Tag: insurance

AI & Medicare Coverage: The New WISeR Model 

On January 1, 2026, the Centers for Medicare and Medicaid Services (CMS) introduced the Wasteful and Inappropriate Service Reduction Model (WISeR). The goal of this model, according to CMS,  is to use artificial intelligence (AI) to encourage safe and effective navigation for Medicare participants on certain services, which will assist timely and appropriate payment. Additionally, the model hopes to reduce waste, fraud and abuse. 

There are two ways in which providers can seek coverage determinations through WISeR: by obtaining prior authorization by an authorized WISeR participant or by pre-payment medical review by an authorized WISeR participant. The model establishes new prior authorization requirements for services that have “little to no clinical benefit for certain patients.”  These services include skin and tissue substitutes, some nerve stimulator implants, and some services for knee osteoarthritis. This is important, because traditional Medicare historically has not required prior authorization.  However, CMS urges that WISeR does not change Medicare coverage or payment policy. Six states have been selected to test the WISeR model: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. The prior authorization will be determined by artificial intelligence, which is a huge concern for many people. Further, appeals are only available if a service is performed and the provider then submits a claim after not receiving prior authorization. It is unclear at this stage how long these appeals may take, however standard appeals can take months to reach a favorable decision.  

Many people within the health care industry have concerns and comments regarding the new WISeR model. For example, the American Hospital Association urged CMS to delay implementation of WISeR because of concerns with payment structure and the use of AI in Medicare. The Community Oncology Alliance expressed concerns about WISeR, stating that there are inadequate safeguards in place for the untested model, which experiments directly on Medicare beneficiaries. Further, the Center for Medicare Advocacy stated that instead of accomplishing the goals WISeR hopes to, WISeR will likely delay and even deny necessary care for some Medicare beneficiaries. The  Medicare Policy Initiative fears that WISeR will cause burdens for providers, and even cause some providers to exit traditional Medicare. At this point, it is hard to tell how the WISeR model is actually performing, but these concerns seem to be standard across the health care community. 

Further, multiple members of Congress have spoken up about the WISeR model. For example, a bill was introduced into the House of Representatives in November 2025 to prohibit the implementation of the WISeR model. Further, an amendment to the Health and Human Services, Education, and Related Agencies Appropriations Act was approved in the House in September 2025, but was not included in the final Act that was signed into law February 2026. Further, members of the Senate Committee on Finance wrote a letter to CMS in September 2025 urging them to provide further safeguards and transparencies surrounding WISeR. These safeguards include ensuring that the AI program is fully compliant with HIPAA, and that the AI will be unbiased. However, despite all of these concerns, WISeR was launched January 1, 2026.     

It will be important for CMS and the health care industry to closely monitor the new WISeR model, given all of the concerns. If it is shown that WISeR is inefficient, presents a new burden, and denies necessary medical care to Medicare beneficiaries, it will need to be reevaluated to ensure it is actually meeting the goals CMS hopes it will. Additionally, it is important that CMS constantly evaluates the safeguards and privacy considerations surrounding WISeR, to ensure beneficiaries are always protected.

Surprise Billing is “Banned”: So Why are Patients Still Being Billed? 

Surprise billing occurs when a patient with health insurance unknowingly or unavoidably receives care from an out-of-network provider and is billed directly for charges not fully covered by their plan. Before the No Surprises Act was passed, patients could be billed for the difference between what a provider charged and what their insurance paid, as well as for additional out-of-network fees. 

The No Surprises Act of  2020 protects individuals covered by group and individual health care plans from receiving surprise medical bills after most emergency services and certain non-emergency care at in-network facilities. Beginning in 2022, the law added additional protections to prevent surprise billing. For privately insured patients, these protections include limits on balance billing and a federal dispute resolution process. For uninsured patients or for those who choose not to use their health insurance for a service, the law requires good faith estimates to be provided before you undertake the service. 

Despite these additional protections, consumers continue to report disputed charges and billing confusion. According to data from CMS, roughly 1.2 million payment disputes were filed by providers and health insurances in the first half of 2025 alone. This was almost 40% higher than the last half of 2024. This increase has drawn attention to the statute’s Independent Dispute Resolution system (IDR), which is a federal arbitration process designed to settle payment disagreements between insurers and out-of-network providers. Under the IDR, insurers and clinicians submit competing payment offers to a certified arbitrator, who must select one amount rather than splitting the difference. Lawmakers adopted this structure to pressure both insurers and providers to submit realistic numbers instead of inflated demands. 

Although the system was designed to keep patients out of reimbursement fights, the large volume of disputes being filed, and surveys suggesting many filed cases may be ineligible under the statute’s terms have raised administrative and enforcement challenges within CMS’s implementation framework. Although the law prohibits balance billing for covered emergency and certain non-emergency services, the continued pace of arbitration filings and associated enforcement work shows that disputes over payment amounts can persist even after protections are in place. 

Patients sometimes receive bills while these payment disputes are pending, and they may not know whether the charge is lawful or subject to dispute, reflecting gaps in implementation and public awareness. This creates a legal issue because the No Surprises Act’s promise of protection depends on the proper operation of the arbitration and complaint processes rather than automatic relief, meaning patients can be left uncertain about their rights unless enforcement and administration keep up with disputes. The continuing volume of arbitration cases shows that the No Surprises Act’s consumer protections depend heavily on administrative systems that are clearly still under strain.

The Affordable Care Act’s Impact in Reducing the Uninsured Rate in America & the Upcoming Health Insurance Cliff

In March 2010, President Barack Obama signed the Patient Protection & Affordable Care Act, commonly known as the ACA or Obamacare, into law. One of the legislation’s main goals was to reduce the number of Americans lacking health insurance coverage. Between the law’s passage in 2010 and 2023, the number of uninsured Americans fell from 46.5 million to 25.3 million.

The ACA sought to increase health insurance coverage for Americans through two main mechanisms: Medicaid expansion and subsidies for Americans to buy insurance through the health insurance marketplaces administered by the federal government and many states. The ACA sought to expand the number of adults under the age of 65 eligible for Medicaid, a jointly funded federal and state program, which traditionally provided coverage to the lowest income Americans. Specifically, the maximum income eligibility threshold for most Medicaid members effectively increased from 100 to 138% of the federal poverty level. However, the Supreme Court, in National Federation of Independent Business v. Sebelius, ruled that states could choose whether to expand Medicaid in their states. As of 2025, 10 states, including populous states such as Texas and Florida, have still not expanded Medicaid.

For Americans ineligible for Medicaid and earning less than 400% of the federal poverty level annually, the Affordable Care Act provides subsidies in the form of a tax credit, the Advanced Premium Tax Credit (APTC), to help people afford their health insurance premiums. By 2019, the number of uninsured Americans had fallen to 28.9 million.

In 2021, President Joe Biden signed the American Rescue Plan Act (ARPA) into law. The legislation provided enhanced subsidies, known as the Enhanced Premium Tax Credit (EPTC), which expanded assistance to Americans seeking to purchase health insurance through the ACA marketplaces. Specifically, ARPA removed the cap on premium tax credits for those making more than 400% of the federal poverty level, providing subsidies for middle-income Americans for the first time. The EPTCs have been successful in increasing health insurance coverage through the ACA marketplaces, as a record 21 million Americans purchased insurance coverage through the marketplace in 2024. Bolstered by these subsidies, a low unemployment rate, and pandemic-era policies protecting Medicaid coverage, the nation’s uninsured rate reached a record low 7.9% in early 2023.

The EPTCs are currently set to expire at the end of 2025, as they were not extended in the One Big Beautiful Bill Act signed into law by President Donald Trump in July. In fact, the EPTCs have become more important in the health safety net because of the impact of the One Beautiful Bill Act’s cuts to Medicaid and other assistance for low- and middle-income Americans, which are estimated by the nonpartisan Congressional Budget Office (CBO) to increase the number of uninsured Americans by 10 million through 2034. The CBO also predicts that the expiration of the EPTCs would increase the number of uninsured Americans by an additional 3.8 million people by 2034, with 2 million Americans losing their insurance next year alone.

For Americans able to still afford their health insurance coverage, their premiums may skyrocket. According to a 2024 analysis, EPTCs saved the average subsidized health insurance plan enrollee more than $700 on their monthly premium. In anticipation of the expiration of these enhanced subsidies, insurers on the ACA marketplace are raising premiums by roughly 20% for 2026.

Health insurance coverage is important for two main reasons. First, it allows Americans to utilize health care services without paying exorbitant out of pocket costs. Secondly, the reimbursement hospitals and other health care facilities receive from insurance companies for services provided to insured patients provide needed financial support to help allow these facilities to stay open. In an time with rising economic headwinds for both Americans and for health care providers, a rise in the health uninsurance rate caused by the expiration of the Enhanced Premium Tax Credits would add to economic challenges faced by patients and health care providers alike.

Breast Pumps For All, But Not Necessarily The Best

The ACA requires insurance companies to provide new mothers with breast pumps and other equipment that is necessary to help them breast feed.

Unfortunately, the law doesn’t specify the type or quality of the breast pumps to be provided, so the companies (with doctors’ recommendations) get to decide. This issue leads to whether a company will provide a manual or an electric pump.

The benefits of an electric pump over a manual pump are several: they’re high-powered and can simulate a nursing child, while manual pumps can be weak, clumsy, and cumbersome for a working mother to use. They take more time to pump than an electrical pump.

The costs are also considerably different, when a high-end electric pump coming in at around $300, and a manual pump costing as little as $35.

Anti-Trans Insurance Policies Banned in Oregon

It was announced on December 19, 2012 by the Oregon Insurance Division of the Department of Consumer and Business Services that private health insurance companies could no longer discriminate against trans policy holders.

Transgender advocates have been lauding the regulations, which prohibit denying coverage of hormone therapy, hysterectomies, mastectomies, and other medically-necessary treatments for gender dysphoria and sex-reassignment surgery. Even though many of these surgeries are already protected for non-trans policy holders, the law now specifically prohibits denying coverage for a surgery because the recipient is trans. The regulations also expand mental health services to include trans policy holders.

Being transgender is considered a mental health disorder known as Gender Identity Disorder in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) – a highly controversial decision. On December 2, 2012, the APA announced that it would be removing Gender Identity Disorder from DSM-V and replacing it with Gender Dysphoria. The difference is that GID focuses on whether a person feels their birth sex and gender are in alignment, and GD focuses on the anguish caused by being unable to make the alignment between sex and gender. For example, a person who might be diagnosed with GID doesn’t necessarily suffer from dysphoria if they have access to gender reassignment surgery, but a person who might be diagnosed with GID could suffer dysphoria if they’re prevented from getting medical treatments and surgeries to change their sex to suit their gender.

In the US, payment for health care treatment by insurance companies, Medicare, and Medicaid relies on the diagnosis of a specific disorder categorized in the DSM-IV. Some say the “disorder” should be struck because it inappropriately stigmatizes trans identities, much like homosexuality was until 1973, and some say it’s necessary in order for trans people to receive the health care they need, such as gender reassignment surgery. The American Psychological Association seems to agree that it is not being trans that causes the requisite distress or disability that qualifies a psychological state as a disorder, but rather the social stigma, discrimination, violence, and difficulty obtaining access to health care that trans people face.

For more information on what being trans means, you can visit the APA’s website on sexuality and gender identification.