New Prior Authorization Rule: What Seniors with Original Medicare Need to Know

Written by: Jamon White

If you have Original Medicare (Parts A and B), big changes are coming in 2026 that could affect how you receive medical care. Starting January 1, 2026, prior authorization (PA) will be required for certain medical procedures, tests, and treatments. This means Medicare will need to approve some services before they’re covered, which could impact how quickly you get the care you need.

What Does This Mean for You?

Prior authorization means that before you can receive certain treatments or tests, Medicare will need to approve them first. If prior authorization is required, your doctor will need to submit a request to Medicare for approval. This step was not always necessary before, but with the changes coming in 2026, many services will now require this additional approval.

Which States Will Be Affected First?

While the changes will eventually roll out nationwide, the first states to be impacted by the prior authorization changes starting January 1, 2026, will be:

• California

• Florida

• Texas

• New York

• Pennsylvania

If you live in one of these states, you will immediately see the impact of these changes in 2026.

These states will be the first to experience the full effect of the new prior authorization process. If you're in one of these states, you may experience delays or additional steps in getting approvals for certain treatments, surgeries, or tests. It's important to be aware of this so you can plan ahead and avoid unnecessary hold-ups in care.

Which Procedures Are Affected?

Here are the types of procedures, tests, and services that may require prior approval under the new rules:

1. Surgical Procedures: Certain elective surgeries, such as knee replacements and spinal surgeries, will need prior authorization.

2. Medical Tests: Diagnostic tests like MRIs, CT scans, and PET scans will require Medicare’s approval before you can have them.

3. Durable Medical Equipment: Items like wheelchairs, oxygen tanks, and prosthetics will likely require prior approval to be covered.

4. Home Health Services: If you require home health care, such as nursing care or physical therapy, it may need prior approval.

5. Expensive Medications: High-cost medications, like chemotherapy or biologic drugs, may need to be approved by Medicare first.

6. Outpatient Services: Certain outpatient treatments like physical therapy or sleep studies may also require prior authorization.

   
   

Why Are These Changes Happening?

Medicare is implementing these changes to better manage healthcare costs and ensure that services are medically necessary. By requiring prior authorization for certain procedures, Medicare hopes to reduce unnecessary treatments and tests, and ensure that you receive the care that is both effective and cost-efficient.

What Should You Do Now?

1. Talk to Your Doctor:

   • If you're in one of the affected states (California, Florida, Texas, New York, or Pennsylvania) and have upcoming procedures, treatments, or tests, ask your doctor if prior authorization is required. Your doctor will submit the request to Medicare for approval.

2. Plan Ahead:

   • Expect delays. The prior authorization process can take time, so it’s important to schedule appointments early. Make sure to give yourself enough time for Medicare’s approval before moving forward with treatments.

3. Review Your Medicare Notices:

   • Check your Medicare Summary Notice regularly to see if prior authorization is needed for any upcoming services.

4. Need Help? Reach Out to Us!

   • If you have questions or need guidance on how the new prior authorization rules will impact you, Four Oaks Medicare Planning is here to help. We’ll make sure you understand the changes and help you navigate the process.

     
     

Bottom Line:

Starting January 1, 2026, prior authorization will be required for many services under Original Medicare in California, Florida, Texas, New York, and Pennsylvania. If you live in one of these states, you need to be prepared for the delays and additional steps involved in receiving care.

We recommend planning ahead for any upcoming procedures and staying in close communication with your doctor to ensure a smooth process.

Remember, Four Oaks Medicare Planning is here to help you understand these changes and guide you through the transition—don't hesitate to reach out!