CMS's WISeR Model Is Under Fire: What Medicare Advantage Enrollees Need to Know

If you're enrolled in a Medicare Advantage plan — or thinking about joining one — a regulatory battle playing out in Washington right now deserves your attention. The Centers for Medicare & Medicaid Services launched a payment model called WISeR, which stands for the Wasteful and Inefficient Spending Reduction model, as part of its ongoing effort to reshape how private insurers are compensated for covering Medicare beneficiaries, particularly those with serious or complex health needs. Now, following a determination by the Government Accountability Office, that model faces a real possibility of being repealed before it ever fully takes effect.

To understand why this matters, you need to know a bit about how Medicare Advantage plans get paid in the first place. Unlike Original Medicare, which pays doctors and hospitals directly for each service, Medicare Advantage works through private insurance companies that receive a fixed monthly payment from the federal government for each enrollee. That payment is adjusted upward based on how sick or complex a beneficiary's health profile is — a system called risk adjustment. The idea is that insurers who take on sicker patients should receive more money to cover those patients' care. The WISeR model was CMS's attempt to tighten and reform that risk adjustment process, targeting what the agency identified as inflated or inaccurate diagnosis coding that some insurers use to collect higher payments without necessarily delivering more care.

The GAO's involvement came through a specific legal mechanism that many beneficiaries have never heard of: the Congressional Review Act, or CRA. Under this law, major federal rules can be reviewed by Congress, and if the GAO determines that a rule qualifies as a "major rule" subject to CRA oversight, Congress can vote to repeal it using a streamlined process that bypasses the usual committee hearings and filibuster rules. The GAO issued exactly that kind of determination regarding WISeR, finding that it meets the threshold for congressional review. That opens a 60-legislative-day window during which a simple majority in both chambers can vote to nullify the rule entirely — and given the current political climate around federal regulatory rollbacks, that outcome is considered a genuine possibility.

For everyday Medicare Advantage enrollees, the immediate question is: what does this actually mean for my plan? In the short term, probably nothing changes in your premium, your copays, or your covered benefits. Medicare Advantage plans set their benefit structures annually, and the plans you enrolled in for 2025 or 2026 are locked in for those plan years regardless of what happens to WISeR. But the longer-term implications are more significant, particularly if you have chronic conditions like diabetes, heart failure, COPD, or cancer — the kinds of diagnoses that generate the high-cost claims WISeR was specifically designed to address.

Here's the concern that patient advocates and health policy researchers have raised: if WISeR is repealed, the pressure on Medicare Advantage insurers to accurately and efficiently code diagnoses — rather than upcoding to maximize payments — is reduced. Some analysts argue this could actually benefit insurers financially in the short run, since they would continue collecting risk-adjusted payments under the existing, less-reformed system. But the downstream effect on beneficiaries is less clear. Critics of the repeal argue that without payment reform, there's less financial incentive for plans to invest in care coordination and disease management for high-need enrollees. Supporters of repeal argue that WISeR's methodology was flawed and could have inadvertently penalized plans serving genuinely sick populations.

According to CMS.gov data, there were approximately 7,400 Medicare Advantage plan options available to beneficiaries nationwide in 2024, with average monthly premiums for Medicare Advantage Prescription Drug plans hovering around $18 per month — though that figure masks enormous variation by county, insurer, and benefit design. More than 33 million Americans were enrolled in Medicare Advantage plans as of 2024, representing over half of all Medicare beneficiaries. That scale means any systemic change to how these plans are paid — or how payment reform efforts are blocked — has real consequences for tens of millions of people, not just a policy footnote in a federal register.

If you're a Medicare Advantage enrollee with significant health needs, the most practical thing you can do right now is not panic, but prepare. The Annual Enrollment Period, which runs from October 15 through December 7 each year, is your primary window to switch Medicare Advantage plans, drop Medicare Advantage and return to Original Medicare, or add or change a Part D prescription drug plan. Changes made during AEP take effect January 1 of the following year. If you're concerned that your current plan may reduce benefits or tighten prior authorization requirements in future years — a real possibility if payment models shift — use the Medicare Plan Finder tool at Medicare.gov to compare plans in your ZIP code before the AEP deadline.

There's also the Medicare Advantage Open Enrollment Period to know about, which runs January 1 through March 31 each year. During this window, you can switch from one Medicare Advantage plan to another, or drop Medicare Advantage and return to Original Medicare with a standalone Part D drug plan. You cannot, however, use this period to switch from Original Medicare into a Medicare Advantage plan. This is a narrower window than AEP but still gives you a meaningful second chance to course-correct if your plan's coverage turns out to be inadequate for your needs.

For beneficiaries who are considering switching from Medicare Advantage back to Original Medicare — either because of WISeR-related uncertainty or for any other reason — the Medigap landscape is an important piece of the puzzle. Medigap, also called Medicare Supplement insurance, helps cover the out-of-pocket costs that Original Medicare doesn't pay, like deductibles, coinsurance, and copays. The challenge is that in most states, if you've been enrolled in Medicare Advantage for more than 12 months, you may not have a guaranteed right to buy a Medigap policy — insurers can use medical underwriting and decline to cover you based on pre-existing conditions. There are exceptions: if you're in your first year of Medicare Advantage and want to switch back, you have a guaranteed issue right. Some states also have birthday rules that give you a 30-day window each year to switch Medigap plans without underwriting, regardless of your health status. Those states currently include California, Idaho, Illinois, Kentucky, Louisiana, Maine, Maryland, Missouri, Nevada, New Jersey, New York, Oklahoma, and Oregon.

The WISeR debate also connects to a broader, ongoing tension in Medicare Advantage policy: the question of whether the program saves money for taxpayers or actually costs more than Original Medicare would for the same beneficiaries. The Medicare Payment Advisory Commission, known as MedPAC, has repeatedly found that Medicare Advantage plans are overpaid relative to what Original Medicare would spend on the same enrollees — a gap that has been estimated at billions of dollars annually. WISeR was one of several CMS initiatives aimed at narrowing that gap by improving the accuracy of risk adjustment. Its potential repeal is seen by some policy analysts as a setback for that broader cost-containment effort, while others argue the model's specific design was too blunt an instrument.

What should you actually do with all of this information? First, don't make any hasty changes to your coverage based on a rule that hasn't been repealed yet. Second, if you have a complex health history and rely heavily on your Medicare Advantage plan's care management programs, specialist networks, or drug coverage, make a note to carefully review your plan's Annual Notice of Change letter when it arrives in late September. That letter will tell you exactly what's changing in your plan for the upcoming year — premiums, copays, covered drugs, and network changes. Third, if you want to understand how payment policy changes might affect your specific plan, Medicare.gov's Plan Finder allows you to see a plan's star rating, which reflects quality and performance metrics that CMS updates annually. Plans with lower star ratings may face financial penalties under existing CMS rules, which can affect their ability to offer rich benefits.

Finally, if you have questions about your specific Medicare Advantage plan, your rights during enrollment periods, or how to file a complaint if you believe your plan is denying medically necessary care, you can call 1-800-MEDICARE (1-800-633-4227) at any time, 24 hours a day. Your State Health Insurance Assistance Program, known as SHIP, also provides free, unbiased counseling from trained volunteers who can help you compare plans and understand your options without any sales pressure. You can find your local SHIP contact through Medicare.gov or by calling the national number above. These resources exist precisely for moments like this — when policy changes create uncertainty and you need a clear-eyed guide to what your options actually are.