By Elizabeth O'Brien

The Trump administration has started experimenting with artificial intelligence in Medicare. The goal is to use AI to help curb waste in the program. It could also mean that some enrollees face more hurdles for covered procedures.

The issue is pertinent: It's the middle of open enrollment for Medicare Advantage, the privately run insurance program that administers Medicare for 34 million Americans. If you aren't happy with your coverage, this is the time to switch Advantage plans or return to traditional Medicare.

AI is upending things as the federal government starts using it in traditional Medicare -- making it look a bit more like Advantage plans.

Unlike traditional, fee-for-service Medicare, Advantage plans impose hurdles to care. These take the form of restricted doctor choice, referrals, and prior authorization, which requires providers to get insurers' permission to perform a procedure.

Prior authorization aims to reduce unnecessary spending. According to the Medicare Payment Advisory Commission, Medicare spent up to $5.8 billion on unnecessary or inappropriate services in 2022, or 0.6% of total program spending that year.

However, prior authorization often results in delays or denials of needed care, doctors and patients say.

Under a pilot program that started on Jan 1., prior authorization will be required for some procedures in traditional Medicare in a few states. The program, called the Wasteful and Inappropriate Service Reduction (Wiser) Model, is now running in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

The Wiser model applies only to a handful of procedures, such as skin and tissue substitutes (used to replace damaged skin), electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis. Still, procedures included in the model accounted for 5.3% of all Part B spending in traditional Medicare in 2024, according to KFF, a health policy nonprofit.

Medicare's contractors are partnering with AI firms to implement the program. The tech companies will get a cut of the savings attributed to their reduction of wasteful spending, the Centers for Medicare and Medicaid Services said in a fact sheet. The government says clinicians will be on hand to "conduct medical reviews to validate determinations."

Advantage insurers already use AI, but this appears to be the start of its use in traditional Medicare. It raises concerns about whether AI-fueled algorithms will increasingly help make coverage decisions for seniors. And it's blurring lines between the programs.

"It's something to take the least popular point of Medicare Advantage and apply it to traditional Medicare," says Neil Patil, health policy director at the Medicare Policy Initiative at Georgetown University.

Now that it's starting to happen, seniors may need to rethink whether to go with traditional Medicare or an Advantage plan.

Advantage plans, known as Part C, provide Part A hospital coverage and Part B outpatient coverage, as does traditional Medicare. Beyond that, Advantage plans typically offer supplemental benefits that aren't included in traditional Medicare, such as dental, vision, and hearing coverage.

Through March 31, enrollees can switch to another Advantage plan or go back to traditional Medicare and buy a stand-alone Part D drug plan.

Many analysts say traditional Medicare can still be better than Advantage, since it imposes fewer restrictions on care.

Mary Johnson, an independent Social Security and Medicare policy analyst, says she made a decision to go with the traditional program, plus a Medigap and Part D plan. "We pay more upfront, but the trade-off has been freedom from worries that the insurer will close our plan and leave the market, the problem of small networks, and avoiding prior authorization issues," she says. "No more."

Advantage enrollees who want to return to traditional Medicare should keep in mind that they are generally not guaranteed the right to buy a Medigap policy to cover additional costs. In most states, these supplement policies are medically underwritten, so you can be charged more or denied coverage based on your health status, outside of certain limited circumstances.

If you're denied coverage for a procedure in the AI pilot program -- or anywhere in the Medicare program -- you have a right to appeal, notes Georgetown's Patil. Presumably, an AI bot won't be making the final decision.

Write to Elizabeth O'Brien at elizabeth.obrien@barrons.com

This content was created by Barron's, which is operated by Dow Jones & Co. Barron's is published independently from Dow Jones Newswires and The Wall Street Journal.

(END) Dow Jones Newswires

February 11, 2026 12:17 ET (17:17 GMT)

Copyright (c) 2026 Dow Jones & Company, Inc.