Understanding the New Medicare Preauthorization Pilot: What Agents Need to Know

If you’re an insurance agent, advisor, or just someone who loves to stay on top of Medicare changes, episode 85 of the Insurance Business Babes podcast is a must-listen.

Hosts Joanna Wyckoff and Kathe Kline dive deep into Medicare’s new pilot program for prior authorizations on certain Part B services—sparking lots of questions (and a bit of anxiety) among agents and clients alike. Here’s a summary and further commentary on what you need to know.

What’s Changing and Where?

This new prior authorization program doesn’t signal an immediate, nationwide overhaul; for now, it’s a six-year pilot launching in 2026, affecting just six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Importantly, it targets only specific services, not everything under Part B. As Joanna reassured, “It’s not a complete change across the board,” so there’s no need to panic—yet".

Which Services Are Included?

There’s a preliminary list of 17 service categories that will require prior authorization, including procedures like knee arthroscopy, spinal fusion, epidural steroid injections, implants for sleep apnea, and expensive wound care products. Many of these (like knee scopes and advanced wound care) have been flagged for possible overuse and abuse in the past.

Kathe pointed out how this pilot likely aims to rein in unnecessary spending, similar to how the system already handles powered wheelchairs or certain prosthetics nationwide.

Impacts for Agents and Clients

Joanna stressed the need for communication: If you have Med Supp clients in the affected states, you should proactively reach out to prepare them—before they hear from a competitor. It’s crucial to clarify that Med Supp plans still can’t require their own prior authorizations; the requirement comes from Medicare itself.

For now, most “normal” Part B services won’t require pre-auth, and providers demonstrating “clean requests” may even earn exemptions. AI programs will help process authorizations, but final decisions should still involve a human touch.

Looking Ahead

Though limited for now, both hosts agreed agents should keep a close eye on this pilot. The landscape could shift significantly if results push Medicare to roll out prior authorizations nationwide. Stay informed, keep your clients prepared, and remember—clear, early communication keeps your relationships strong.

This episode is sponsored by ⁠CertifiedMedicareAgents.com⁠. Use the coupon code BABES2024 for a free lifetime BRONZE membership.