CMMI Defends WISeR Model Amid Lawmaker Concerns Over AI Prior Authorization

The Centers for Medicare and Medicaid Innovation (CMMI) Center is defending its Wasteful and Inappropriate Service Reduction (WISeR) model after Democratic lawmakers warned it could delay or deny needed Medicare services. The program uses AI to flag certain prior authorization requests, but CMMI says all provisional denials will be reviewed by human clinicians and safeguarded through audits, payment penalties for errors, and possible removal of high-error participants. CMMI also notes that the Chief Actuary must certify the model’s impact on quality and costs before it can expand. Lawmakers’ Aug. 7 letter criticized the WISeR model for adding provider burden and potentially contradicting efforts to reduce prior authorizations in Medicare Advantage. Lawmakers also requested details on algorithm vetting and performance metrics. CMMI maintains that WISeR targets waste-prone services in Traditional Medicare and differs from Medicare Advantage practices, though it did not address concerns about contracting with vendors used in those plans (Inside Health Policy, August 13).

HHS Restores Childhood Vaccine Task Force

On August 14, the HHS announced the revival of the Task Force on Safer Childhood Vaccines (The Task Force), which was previously disbanded in 1998. The decision follows a Children’s Health Defense (CHD) lawsuit that argued HHS was legally obligated to bring The Task Force back. The Task Force will be composed of senior leadership from the NIH, the FDA, and the CDC. It will work in tandem with the Advisory Commission on Childhood Vaccines (ACCV) to offer recommendations on the development of safer childhood vaccines, improve vaccine production processes, and support related research. The Task Force will be expected to submit a formal report to Congress every two years. This is the latest in several administration moves to scrutinize the safety of childhood vaccines, which have drawn significant criticism from physicians and professional organizations like the American Academy of Pediatrics (HHS, August 14; Inside Health Policy, August 14).

President Trump Revokes Executive Order on Market Competition

On August 13, President Donald Trump issued an executive order rescinding a 2021 executive order issued under the Biden Administration. Citing issues around market consolidation, the now revoked executive order aimed to bolster agencies’ antitrust activities, aiming to address problems like rural hospital closures and rising prescription drug prices. In a statement supporting President Trump’s executive order, Federal Trade Commission Chair Andrew Ferguson opined that the move would help end the “Biden-Harris Administration’s undue hostility toward mergers and acquisitions.” (Fierce Healthcare, August 15).

Draft MAHA Report Outline Released

Several news organizations, including the New York Times, obtained a draft outline of a Make America Healthy Again (MAHA) report on Thursday, August 14. The draft strategy document includes recommendations on topics ranging from food to environmental factors that impact health to vaccines, which largely echo issues raised in the May MAHA report and statements from administration officials. The document accepts the EPA’s current review process for pesticides as adequate. The report stops short of recommending removal of fluoride from the water supply but recommends educating the public on appropriate fluoride levels. The report recommends HHS develop new guidelines around the direct marketing of “unhealthy food” to children and also recommends the removal of restrictions on full-fat milk offered in schools and through the WIC program. The document recommends development of a new vaccine schedule framework for children, even as the American Academy of Pediatrics continues this week to recommend the current vaccine schedule. The strategy also includes requesting CMS to work with states around Medicaid prior authorization procedures to reduce purported overuse of medications, such as ADHD medications, among school-aged children, as well as working with states to develop new Medicaid quality metrics to promote health through nutrition coaching and fitness indicators (New York Times, August 14; Politico, August 15).

CMS Announces Monthly Enrollment Reviews for Medicaid Beneficiaries’ Citizenship and Immigration Status

On August 19, CMS launched a new oversight initiative to ensure that Medicaid and CHIP enrollees are US citizens, US nationals, or immigrants with sufficient status for benefits. Starting immediately, CMS will send states monthly enrollment reports that identify individuals whose status could not be confirmed through federal databases. States are responsible for reviewing the cases, verifying information, requesting additional documentation if required, and taking appropriate enforcement action when needed. This includes modifying coverage or disenrolling non-citizens (CMS.gov, August 19).

Trump Administration Announces It Will No Longer Enforce Restrictions on Short-Term, Limited-Duration Plans

The Departments of Labor, Health and Human Services, and the Treasury have indicated their intention to no longer enforce the restrictions on short-term limited-duration (STLD) health plans in a statement published on August 7. In April 2024, the Departments under the Biden Administration promulgated final rules that excluded these plans from the definition of “individual health insurance coverage” and limited their coverage to no more than four months. The Departments’ current decision to waive enforcement follows President Trump’s executive order earlier this year to identify regulations that “impose undue burdens on small businesses or significant costs on private parties” without significant benefit to the public. Last year, the American Association of Ancillary Benefits filed suit against the Biden Administration over the limits on STLD health plans. The case was paused for several months as the Trump Administration came into office. In May, the DOJ notified the court that it would follow standard rulemaking procedures to revise the Biden rule and requested that the case remain paused until November 19. The court instead extended the pause until August 28 and requested that the Administration provide more information on the timeline for rulemaking (Inside Health Policy, August 15).

CMS Relaxes Requirements for ACA Health Plan Renewal Notices

Earlier this summer CMS announced that qualified health plans in the federally facilitated Affordable Care Act Marketplace do not have to provide information on premium and tax credit data in their upcoming renewal notices, unlike previous years. The agency announced this departure from normal policy due to the uncertainty of enhanced premium tax credits (EPTCs) that are set to expire at the end of this year. Without concrete information, insurers that base their 2026 benefit estimates on EPTCs in the current plan year may see “significantly inflated estimates” provided to consumers. However, experts point out that consumers who receive notices detailing the cost of coverage without any subsidies may drop coverage due to increases in price. As such, plans and vendors are gearing up to raise awareness of the situation and provide thorough consumer education and outreach. The last time CMS allowed similar flexibility in notices was 2022, when premium tax credits were also facing uncertainty. However, the notice flexibility may not apply to insurers in state-facilitated Exchanges which may have more stringent requirements. It remains to be seen whether Congress will act to extend EPTCs between now and the end of the year (Inside Health Policy, August 14).

New CBO Letter Details Potential Budget Cuts from Deficit Increases, Impacting Medicare

According to a letter published by the Congressional Budget Office (CBO) on August 15, Medicare may be subject to significant cost reductions through 2034. The Statutory Pay-As-You-Go Act (S-PAYGO) of 2010 requires Congress to ensure that new legislation is budget neutral. If lawmakers increase the deficit, then statutory requirements dictate that excess costs must be accounted for through sequestration. CBO estimates that the One Big Beautiful Bill Act (OBBBA) will increase the federal deficit by $2.1T over the next four years, totaling $3.4T through 2034. As a result, the Office of Management and Budget would be required by law to automate spending cuts unless Congress passes legislation to amend the deficit. In the August 15 letter, CBO estimates that without corrective measures OBBBA would sequester $415B in FFY2026, which begins on October 1. Medicare cuts, which are capped 4%, would account for $46B in 2026. The remaining $370B in FFY2026 would need to be sequestered from other programs that are not exempt from the cost-cutting process. However, only $120B would be available to sequester from available budget sources. Total Medicare cuts would increase over the 2027-2034 period to a total reduction of $419B (Becker’s Hospital Review, August 18).