic
  

...you’ll want to prepare for potential operational shifts—especially if your practice has locations or referrals in any of the WISeR states. Expect more documentation, longer timelines, and new administrative strain.

What This Means for You

• Delays in Care: Patients may wait longer for procedures while authorizations are reviewed.

• Provider Pushback: Skilled nursing facilities and outpatient providers may face denied claims, appeals, and more overhead.

• Increased Confusion: Many seniors chose Original Medicare to avoid prior authorizations. That clarity is eroding.

How We Help at Mere Benefits

As a licensed health insurance agency headquartered in Jacksonville, we provide no-cost, no-obligation support to Medicare beneficiaries across the U.S.

We:

• Track CMS rule changes and enrollment period shifts

• Explain how policy updates like WISeR may affect your choices

• Work directly with clients and providers to help avoid coverage gaps or care delays

• Serve as your ongoing advocate — not just a one-time sign-up helper

We understand how frustrating prior authorizations can be, and our job is to make sure you’re prepared for what’s ahead — with confidence.

💬 Let’s Talk

Whether you live in Jacksonville full-time, split time between Florida and one of the WISeR states we serve, or you’re a provider preparing your office for policy shifts…

We’re here to help.

📞 Call us: 904-654-5450
🌐 Visit: www.merebenefits.com
📧 Email: [email protected]

#simplyforyourbenefit
Kate Spilsbury, RSSA®