Gillibrand leads Senate Democrats in push to halt Trump AI Medicare pilot threatening seniors' care

Sen. Gillibrand urges halt to Medicare WISeR pilot that shifts coverage decisions to AI and private vendors

September 28, 2025 - U.S. Senator Kirsten Gillibrand, the top Democrat on the Senate Aging Committee, is pressing the Trump administration to pause a new Medicare pilot that could delay or deny treatment for seniors by routing key coverage calls through private vendors and AI tools.

Joined by Senators Ron Wyden (D-OR) and Richard Blumenthal (D-CT) and 18 other Senate Democrats, Gillibrand is seeking a halt until the impact on patient access can be fully analyzed. Her concern: seniors in Traditional Medicare could face new hurdles to get medically necessary care.

What the WISeR model would change

The WISeR model relies on third-party vendors using AI to determine whether certain procedures are covered for patients in Traditional Medicare. While labeled "voluntary," stakeholders say it functions as mandatory across selected geographies because providers that do not submit prior authorization for targeted services would face pre-payment medical review.

• States included: New Jersey, Ohio, Oklahoma, Texas, Arizona, Washington
• Non-submission triggers pre-payment review, adding administrative work and potential care delays
• Limited clarity on beneficiary notification, support, and appeal pathways if coverage is denied

Why insurance professionals should care

• Operational burden: Prior authorization volume, turn-times, and pre-payment review workflows may climb quickly in affected states.
• AI accountability: Any algorithmic decision support tied to Medicare coverage must be explainable, clinically defensible, and auditable.
• Beneficiary protections: Clear notice, appeal routes, and live-agent support will be scrutinized by policymakers and the press.
• Provider relations: Expect heightened friction if clinicians see higher admin load or unclear criteria. Proactive education is essential.
• Compliance risk: Misalignment with Medicare coverage rules can trigger denials, repayments, and oversight inquiries.
• Reputation risk: Headlines about delayed care for seniors can escalate quickly; ensure oversight and rapid issue remediation.

Immediate actions to consider

• Identify the specific procedures/services in scope and map current vs. proposed prior authorization flows.
• Stand up a cross-functional response (medical policy, UM, compliance, legal, provider ops, data/AI) for rapid decisioning.
• Require human-in-the-loop review and clear escalation for any AI-influenced coverage denial or deferral.
• Publish plain-language criteria and documentation checklists for providers; add a fast-track for urgent cases.
• Create beneficiary notice templates that explain decisions, next steps, and appeal options in simple terms.
• Instrument metrics: submission-to-decision time, denial reasons, overturn rates on appeal, and disparities by site/setting.
• Ensure audit readiness: retain decision rationale, evidence, timestamps, and reviewer identity for each case.

What lawmakers are demanding

Senators are pushing for a pause until there is a clear assessment of patient access impacts and stronger safeguards. Priorities include transparent criteria, prompt beneficiary notice, robust appeals, and attention to small, rural, and low-income practices that could be hit hardest by new administrative requirements.

Open questions for CMS and vendors

• How and when will beneficiaries be notified of denials or deferrals, and by whom?
• What transparency will providers get into the AI's rationale and the clinical criteria applied?
• What are the service-level standards for prior authorization decisions and pre-payment reviews?
• How will appeals be handled, and how quickly? What is the escalation path for urgent care?
• What guardrails exist to manage conflicts of interest for private vendors participating in determinations?
• Which metrics will CMS use to evaluate access, quality, and equity during the pilot?

Context and further reading

• KFF Health News coverage on Medicare, prior authorization, and AI
• Centers for Medicare & Medicaid Services (CMS)

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