New Medicare Pilot Program in Ohio

CLEVELAND, Ohio — A new Medicare Pilot program is set to launch next year in Ohio and other states, potentially reshaping how older Americans receive specific medical treatments. This initiative has sparked varied reactions from doctors, patient advocates, and some lawmakers.

Experts in health policy have noted that Medicare recipients should be aware that getting approval for certain procedures could take time, alongside the possibility that caregivers will have to submit additional documentation for prior approvals.

This model, referred to as the futile and inappropriate service reduction (smart) approach, originated from the Trump administration’s efforts to curb fraud, waste, and abuse in traditional Medicare. It mandates prior approval for around 12 procedures, which officials claim could save billions annually.

Ohio is among six states participating in this six-year study, which will start in January. However, there’s mounting opposition from Congress regarding the program’s funding, with advocates warning that it might hinder timely care for vulnerable patients.

To help people familiar with traditional Medicare navigate this change, here are some tips and institutions to assist them in filing complaints if their care is denied.

This information has been provided by the Medicare Policy Initiative at Georgetown University, the Center for Medicare Advocacy, and the affordable healthcare advocacy organization Wukan Ohio.

• Check the List of steps to determine if your needs require prior approval under traditional Medicare in 2026.
• Clarify whether your health plan is the original Medicare or has additional Medicare benefits, as only original Medicare is impacted by this program.
• Discuss with your healthcare provider about transitioning to traditional Medicare and the implications of advance permissions.
• If you’re denied treatment, review Medicare documents to understand the reasons behind it.
• Follow the appeal process and don’t hesitate to get help from the providers who initiated your care.

Where to seek assistance:

• Centers for Medicare Advocacy – Aids seniors and people with disabilities in navigating the Medicare system.
• Ohio Senior Health Insurance Information Program (OSHIIP) – Offers free and unbiased health insurance guidance and personal counseling to Medicare beneficiaries.
• Aging Life Care Association – Features over 2,000 professional life care managers who can assist seniors and their families.
• Cuyahoga County Senior and Adult Services Division – Provides support and resources for seniors and adults with disabilities.
• Medicare Rights Center – Offers professional counseling for Medicare recipients and their families. The national helpline can be reached at 800-333-4114.
• National Association of Elderly People’s Lawyers – A professional group focused on improving legal services for seniors and individuals with disabilities.
• National Council on Aging – Provides resources to promote health and financial security, including Medicare assistance.
• Ohio Club of Aging – Supplies resources for older adults, caregivers, and professionals in Ohio.

Key steps to consider

This new Medicare initiative targets billing practices including pain management, electrical nerve implants, surgical replacements, incontinence devices, steroid injections, knee arthroscopies, and treatments for impotence. However, hospital admissions and urgent care procedures are excluded from this requirement.

Federal officials project that implementing prior approvals could save approximately $5.8 billion in Medicare spending. They argue this step will confirm that services are medically necessary.

Concerns about AI involvement

The initiative has generated attention for incorporating artificial intelligence in billing evaluations. The AI system is set to analyze patient records to decide if procedures meet coverage criteria. Officials emphasize that denials must be validated by licensed professionals, not solely by algorithms.

Despite this assurance, patient rights groups and health policy experts are concerned that AI reliance might intensify existing inequalities. Studies indicate that algorithms built on biased data can perpetuate disparities, especially affecting aging populations and ethnic minorities.

Critics highlight the financial motivations for companies managing this program, as they stand to benefit from cost savings achieved through rejected claims.

Supporters counter with their concerns

Those in the healthcare field, including doctors and advocates, contend that this change could significantly hinder access for patients dependent on traditional Medicare. Presently, original Medicare typically does not mandate prior approvals, a stark contrast to Medicare Advantage Plans and many private insurers.

Judith Stein, founder of the Centers for Advocacy at Medicare, expressed concern over the potential disconnect between what healthcare providers recommend and what algorithms permit. This shift, she asserts, risks prioritizing cost savings over patient needs.

Charlottldorf, director of Wukan Ohio, voiced a strong sentiment: “We save money at the cost of our patients,” highlighting that Medicare recipients often belong to the most vulnerable groups in Ohio.

Wider implications for prior approvals

The pilot program reignites discussions on advance approvals, a contentious aspect of the U.S. healthcare landscape. Proponents claim it can help manage costs and prevent ineffective treatments affecting over 65 million individuals nationwide.

However, opponents argue that this system frequently delays necessary care, adds to administrative burdens for doctors, and can leave patients with unexpected medical bills if claims are denied. A survey from KFF in 2023 revealed that almost one in five insured patients had a claim rejected within the past year, with Medicare Advantage members also facing significant challenges.

In 2023, about 12% of denials in the Medicare Advantage program were appealed, and over 80% of those appeals were successful, according to the Centers for Medicare Advocacy. Nonetheless, many patients do not dispute their rejections, often due to the perceived complexity of the process. Providers, already inundated with red tape, can find it challenging to assist patients in navigating these hurdles.

Blurring the lines between types of Medicare

This pilot initiative blurs the often clear lines distinguishing traditional Medicare from Medicare Advantage plans. For many seniors opting for traditional Medicare to avoid administrative complexities, the push toward prior approvals shifts that landscape, potentially coercing them into Advantage plans that offer added benefits like dental and vision coverage.

In Ohio alone, over half of Medicare recipients are enrolled in Medicare Advantage plans, as noted by HealthInsurance.org.

Executive director of Georgetown University’s Medicare Policy Initiative, Carrie Graham, remarked that these proposed changes seem like backdoor tactics to funnel everyone into Medicare Advantage plans, undermining the original Medicare’s freedom of choice.

Increased scrutiny of insurance companies

This ongoing dialogue occurs amid heightened scrutiny of insurance companies’ practices. Following the 2024 incident involving UnitedHealthcare CEO Brian Thompson, public frustration over denied claims has gained significant media attention, including a class action lawsuit against the company for an AI system’s alleged role in denying care for elderly patients.

Reports emphasize the growing dependence on algorithms among insurance firms, raising concerns that patients might be unaware that many claim denials result from machine decisions.

Looking ahead

The Wiser model is set to commence in January, though Congressional pushback may delay or complicate its implementation. Skeptical lawmakers are questioning whether it is appropriate for AI to play such a pivotal role in medical decision-making.

Federal officials maintain that this initiative is necessary to address rising Medicare costs, which affect over 2.5 million individuals in Ohio alone. They assure that all rejections related to the program will undergo review by qualified human clinicians, and that critical or life-threatening care requests will not face delays.

Yet, this resistance underscores the struggle to find a balance between cost control and access to care within one of the nation’s crucial social programs. For patients depending on certain treatments, such changes could lead to longer wait times, more appeals, and growing uncertainty about the coverage of their care.