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HCA: WISER model applies to original Medicare in WA; early data show no member impacts so far
Summary
Laura Ryan briefed the board on CMS's WISER model (began Jan 1 2026 in six states including Washington), noting it applies to original Medicare and that HCA has not observed negative member impacts to date; plans in the PEB portfolio that are Medicare Advantage are unaffected.
Laura Ryan outlined the CMS WISER model, which launched January 1 and runs through 2031 in selected states, and described how it functions: providers for original Medicare may seek prior authorization for a curated set of services or face retrospective reviews. The program targets services that CMS deems vulnerable to inappropriate utilization, such as certain spine and orthopedics services.
Ryan emphasized WISER applies only to original Medicare. "This is applicable to original Medicare only," she said, noting Medicare Advantage plans (Kaiser, UnitedHealthcare MAPD plans in the PEB portfolio) are outside the model. She told the board that HCA had requested claims data from carriers and that, while data collection is early, agency review so far shows no evidence of member cost shifting; adverse impacts would be escalated if observed. The board discussed provider administrative burden and agreed to continue monitoring provider experience and member outcomes.
The board asked HCA to return with any new claims evidence and to monitor whether retrospective review leads to provider appeals or provider liability patterns that could affect access.
