In this Episode of the Secure Your Retirement Podcast, Radon Stancil and Murs Tariq discuss emerging Medicare policy changes with Medicare specialist Sean Southard, focusing on a new Medicare pilot program introducing prior authorization into Original Medicare. This important conversation highlights how Medicare prior authorization could reshape retiree healthcare, especially for those relying on Medicare and Medigap plans for flexibility and simplicity in their retirement financial plan.

Listen in to learn about how Medicare changes in 2026 may impact Healthcare in retirement, including new Medicare coverage rules and the evolving Medicare approval process. The discussion explains prior authorization explained in simple terms and explores how these changes may affect Medicare costs, access to care, and long-term retirement planning strategies for those looking to retire comfortably and secure your retirement.

In this episode, find out:

• What Medicare prior authorization is and how it changes the current structure of Original Medicare
• Details of the Medicare pilot program launching in select states and what it could mean nationwide
• How Medicare and Medigap plans may be impacted by new Medicare policy changes
• Which procedures may require approval under new Medicare coverage rules
• How these changes could affect your retirement checklist and overall plan for retirement

Tweetable Quotes:

“Prior authorization is about checking before a procedure happens instead of paying first and reviewing later—and that’s a big shift for Original Medicare.” – Murs Tariq

“Even if this starts as a small pilot program, the writing on the wall suggests it could expand and impact how retirees experience Medicare nationwide.” – Radon Stancil

As Medicare for retirees continues to evolve, understanding changes like prior authorization is essential for building a strong retirement financial plan. While the goal of these Medicare policy changes is to reduce fraud, waste, and rising Medicare costs, they may also introduce new administrative steps, potential delays, and added complexity in accessing care.

For those focused on planning retirement, staying informed about healthcare in retirement is just as important as managing investments. Whether you rely on Original Medicare, supplement with Medigap plans, or are evaluating options, being proactive about these changes can help you better plan for retirement, update your retirement checklist, and continue retiring comfortably with confidence.

Resources:

If you are in or nearing retirement and you want to gain clarity on what questions you should be asking, learn what the biggest retirement myths are, and identify what you can do to achieve peace of mind for your retirement, get started today by requesting our complimentary video course, Four Steps to Secure Your Retirement!

To access the course, simply visit POMWealth.net/podcast.

Here’s the full transcript:

Welcome back to the Secure Your Retirement show. And thanks again for joining us. 

The goal of this show is to bring value in a lot of different areas around financial planning 

topics, investments, taxation, and really everything that we come across in our firm, 

questions that we get from clients, questions that we get from people that have been listening to 

us for a while. We just try to make this podcast as educational as possible and deliver as much 

value as we can. One of the bigger topics that we do bring on from time to time is Medicare. 

topic, constantly changing topic. And there’s a lot of things that you need to know, especially as 

you’re entering into Medicare, making the right decisions up front, but then also kind of 

understanding how it’s going to impact your life throughout the years, especially as we do have 

some significant changes around policy and structure. And while that in itself is a mouthful, 

it’s a lot to keep up with. And so, for that reason, in our firm, I’m sure you guys, if you’ve been 

listening to us for a while, you know who Shawn Southard is in our office. He is our health 

insurance professional. He helps people if they retire early before Medicare to think through what 

private insurance and pre-Medicare insurance is going to look like for them. But as they start 

transitioning to Medicare, he helps in a very consultative manner to help them kind of think 

through what’s going to be best for them based off of the lives that they live and what type of 

help they’re going to need on the medical side. And so, Shawn’s got a really great topic for us 

today. So, before we dive in, I just want to say, Shawn, thanks. right now, is, well, it’s always a 

busy time for you. You’re constantly on the phone talking with clients, meeting with clients, 

helping them think through these decisions. So, thanks for carving out some time today for us. Oh, 

you’re welcome, Murs. It’s always great to be here. And I know when we talk about Medicare, you 

always get really giddy. So, I always enjoy the giddy Murs. So, pleasure to be here. 

Well, it’s one nice thing that I don’t have to keep up with Medicare as much as I used to. 

And a big reason of that is we brought Shawn in a few years ago to just really take on that role of 

being that Medicare expert. And so, we really appreciate having him in the firm, and I know our 

clients do too. So on to the topic for today, it’s around prior authorization. Now, 

if you don’t know what prior authorization is, Shawn’s going to explain that throughout the episode. 

But is it coming to Original Medicare? And what do we need to know here in 2026? 

If you’ve been on Original Medicare and have a Medigap plan… this may potentially impact, you. 

And that’s why Shawn brought this topic to me and he said, hey, you know, I think this one is a 

little bit niche and a lot of people, it may not impact, but I think if things are headed the way 

they are, it could be something that everyone should be aware of. And so that’s the whole driving 

reason. to spending about 20 minutes on this podcast today, walking through what’s going on in 

Shawn’s brain. There’s always a lot of things going on in Shawn’s brain. But when it comes to 

Medicare, he said, I think people really need to understand this and know about this. So, Shawn, 

thanks again. Anything you want to add before we dive in? Just to kind of reiterate what you said, 

Murs, I think this is a niche topic. And even though it’s not going to impact everybody at this 

point in time, I do believe the writing on the wall, where the powers that be are going to be 

taking this, I do believe it’s going to get expanded and it’s going to eventually impact. everybody 

in Medicare. So that’s why I really want to spend some time on it today. Okay, well, great. So 

let’s just jump right into it then. So, what’s actually happening? What do you see that’s what is 

changing? Yeah, so basically, starting here in this year, 2026, Medicare is launching a new pilot 

program in six specific states. That’s going to include, it’s introducing prior authorization for 

certain procedures under original Medicare. Because right now, in the original Medicare, 

there really isn’t prior authorization for these procedures. But they’re going to pilot a program 

in six states that’s going to introduce this into the mix. And the states are New Jersey, Ohio, 

Oklahoma, Texas, Arizona, and Washington. Okay, 

so, it’s not nationwide yet. So do you see… Is part of this that you’re worried that it could go 

nationwide? Yeah, as I mentioned, I do think that is going to. It’s going to run through 2031, 

so, it’s five years. And depending on the results, it could expand. I’m fairly certain that it’s 

going to do that. So just remember for the listeners right now, it’s just a pilot program. 

It’s not nationwide yet. It’s applying only to the six states that I mentioned, but it will impact 

the residents of those states that are on original Medicare. They are going to see the impacts of 

this pilot program. Okay. So, then the bigger question becomes why? Why is this happening? 

Why is Medicare running a pilot program? Medicare has been around forever. You would think that 

they’ve got it somewhat figured out. So why a test program? Why now? Yeah, exactly. So, Centers for 

Medicare and Medicaid Services, known as CMS for short, they’re targeting what they call… 

have been calling it for years and years and years, fraud, waste, and abuse. So, breaking that down, 

fraud, billing Medicare, basically fraud in this context is billing Medicare for services that were 

not needed or didn’t even happen. So, there’s a lot of that, unfortunately, going on. Waste, 

which is defined here as overuse of expensive procedures that may not improve outcomes for people, 

but they’re getting done and they’re getting… and then the overall abuse, 

just using services in ways that don’t follow Medicare guidelines. So, with the exponential… 

rise in costs of everything these days, as everybody knows about and is feeling on a day-to-day 

basis, it’s impacting Medicare as well. And they are looking to clean this up, 

see if introducing this prior authorization can help clean this up. Okay. Yeah, I know we did a 

podcast probably a few months ago at this point related to the drug plans and some of the… 

cost changes there to make it a little bit, I guess you could say, more fair across the board on 

prescription drugs. But some people end up paying a little bit more to try to make it a little bit 

fair. But anyways, the topic was that they’re constantly looking at the cost. So it sounds like 

this is a cost measure as well. Is that right? Yes, exactly. It’s really about controlling costs, 

I believe, at the heart of the matter. And also, but it’s also about quality of care. So, 

you know, Medicare has, through this program, identified certain procedures that are high cost. 

And they are many times overused and have a history of questionable billing patterns by providers. 

So, you know, I’m sure people out there are saying, well, why prior authorization, like you said, 

and why now? 

so basically, the premise here is what what they’re saying with the pilot program is instead of 

just having Medicare, original Medicare pay first for things and then review it later, which is. 

the standard procedure, standard operating procedure right now. What they’re saying is let’s put 

the brakes on. We’re going to check before these procedures happen, right? And in doing that, 

we’re hoping to prevent unnecessary procedures to be done. We’re going to reduce improper payments 

out to providers and hopefully catch potential fraud earlier on in the process. 

OK, so, you know, from a from a top-down view, Shawn, it kind of seems like this is something that 

is to get rid of a lot of issues in the system, which are creating additional cost. And so, it all 

sounds pretty good so far. But I think there’s never a perfect solution to anything in most cases, 

especially when in government type of run policy. So, what’s the tradeoff here? 

What are we what are we missing? Yeah, well, there is a trade-off exactly. And, you know, so the 

same system that is looking to stop and prevent fraud and waste and so forth can also, 

you know, bog and slow things down. As we all know, I add, 

of course, administrative hurdles and hula hoops that people have to jump through and overcome and 

create access issues, you know, to providers and procedures if things are not done carefully. 

So, you know, as we know that the overall goal and intention here of CMS and Medicare is to reduce 

the fraud, the waste and the abuse that’s going on within the system. They’re focusing on… 

high risk procedures. 

And then of course, the prior authorization is meant to prevent the problems before they happen. 

But as we know, this may also introduce to us delays and a lot of friction and things for patients 

and getting their continuity of care. Right. Yeah. There’s always, I think when there’s change in 

procedure, change in policy, change in a program, there’s always going to be some element of, 

there’s a lot of well, there’s a lot of nuances and a lot of everyone learning a new way of doing 

things. And that does create friction and issues in any environment. So, it’s just one of those 

things we have to deal with change. But hopefully, you know, it does help out on the cost side 

in the big picture. But you’ve mentioned this term quite a bit throughout so far, 

which is prior authorization. Now, if you go to the doctor a lot, you probably know exactly what 

prior authorization is. But help us kind of understand, you know, what is prior authorization in a 

simplistic manner, Shawn? Absolutely. So, most people, you know, before they get into Medicare, 

being enrolled in employer group health insurance plans and being enrolled in ACA marketplace and 

health insurance plans, if they’re self-employed or if they don’t have employer-based coverage, 

they’re probably used to prior authorization and may not. You may have heard that term 

specifically, but they’ve dealt with it most likely if they’ve had to have procedures and different 

things done throughout their lifetime. So basically, very simply, prior authorization means that 

your doctor or your medical provider may need or will need to get approval before certain 

procedures are actually done. uh you know for you things that they’re going to recommend that you 

need to have done they’re going to need to get approval from the carrier the health insurance 

carrier or Medicare in this case uh if they’re they have to say hey we agree with you that this 

needs to be done and they’re going to they’re going to pay for it um and if they don’t get prior 

authorization, the provider or the doctor, and they go ahead and they do it anyway, 

the plan or Medicare may delay or deny payment altogether in the end. So, it’s really today versus 

the new system, getting back to Medicare beneficiaries. Today, people that are in original Medicare 

do not have to worry about prior authorization. Those on Medicare Advantage are dealing with prior 

authorization, but right now, original Medicare. not the case. However, 

this new system being piloted in these six states, they are going to have to be getting prior 

authorization for certain procedures beforehand and moving forward. 

So that’s kind of the gist here is that original Medicare beneficiaries are going to have to be 

working with prior authorization before procedures are done if they want Medicare to pay. 

Okay. So yeah, then let’s speak to the ones that are original Medicare and have Medigap plans as 

well. Why does this matter for them? Let’s talk to that demographic that’s not on Advantage plans. 

Yeah. So, there’s approximately 73 million people right now enrolled in Medicare. 

And there’s about 35 million. to 38 million people that are on original Medicare with Medigap 

plans. The rest are in Medicare Advantage plans. So, there’s a significant amount of people out 

there that are set up on original Medicare supplemented by a Medigap plan. And many of those people 

that do that structure, that coverage structure, have done it specifically to avoid network. 

issues, provider and hospital network issues, getting access to providers and hospitals. 

Are they in the network? Are they out of the network? They’re looking to avoid referrals from 

primary care to specialists if they need, you know, advanced care or advanced procedures. 

And of course. avoiding prior authorization. They don’t want to have to deal with that 

administrative red tape and so forth. However, this new pilot program, once again, 

that’s why I wanted to talk about it today, is introducing a piece of managed care into original 

Medicare now. So, people that are in that structure are going to have to be aware of it and are 

going to have to start dealing with it. But just know overall key takeaway here that even if you 

are in this this cover structure with original Medicare to Medigap, you still are going to have 

your doctor, your freedom of doctors. You’re going to have nationwide access to providers and 

hospitals, and you’re still going to be able to keep your Medigap plans, and it’s all still going 

to work the same. It’s just that you need to know that some procedures that you may have 

recommended to you or you may need may require some extra steps with this prior authorization. 

Okay. Well, that’s helpful to know. So, I mean, if you’re listening, you’re probably, 

and you’re on Medigap, plans, and you’re probably wondering how this is going to affect the health 

care services that you receive now. So, Shawn, do we know yet what could be impacted as far as 

services to people that are affected by this? There are, 

and there’s not a laundry list, but there’s about 17 to 20 things that are out there. So, people 

can, I’m going to bring up just a few here because I know we’ve got some time. 

We just need to make sure we’re not here for a long time with people on the podcast. 

But some things that are going to be impacted. that are common out there. 

Certain surgeries, such as orthopedic procedures, are going to be involved with this. 

There’s something called cervical fusion, where providers surgically join two or more vertebrae 

together. That’s done to treat severe pain that people are experiencing or herniated discs or nerve 

compression issues. That’s going to fall under this pilot program of Prior authorization. 

Pain injections are going to fall under this. Epidural steroids for one. is going to be impacted by 

it. Nerve stimulator procedures, such as a common one that’s a test that’s used to diagnose carpal 

tunnel syndrome in people, that’s also going to fall under this, and then some advanced wound care 

and so forth. So, these are some of the types of procedures and services that will be impacted by 

the prior authorization pilot program, but routine doctor visits, lab work that people need to get 

done in most everyday care that that they’re needing is not going to be impacted at this point. So 

remember that this is targeting specific higher cost procedures, not every day healthcare 

procedures. Gotcha. So, you know, we sit here in North Carolina, and this is a limited state trial 

that they’re running. I think you said six different states. So, you know, the people listening, 

the bulk of our listeners are North Carolina, but we have people all over the country. actually all 

over the world at this point too, which is pretty cool to say. But, you know, I guess, 

Shawn, for the ones here in North Carolina, it’s not here yet, but help us kind of think through 

just real-world impact to them if this trial was to be a success, and I don’t even know what a 

success looks like in the eyes of the Medicare people, but what’s the real-world impact here? 

Yeah, no, it’s a great thought, a great ask. So, you know, once again, I bring in this up because 

it is niche, but, you know, being involved with Medicare and healthcare for close to 25 years, 

I’ve seen a lot of things happen over this time. And I kind of know the writing on the wall, as 

they say, with a lot of things that are brought up or being talked about. And I do think that… 

that this program is going to expand. So, the challenges that people start to need to prepare for 

with original Medicare, because remember, original Medicare is the primary health insurance and a 

Medigap plan is a secondary payer backing up original Medicare. So, you just need to make sure that 

you’re preparing for possible delays for procedures that you may need. Be patient and know that 

you’re going to have more administrative paperwork involved with some procedures that are going to 

be falling under this. And also, we hate to talk about this, but denials. Because remember that 

people that have been working with prior authorization, not everything gets approved by the plan, 

per se. Just because the doctor recommended it and said, hey, you need to have this done, and then 

it goes to review with the health plan and the team that’s… that’s put together to review these 

requests not everything is approved so there could be some denials and obviously you can appeal 

this but that’s more administrative you know uh hula hoops and things you got to jump through so 

but overall, we just need to know also in a holistic approach that this is and the intentions behind 

this is to reduce unnecessary procedures to reduce the fraud and abuse and protect Medicare and 

the Medicare funds and the whole system for everyone involved. But overall, 

just get ready to expect more administrative processes for certain procedures and delays that may 

happen, even if it’s a short delay and or denials for things. Yeah, I think just being proactive, 

especially if it was to make it in North Carolina, if you’re in one of those states that is 

piloting the program right now, being proactive. I think is going to be the biggest takeaway. And, 

you know, having someone in your corner like Shawn that can help you kind of think through the right 

plan for you. And if Medigap is the right plan for you, kind of understanding what may be the new 

normal here going forward if it was to be approved broadly nationwide. as a program. 

So, you know, Shawn, I think this is fantastic to get out ahead of where sometimes we end up being 

very reactive. Oh, the policy changed. And so now we got to figure it out. But I think in this 

case, we’re being rather proactive, getting it out there. And so, for everyone listening, you know, 

Shawn in our office, I’ve said this at the beginning, but he is our Medicare and health insurance 

professional. And, you know, he works closely. He’s got a very nice consultative process as far as 

helping people think through what’s going to be the right plan for them pre-Medicare or walking 

into Medicare and thinking through the cost, thinking through the types of prescriptions that you 

already take, thinking through the types of… that work well for ones that want to travel a lot in 

retirement versus ones that are more regional in their travel. 

And so, what I would say to anyone that if this is, especially if you’re in one of those states and 

you want to understand more, but if… you don’t understand any facet of Medicare or you’re walking 

into it and you want more guidance, a big reason as to why we brought Shawn into our program at 

Peace of Mind Wealth Management is we wanted him to serve as a value add to clients, as a 

consultative approach rather than pushing products. Shawn doesn’t do that. He doesn’t have to the 

way that we’ve got him set up here. So, I think that’s a huge, huge benefit. And also, the feedback 

that we do get from clients around the conversations. Shawn’s a prior educator before he got into 

Medicare. So, he teaches first and then you make decisions together. And I think that’s what true 

collaboration looks like. On top of that, Shawn does a monthly Medicare webinar for those that are 

getting close to Medicare and they want to start learning more about it. We’re happy to provide you 

access to that as well. So, I just want to say again, Shawn, thanks for hopping on with me and taking 

some time. to explain what is niche right now, but could become a much bigger conversation down the 

road. And so, I think it’s good that we’re being proactive here today. Yeah, no, I really appreciate 

the invite and it’s always great to be on the podcast. talking about Medicare, 

do love Medicare a lot. I know you do too, Murs. And so, I’m always eager and happy to be involved 

and to help people with their Medicare and their healthcare decisions and their choices. Yeah. 

And we’re glad to have you. So, if you do have any interest of striking up a conversation with Shawn, 

a handful of ways to do that, you can go to our website and there’s a form that you can fill out 

and you just put down that I’d like to speak with Shawn around Medicare. care. Or if you want to hop 

on to one of his monthly webinars, we’re happy to give you access to that as well. Easiest thing 

that you can do is just reach out to us at our office, 919-787-8866. And that’ll get you to 

someone who can get you to Shawn or can get you to the invites for our monthly Medicare webinars 

that Shawn does. But as always, thank you all for being here. Thanks for taking some time to listen 

on your commute or on your drive home or just while you’re out for a walk. We do appreciate it.