Understanding Medicare vs. Medicare Advantage: What Every Senior Needs to Know

As we age, our health care needs increase — and so does the complexity of choosing the right Medicare plan. With new changes on the horizon, it’s more important than ever for seniors in Orlando and across the country to understand the differences between Traditional Medicare and Medicare Advantage, especially when it comes to something called prior authorization.

Traditional Medicare vs. Medicare Advantage: What’s the Difference?

Medicare comes in two main forms:

• Traditional Medicare – This is the government-run program that allows you to see any doctor or hospital that accepts Medicare. Historically, it has not required prior authorization for most services, which means your doctor could proceed with a medically necessary treatment without waiting for outside approval.
• Medicare Advantage Plans (Part C) – These are insurance-based plans offered by private companies that contract with Medicare. They often come with added benefits like vision, dental, and hearing, and usually have lower monthly premiums than Traditional Medicare. However, they typically require prior authorization before you can receive certain treatments, procedures, or medications.

What Is Prior Authorization?

Prior authorization is a process where your doctor must get approval from your insurance plan before certain services are provided. This is supposed to make sure the care is necessary and cost-effective — but it can also lead to delays, denials, and extra paperwork for both patients and doctors.

According to a 2025 Kaiser Family Foundation (KFF) report:

• In 2023, Medicare Advantage plans denied 6.4% of all prior authorization requests — around 3.2 million out of nearly 50 million.
• Only 11.7% of those denials were appealed, but when appeals did happen, over 81% were approved on review.

This means many initial denials may have been inappropriate. And if they had been appealed, the patient might have received the care they needed. Unfortunately, many seniors never appeal—often because they don’t know they can, or because the process feels overwhelming.

A New Twist: Prior Authorization Is Coming to Traditional Medicare

Until now, Traditional Medicare did not require prior authorization for Medicare-approved treatments. That’s about to change.

Starting in 2026, a pilot program called WISeR (Wasteful and Inappropriate Service Reduction) will be rolled out in six states:
Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

The goal of WISeR is to prevent unnecessary or overly expensive treatments. However, it introduces prior authorization into Traditional Medicare — using private companies and artificial intelligence (AI) to decide whether a medical service is “necessary.”

What You Need to Know About WISeR

• Applies only to Traditional Medicare (not Medicare Advantage — for now).
• Starts in 2026 and lasts six years, only in the six pilot states.
• 17 types of procedures (to be named by Medicare) will require approval.
• Doctors must submit requests to private contractors, who will review them using AI algorithms.
• These contractors get to keep a share of the money they save, meaning they are financially motivated to deny more requests.
• Emergency and hospital-only care is not affected.

While the goal is to cut waste and fraud, many doctors and patient advocacy groups are concerned that this could result in unnecessary denials, delaying or even preventing important care for patients.

What This Means for Florida Seniors

The WISeR program is not active in Florida, but that could change depending on how the pilot program goes. In the meantime, many seniors in Florida are already enrolled in Medicare Advantage plans, which do require prior authorization — and these issues are happening now.

As a senior or caregiver, you should:

• Ask questions before selecting a Medicare Advantage plan. What services require pre-approval? What is the appeals process like?
• Know your rights. If a treatment is denied, you can appeal—and many appeals are successful.
• Talk to your doctor. They can help guide you through the prior authorization process and may assist with appeals.
• Stay informed. Changes to Medicare happen often. Programs like WISeR could expand nationwide depending on the results of the pilot.

Final Thoughts

Choosing between Traditional Medicare and Medicare Advantage isn’t just about premiums or perks — it’s also about how easily you can access the care you need.

At Orlando Senior Help Desk, we’re here to help you make sense of your options and understand your rights. If you’re confused about prior authorization, appeals, or plan benefits, reach out to a trusted Medicare counselor or licensed insurance professional. The more you know, the better decisions you can make for your health and your future.

Need help navigating Medicare? Contact the Orlando Senior Help Desk for local guidance and resources.