Nonprofit Files Suit Against CMS Over WISeR Model Concerns, Lack of Information
The Electronic Frontier Foundation (EFF), a digital and privacy rights nonprofit, filed suit against CMS on March 25, seeking more information from the federal agency on the Wasteful and Inappropriate Service Reduction (WISeR) model. Launched in January 2026, the WISeR model from the CMS Innovation Center utilizes artificial intelligence to review prior authorization requests for certain services in Original Medicare, with the goal of reducing potential fraud, waste, and abuse in the program. EFF’s lawsuit alleges that the WISeR model has already brought harm to beneficiaries, citing a Washington Post article which stated that, in Texas, only 62% of prior authorization requests were approved by AI. That number jumped to 84% after being reviewed by a person. These numbers contrast with the national 92% approval rate for prior authorizations in Medicare Advantage.
Moreover, EFF alleges that the public does not have sufficient information on how the AI algorithms in WISeR were trained and how they are currently operated. The EFF filed a FOIA request in January of this year to gain more insight into the program, but according to the complaint, the request has remained unanswered. The foundation is seeking, among other items, the agreements with software vendors participating in WISeR, documents describing how companies would be paid, how their technology is tested, and any data sharing agreements between the federal government and vendors (Healthcare Dive, March 30).
CMS Indicates Possible Delays in 2027 Marketplace Rule
Speaking to state insurance officials last week at the National Association of Insurance Commissioners (NAIC) Spring meeting in San Diego, CMS officials indicated that several major proposals in the draft 2027 Marketplace rule may not be finalized this year and could be delayed. As CMS works to better understand enrollment and coverage trends, the draft rule outlines several proposed policy changes to the Marketplace. These include expanding access to catastrophic plans, allowing multi-year contracts up to 10 years, and permitting certain non-network plans to participate in the Marketplace. The rule also includes changes related to eligibility verification, state benefit defrayal, and exchange flexibility. Given tight timelines between the rule release, comment period, and upcoming plan submissions, CMS indicated it may take a more gradual approach, and some stakeholders have urged delaying more complex proposals until at least 2028 (Inside Health Policy, March 25).
CMS Releases Health Insurance Exchanges 2026 Enrollment Report
On March 27, CMS released the Health Insurance Exchanges 2026 Enrollment Report, describing data on plan selection activity on the Marketplace across all 50 states and the District of Columbia. The report includes information on demographics, premium cost, financial assistance, and cost sharing. During the 2026 Open Enrollment Period (OEP), 23.1 million individuals selected or were automatically re-enrolled in coverage, representing a 5% (1.2 million) decline from 2025, though enrollment remains above prior years. CMS terminated advance payment of the premium tax credit (APTC) or healthcare coverage for approximately 1.5 million individuals, citing ineligibility for financial assistance or being enrolled without their authorization on the HealthCare.gov platform. Almost 50% had household incomes between 100-150% of the federal poverty level, with most of these individuals receiving financial assistance. Plan choices shifted from 2025 to 2026, with bronze plan enrollment increasing by 10% and silver plans decreasing by almost 14%. This shift reduces access to cost-sharing reductions tied to silver plans. Enrollment in gold plans increased by 4% in the 2026 OEP.
Further data shows enrollment in Health Savings Account (HSA)-eligible plans rose to 43% (up from 2%) following recent policy changes. Enrollment dynamics also shifted, with new enrollments declining by 13%, active shopping increasing by 15%, and automatic re-enrollment decreasing by 19%. External analysis aligns with CMS findings, with Charles Gaba reporting that QHP enrollment declined by 4.9% (1.19 million) from 2025 to 2026, including larger declines in Medicaid expansion states (-7.1%) compared to non-expansion states (-2.9%). The report also provides an overview of insurance agent- and broker-assisted enrollments for states that have used HealthCare.gov for the past six years. Additionally, Health Savings Account-eligible plan selection data will also be available for review, following statutory changes from H.R. 1 (CMS Newsroom, March 27; Inside Health Policy, March 27).
Medicaid Work Requirements and Eligibility Checks Expected to Cause Coverage Losses of Up to 10.1M Americans in 2028
In a new study, experts at the Urban Institute estimate that Medicaid work requirements and six-month eligibility checks could lead to coverage loss for about 4.9 to 10.1M people in 2028, of which 2 to 3.1M is expected to result from more frequent eligibility checks. The study puts implementation and expected outcomes into three buckets: high, medium, and low mitigation model scenarios, with states that utilize low mitigation efforts to see Medicaid enrollment decline at higher rates (Fierce Healthcare, March 25).
Nonpartisan Study Finds that TrumpRx Program May Cause Price Increases
On March 17, the Center for American Progress (CAP) released an analysis that evaluates President Trump’s prescription drug program, TrumpRx. CAP’s findings refute the administration’s statements that the program will deliver the lowest prices on prescriptions. The analysis found that only one medication, Cetrotide, has cost savings, while the rest may be repackaged existing discounts or may potentially raise costs for the others (Inside Health Policy, March 27; CAP, March 17).
