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The Trump administration has established a pilot program to expand prior authorization requirements within traditional Medicare, one of the most significant shifts in how the system processes medical care.
Traditionally, Original Medicare (Parts A and B) has offered seniors and eligible individuals a streamlined path to procedures and treatment, with minimal bureaucratic overhead and few hurdles to cross before care is delivered. The new pilot, however, will roll out in January across six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, and introduces an AI-supported approval process for a specific set of procedures.
For beneficiaries, pairing Original Medicare with a Medigap plan can help cover out-of-pocket costs and provide financial peace of mind, even as new approval requirements are rolled out.
What the Pilot Program Does
Under the plan, private firms will use artificial intelligence to prescreen claims for procedures such as skin and tissue substitutes, certain nerve-stimulator implants, deep-brain stimulation and arthroscopy for knee osteoarthritis.
Supporters within the administration say the pilot is crucial to curbing waste, fraud and abuse, referred to as the Wasteful and Inappropriate Service Reduction (WISeR) Model. They cite rapidly rising spending for certain treatments, such as skin substitutes, whose Medicare payments have more than doubled in recent years.
They believe Medicare can cut unnecessary expenses and protect taxpayer dollars by reviewing high-cost procedures before they are performed.
But some Congressional Democrats say expanding prior authorization in traditional Medicare could backfire. It’s meant to save money, but it can slow care, add extra work for healthcare professionals and make it harder for patients to get the treatments they need. Many people pick traditional Medicare because it lets their providers, not insurance companies, call the shots on their care.
Where Medigap Fits In
Medigap, or Medicare Supplement Insurance, can be a real safety net for people worried about extra costs. These private plans work alongside Original Medicare to pick up things like deductibles, coinsurance and copayments, which can add up fast if you’re sick or need ongoing care.
What makes Medigap especially appealing is that it doesn’t add another layer of red tape. Because it’s tied to Original Medicare, there aren’t extra prior authorization hoops to jump through, and you’re not restricted to a narrow network of doctors. If Medicare covers a service, Medigap helps pay the leftover costs.
If you want to get ahead of the game and search for potential Medigap options, here are some solid options:
- MedicareSupplement.com: MedicareSupplement.com isn’t an insurance company. It’s a site that helps you compare Medigap plans in your area so that you can see what each plan covers, how much it costs and which one might be the best fit
- Blue Cross Blue Shield (BCBS): It offers Medigap plans in most states to help cover costs that Original Medicare doesn’t, like copays, coinsurance and deductibles. Depending on your state, some plans also include extra benefits, like dental or hearing. With multiple options and an extensive network of doctors, finding a plan that works for your budget and needs is easier.
- Humana: Humana provides most of the standard Medigap plans, and they’re available in all 50 states plus Washington, D.C., and Puerto Rico. Many plans include extra benefits, like discounts on hearing, vision or fitness programs.
What Medigap Covers—and Doesn’t
Each Medigap plan is standardized and identified by a letter from A to N, making knowing exactly what coverage you’re getting easier. Popular options like Plan G cover most Part B coinsurance, making healthcare costs more manageable and reducing patients’ financial stress.
But Medigap doesn’t cover everything. It won’t pay for vision or dental services, long-term nursing home care or hearing aids. And importantly, it does not eliminate the prior authorization requirement itself. Instead, its strength lies in ensuring that when Medicare approves care, patients don’t face unexpected bills or heavy out-of-pocket costs.
Bottom Line
The proposed Medicare pilot aims to leverage AI-assessed prior authorizations to rein in excessive or inappropriate use of specific costly procedures. While the effort has fiscal rationale, it raises concerns about access for vulnerable patients.
For those on original Medicare, pairing coverage with a Medigap plan won’t override the new rules. Still, it can provide peace of mind, ensuring smoother access to approved services and protecting patients from surprise costs in an increasingly complex system.
