Plans must deliver Annual Notice of Change packets to current enrollees by September 30 and non-renewal notices on required timelines, which means the first wave of plan-exit calls reaches case management inside four weeks. The reflex answer — they are going back to Traditional Medicare, so the plan's prior-authorization process goes away — is incomplete in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, where the WISeR Model applies prior authorization or prepayment review to selected services in fee-for-service Medicare.
Annual Notice of Change packets must be delivered to current enrollees by September 30, 2026. Members affected by a plan non-renewal or service-area reduction receive a separate CMS-required notice with enrollment rights and deadlines. The precise timing depends on the type of non-renewal or termination. Medicare Plan Finder is expected to refresh with 2027 plan data around October 1, and Annual Enrollment opens October 15.
That is the calendar. The operational fact underneath it is that in many provider organizations, case-management and clinical teams receive the first calls from patients whose immediate concern is continuity of treatment rather than plan selection — because the person reading the letter is frequently already in a course of treatment and their first question is not "what plan should I pick" but "does this stop my infusion."
The volume of those calls may be higher than last year, particularly in markets affected by non-renewals or service-area reductions. UnitedHealthcare reported roughly 7.565 million Medicare Advantage members as of June 30, 2026, against roughly 8.445 million at the end of 2025, and has circulated a preliminary 2027 exit list covering 34 counties across 12 states, weighted toward PPO products. Humana signaled on its July 29, 2026 earnings call an intent to exit 2027 plans covering roughly 8% of its 7.2 million Medicare Advantage members.
The reflex answer is that a patient returning to Original Medicare will no longer face the plan's prior-authorization process. For selected WISeR services in six states, however, the patient may enter a CMS model-specific prior-authorization or prepayment-review pathway instead.
The Wasteful and Inappropriate Service Reduction (WISeR) Model runs six performance years, January 1, 2026 through December 31, 2031, in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. It is a CMS Innovation Center model that applies prior authorization or prepayment review to a pre-selected set of items and services in Original Medicare. CMS names skin and tissue substitutes, implantation of electrical nerve stimulators, and arthroscopic lavage or debridement for osteoarthritic knees as examples of the selected services.
The word CMS uses is "voluntary," and it is worth being precise about what that means operationally. A provider may submit a prior authorization request for an included service, or not. If they do not, the claim goes into the model's prepayment-review pathway. The operational choice is not whether to engage the WISeR process; it is whether to seek an affirmative decision before furnishing the service or submit the claim into the model's prepayment-review pathway. For a UR desk, that is not a choice about administrative burden. It is a choice about where the denial risk sits on the revenue cycle.
The model excludes inpatient-only services, emergency services, and services that would pose substantial risk to the patient if delayed. Coverage and payment policy do not change — WISeR is a review process layered onto existing coverage criteria, not a new benefit rule. And it does not touch Medicare Advantage members at all.
A WISeR non-affirmation is not itself appealable. If the provider furnishes the service and the resulting claim is denied, the provider may use the ordinary Medicare claims-appeal process. That distinction is essential for revenue-cycle operations.
Prior authorization desks are organized by payer. That is the correct organizing principle when every auth requirement belongs to a plan. WISeR is not organized that way.
CMS's operational guide describes submission pathways through the relevant model participant and, in certain workflows, through the MAC. Each participant covers a MAC jurisdiction: Cohere Health in Texas (JH Novitas), Genzeon in New Jersey (JL Novitas), Humata Health in Oklahoma (JH Novitas), Innovaccer in Ohio (J15 CGS), Virtix Health in Washington (JF Noridian), and Zyter in Arizona (JF Noridian). Use the participant-specific instructions in the current guide for the actual submission route, as CMS has updated the guide's participant contact and operational information over time. The routing key is state, then MAC jurisdiction, then service code — not member, not plan.
That means the intake question your staff asks has to change. "What's the insurance?" resolves nothing here, because the answer is Traditional Medicare and the answer is also that an auth may be required. The question that resolves it is where the service is being furnished and what the code is.
There is also a review-standard difference worth naming for your physician advisors. CMS states that all recommendations for non-payment are made by appropriately licensed clinicians applying standardized, evidence-based procedures, with the enhanced technology used to expedite the review rather than to issue the adverse determination. Participants are paid a percentage of expenditures associated with averted inappropriate care, adjusted on performance measures that include provider experience.
CMS has established an exemption program intended to reduce burden for eligible providers and suppliers. Because eligibility and operational criteria may change, organizations should consult the current WISeR Operational Guide rather than treat "gold card" as a fixed statutory entitlement.
Take a composite: a patient in a non-renewed PPO in a WISeR state, on a wound care course involving a skin substitute, whose treatment plan spans December 31. Nothing about the wound changes on January 1. Everything about the authorization pathway does. The plan-based auth that covered the December applications is gone; the January applications sit in a different review process, run by a different entity, against the applicable Medicare coverage and documentation requirements, including relevant NCDs, LCDs, and WISeR guidance.
The enrollment side of that patient's decision has its own overlapping deadlines: Annual Enrollment October 15 through December 7, and a non-renewal special enrollment period for affected members. Some members affected by a qualifying MA plan termination or service-area reduction may have federal or state Medigap guaranteed-issue rights. The specific window and available policy options depend on the termination circumstances and state law. A member who loses MA coverage and does not make a timely new election may face fragmented coverage decisions: Original Medicare, Part D, and Medigap are separate choices, with separate deadlines and eligibility rules — which is a discharge planning problem in February, not an enrollment problem in October.
The four weeks before ANOC letters land is the window to do three things: pull your WISeR-state volume for the included service codes, confirm which of your service lines will be routing to a model participant versus a MAC, and rewrite the one-sentence answer your staff gives when an attending asks whether a fee-for-service patient needs an auth.
The question to bring to your next UM committee is narrower than it sounds. For the included services in your WISeR states, is your default going to be pre-service authorization or prepayment review — and if you have not decided, do you know which one you are currently doing by accident?
Sources: WISeR Model, CMS Innovation Center; WISeR Provider and Supplier Operational Guide (PDF); Examining the Potential Impact of Medicare's New WISeR Model, KFF
Discover how Addie helps health systems, post-acute providers, and payers improve throughput, reduce avoidable days, and deliver better transitions of care.
Get Started
