Upcoming Changes to Medicare in Texas

There’s been some chatter about a new Medicare pilot program in Texas, and one reader wants to know who’s in charge. It’s definitely an issue worth following.

Starting January 1, 2026, Medicare beneficiaries in Texas will have to navigate a new requirement: a pre-approval process for certain medical services. This applies to 17 specific treatments.

Texas is one of six states involved in this pilot program. While supporters believe this could cut down on fraud and save billions by reducing unnecessary surgeries, it seems to be stirring up some skepticism.

Critics argue that this new layer of bureaucracy could complicate healthcare access for Texans. There’s also concern that it might lead toward privatizing traditional Medicare.

No State Oversight

People are rightfully asking who’s overseeing this program. The answer? Not a single person in state government, it appears.

A spokesperson from the Texas Department of Health and Human Services, Thomas Vasquez, clarified to Watchdog that this falls outside their jurisdiction and directed inquiries to the Centers for Medicare and Medicaid Services (CMS).

Interestingly, third-party vendors will be helping to run the program, and they plan to use artificial intelligence for some approval decisions. However, CMS assures that humans will make final decisions.

Concerns About Profits

David Lipshutz from the Medicare Advocacy Center expressed worries about these vendors, who get paid based on reported savings. He fears this could lead to restricted care simply for profit.

“When these vendors prioritize their bottom line, it can hinder access to necessary treatments,” Lipshutz commented, noting that it might introduce some negative aspects of Medicare Advantage into standard Medicare.

What Treatments Are Affected?

Most of the selected treatments focus on pain management, including procedures like electrical nerve stimulation, deep brain stimulation for Parkinson’s, certain knee surgeries, and other interventions for sleep apnea and spinal stenosis.

The pilot program is set to run for six years and is officially named WISeR, which stands for Wasteful and Inprofit Services Reduction. CMS claims it aims to improve patient welfare, streamline approvals, increase transparency, and cut medically unnecessary care.

Doctors, represented by the American Medical Association, have expressed concerns regarding the cumbersome nature of the prior approvals they often need to complete.

If a patient goes through with a procedure without prior approval, their insurance company might deny the claim.

When this program was announced in June, Medicare Administrator Dr. Mehmet Oz stated the goal was to tackle “fraud, waste and abuse.”

It’s worth noting that inpatient-only and emergency services will not be affected by this pilot. Certain services that carry a significant risk to patients if delayed will also be exempt, as per government communications.

Alongside Texas, other participating states include Arizona, New Jersey, Ohio, Oklahoma, and Washington. If the pilot program is deemed successful, it could represent a major shift in Medicare practices, moving away from a system that generally didn’t require prior approvals.

If you have questions or need more information, you can contact the Medicare hotline at 800-252-9240.