In This Newsletter . . .

Medicare prior authorization model

Am I required to pay for this test?

Is Medicare going away?

Are weight loss drugs safe for people over 65?

Are you being scammed by AI (artificial intelligence)?

Prior Authorization Coming to Original Medicare?

The Prior Authorization for OM (original Medicare)  is a test/trial for 17 procedures and only in 6 states initially.

17 services to be subject to prior authorization

Here is the list of services that will go through a prior authorization process in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, between January 1, 2026, and December 31, 2031.

Electrical nerve stimulators

Sacral nerve stimulation for urinary incontinence

Phrenic nerve stimulator

Deep brain stimulation for essential tremor and Parkinson's disease

Vagus nerve stimulation

(see link below for more detail)

Prior Authorization Coming to Traditional Medicare Starting in 2026

The Centers for Medicare and Medicaid Services (CMS) will implement prior authorization requirements for certain traditional fee-for-service Medicare services in six states starting next year.

https://www.kiplinger.com/retirement/medicare/prior-authorization-coming-to-traditional-medicare

This test is part of the WISeR model implemented to identify and lower waste and improve outcomes.

WISeR (Wasteful and Inappropriate Service Reduction) Model | CMS

Wasteful and Inappropriate Service Reduction (WISeR) Model webpage

https://www.cms.gov/priorities/innovation/innovation-models/wiser

This is NOT the same as common prior authorization requirements employed by MA plans to delay and/or deny paying claims submitted by your provider.

Prior authorization is very common in Medicare Advantage plans. Nearly all enrollees (99%) are in plans that require prior authorization for some services. This contrasts with traditional Medicare, where prior authorization is less common, primarily for a limited set of services. 

Prior authorization in Medicare Advantage plans is often used for higher-cost services like inpatient hospital stays, skilled nursing facility stays, chemotherapy, and Part B drugs. The purpose of prior authorization is to ensure that healthcare services are medically necessary before they are covered by the plan, and it's a tool used by insurers to manage utilization and costs.

Is Medicare Going Away?

No.

In spite of political comments, campaign promises (and warnings), social media threads and late night TV comedians who are not funny and losing their jobs . . . Medicare (and Social Security) and Medicaid are fundamental promises that neither party wants to take away.

These programs are currently being audited to verify that only those who are LEGALLY ELIGIBLE to receive benefits are being paid.

Medicare is a federal health insurance program primarily for individuals aged 65 or older, some younger people with disabilities, and individuals with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

Eligibility for Medicare for non-citizens depends on their immigration status and meeting specific requirements: 

Lawfully Present Immigrants with a Qualified Immigration Status: If a lawfully present immigrant has worked in the U.S. and paid Medicare taxes for at least 40 quarters (about 10 years), they may be eligible for premium-free Medicare Part A (hospital insurance) at age 65 or younger with certain disabilities.

Lawfully Present Immigrants without the Required Work History: They may still be able to purchase Medicare Part A, but they must meet both an age requirement (65 or older) and a continuous lawful residency requirement in the U.S. for at least five years immediately prior to enrolling.

Undocumented Immigrants: Are not eligible to enroll in Medicare, according to KFF and other sources. They are also ineligible for Medicaid, the Children's Health Insurance Program (CHIP), and to purchase coverage through the Affordable Care Act (ACA) Marketplaces.

Various resources . . . use the search phrase “are illegal aliens entitled to receive Medicare”

Am I Required to Pay This Bill?

Original Medicare is different from any other health insurance, including MA (Medicare Advantage), in that you are required to be told IN ADVANCE that there is a possibility Medicare may not pay for your test or procedure.

If the patient prepays the bill (before the claim is filed and adjudicated) they will most likely pay the "full retail" cost of the test or procedure. This will almost assuredly be higher than the repriced Medicare amount if the claim is approved.

Patients with MA don't have a choice, at least where a copay is required and prior authorization is not in play.

The ABN (Advance Beneficiary Notification)  is unique to OM. I have never encountered anything like that with other types of health insurance. Basically, if Medicare does not approve the claim, the patient is not obligated to pay the bill.

Period!

As for providers that require prepay for OM patients, my guess is they tell the patient to pay knowing many will comply.

I have used the same dermatologist for 10 years. Early on they would check my deductible status and ask (tell, actually) to pay $X before leaving. I politely declined, reminding them that Medicare does not require prepayment before the claim is submitted and adjudicated.

I always pay bills AFTER they are submitted to Medicare and I tell my clients to do the same.

Your Protections

If you have Original Medicare, your doctor, other health care provider, or supplier may give you a written notice if they think Medicare won’t pay for the items or services you’ll get. This notice is called an “Advance Beneficiary Notice of Non-coverage,” or ABN. The ABN lists the items or services that your doctor or health care provider expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay.

What can I do if I get this notice?

On the ABN, you’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

Option 1: You want items or services that Medicare may not pay for. Your provider or supplier may ask you to pay for these items or services now, but you also want your provider or supplier to submit a claim to Medicare.

If Medicare denies payment: You’re responsible for paying. However, since a claim was submitted, you can appeal to Medicare.

If Medicare does pay: Your provider or supplier will refund any payments you made (not including your copayments or deductibles).

Option 2: You want items or services that Medicare may not pay for, but you don’t want your provider or supplier to submit a claim to Medicare. You may be asked to pay for the items or services now. Because you asked your provider or supplier not to submit a claim to Medicare, you can’t file an appeal.

Option 3: You don’t want the items or services that Medicare may not pay for, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.

The ABN is designed to protect you from having to pay for claims that are not APPROVED BY MEDICARE.

https://www.medicare.gov/basics/your-medicare-rights/your-protections

Read carefully . . .

Are GLP-1 Weight Loss Medications Safe for People Over 65?

GLP-1 weight loss drugs such as Ozempic, Wegovy, Mounjaro, and Zepbound have grown in popularity to help people drop pounds quickly, but the medications could cause health concerns for those 65 years of age and older. The drugs can be very beneficial for people of all ages who are trying to reach a healthy weight. However, we realize medication alone won’t address behaviors, so we prioritize healthy lifestyle modifications, with the drugs, or without.

We know these GLP-1 weight loss drugs can be effective for older adults, but it’s not clear how they might affect this population in the long term. Clinical trials on these medications have not included large numbers of older adults. We also know people over 65 tend to be more prone to drug side effects in general. As I consult with older people who are taking the medications, I make sure they know the possible hazards

https://harborhealth.com/blog/health-tips/are-glp-1-weight-loss-medications-safe-for-people-over-65

AI SCAMMER VIDEO

Please watch . . .

Bonus Thought for the Day

In Closing . . .

This is a longer newsletter than normal but I hope you find it informative.

I had planned a letter devoted entirely to hospice but decided to postpone it, probably to next year. There is a general avoidance of openly discussing death and dying . . . along with preplanning for an event most of us will face at some point.

We have a neighbor who was here 30 years ago when we moved in. She is in her mid 90’s, has alzheimers, and is currently being cared for by her immediate family plus part-time home health care worker. This is a daily reminder to Rachel and I about the circle of life and ways to address the aging process.

A reminder that the Medicare open enrollment starts October 15th and ends on December 7th. So many changes coming up as well as administrative SNAFU’s that happened last year have forced me to make changes in how I will take care of my clients this fall. I will still run PDP reports on request but in order to avoid enrollment problems from last year I will need as many as possible to self enroll in a new plan via their MyMedicare account. 

Detailed instructions will be provided in future newsletters.

The dog days of summer are not far away. Stay active and healthy.

Take care,

Bob & Rachel