Medicare Issue: What Texans Need to Know

A reader recently reached out to The Watchdog, asking for information on the Medicare issue and who in the Texas state government is coordinating with the Medicare pilot program. This is a huge issue that affects many Texans, and it’s essential to understand what’s happening.

Starting on January 1, 2026, Texans on Medicare will be required to get prior approval for 17 select medical services. This is part of a pilot program that Texas is participating in, along with five other states: Arizona, New Jersey, Ohio, Oklahoma, and Washington.

The pilot program is not without controversy. Those in favor of the program say that prior approvals will help cut down on fraud and halt payment for unnecessary surgeries, which could save billions of dollars. However, critics warn that this will add another layer of bureaucracy for Texans seeking medical care and could lead to privatizing traditional Medicare.

Texas is essentially a guinea pig in this test, and many are concerned about the impact it will have on the state’s Medicare recipients.

How the Pilot Program Works

The pilot program is called WISeR, which stands for Wasteful and Inappropriate Services Reduction. The goal of the program is to improve patients’ well-being, speed up approvals, increase transparency of Medicare policy coverage, and reduce medically unnecessary care.

Third-party vendors will help administer the program, and they will use artificial intelligence software to help make approval decisions. However, the Centers for Medicare and Medicaid Services promises that humans, not software, will make the final approval decisions.

The program will last for six years, and if it proves successful, it could signal a significant shift in how Medicare operates. This could potentially replace the traditional system that, in most cases, does not require prior authorization for procedures.

Not State-Run

The reader’s question about who in the state government is coordinating with the Medicare pilot program was answered by Texas Health and Human Services spokesperson Thomas Vasquez. He stated that this request is outside the scope of HHSC and that The Watchdog should contact the Centers for Medicare & Medicaid Services for information.

This means that the state of Texas is not directly involved in coordinating the pilot program. Instead, the federal government is taking the lead, with the help of third-party vendors.

Conflict of Interest

David Lipschutz, co-director of the Center for Medicare Advocacy, expressed his concern that the outside vendors, who earn their money based on reported savings, will restrict care so they can make more money. He stated that people have a harder time accessing care when these vendors are used, and that this would be taking some of the worst elements of Medicare Advantage and injecting it into traditional Medicare.

This is a valid concern, as the use of third-party vendors could create a conflict of interest. If the vendors are motivated by profit, they may be more likely to deny care or restrict access to certain services.

List of 17

The 17 select medical services that require prior approval under the pilot program mostly involve pain management. Some examples include electrical nerve stimulators, deep brain stimulation for Parkinson’s disease, some knee surgeries, epidural steroid injections, treatment for impotence, sleep apnea, and spinal stenosis.

It’s essential for Texans on Medicare to be aware of these services and to understand the prior approval process. If a patient completes a service without approval, the insurance company can deny payment.

Exemptions and Exceptions

There are some exemptions and exceptions to the pilot program. Services that are in-patient only and emergencies are exempt from the prior approval requirement. Additionally, services that would pose a substantial risk to patients if significantly delayed are also exempt.

It’s crucial for patients and healthcare providers to understand these exemptions and exceptions to ensure that necessary care is not delayed or denied.

Conclusion

The Medicare pilot program is a significant issue that affects many Texans. While the program’s goals are to improve patients’ well-being and reduce medically unnecessary care, there are concerns about the impact on access to care and the potential for privatizing traditional Medicare.

It’s essential for Texans on Medicare to be aware of the prior approval process and to understand their rights and options. The Medicare hotline is 800-252-9240, and patients can contact this number for more information and assistance.

FAQs

Here are some frequently asked questions about the Medicare pilot program:

Q: What is the Medicare pilot program?

A: The Medicare pilot program, called WISeR, is a six-year program that aims to reduce wasteful and inappropriate services. It requires prior approval for 17 select medical services, mostly involving pain management.

Q: Who is coordinating the pilot program in Texas?

A: The pilot program is not state-run, and the federal government is taking the lead. Third-party vendors will help administer the program, and the Centers for Medicare and Medicaid Services will make the final approval decisions.

Q: What services require prior approval under the pilot program?

A: The 17 select medical services that require prior approval include electrical nerve stimulators, deep brain stimulation for Parkinson’s disease, some knee surgeries, epidural steroid injections, treatment for impotence, sleep apnea, and spinal stenosis.

Q: What are the exemptions and exceptions to the pilot program?

A: Services that are in-patient only and emergencies are exempt from the prior approval requirement. Additionally, services that would pose a substantial risk to patients if significantly delayed are also exempt.

Q: How can I get more information and assistance with the Medicare pilot program?

A: You can contact the Medicare hotline at 800-252-9240 for more information and assistance.