UBCNews - Business - CMS Final Rule 2026: What Are The New Medicare Benefits For Seniors?

Episode Date: December 12, 2025

Welcome back, everyone. Today we're looking at something that's gonna affect millions of Medicare beneficiaries starting in just a few weeks. We're talking about the CMS Final Rule for 2026 and what it means for seniors with chronic wounds. I've got our healthcare policy expert here to break this down. So, let's start with the big picture. What exactly is happening on January 1st, 2026? KureCare a division of Veracor Group LLC City: Miami Address: 1150 NW 72ND AVE Website: https://curewounds.com

Welcome back, everyone. Today we're looking at something that's going to affect millions of Medicare beneficiaries starting in just a few weeks. We're talking about the CMS final rule for 26 and what it means for seniors with chronic wounds. I've got our health care policy expert here to break this down. So let's start with the big picture. What exactly is happening on January 1st, 26? Right, so CMS is rolling out some major changes to how Medicare covers wounders. care, particularly for chronic wounds like diabetic foot ulcers and venous leg ulcers. We're looking at approximately 10.5 million people across the United States who could be impacted by these policy shifts.

That's a massive number, and I understand these changes are pretty significant for access to treatment. What are the main shifts we're seeing? Well, there are three big changes. First, CMS is changing the payment methodology for skin substitutes shifting from ASP-based payments to a flat standardized rate. This change is expected to reduce Medicare spending on these products by nearly 90%. Second, they're implementing a flat national rate of 127 miles and 28 per square centimeter for covered skin substitute products that aren't biologicals licensed under section 351 of the Public Health Service Act.

And third, they're introducing much stricter clinical requirements. Okay, that third point, the stricter requirements. What does that actually look like for someone who needs treatment? So here's where it gets really challenging. Patients will now have to fail four weeks of standard care before they can even qualify for advanced treatments. That's a mandatory waiting period, essentially. And there are also going to be limitations on the number of covered applications

per treatment episode. Four weeks? That sounds like a long time when you're dealing with a wound that won't heal. What's the rationale behind that requirement? CMS is intensifying scrutiny because of concerns about overutilization and high costs. They've seen spending growth in this area, and there have been fraud concerns, so they're trying to curb what they see as wasteful and inappropriate services. But the trade-off is that patients who genuinely need advanced therapies face delays.

And delays in wound care can lead to serious complications, right? I mean, we're talking about infections, amputations. Exactly. There's actually data from the COVID-19 period that's really striking. A study found that major limb amputations increased from 18% in 2019 to 42% in 2020 when patients couldn't access timely treatment during the pandemic. That shows you how critical timing is with chronic wounds. I actually remember working with a patient back in 20-Wunty who had to wait months for a simple wound evaluation because clinics were overwhelmed. By the time, times she got seen, what started as a small ulcer had become far more serious.

Wow, that really brings it home. So what should people who are currently dealing with chronic wounds be thinking about right now before these changes take effect? Healthcare experts are urging patients to seek treatment immediately before January 1st. If you qualify for advanced wound care under the current system, you want to get that process started now. Once the new rules kick in, you'll face those mandatory waiting periods. and the coverage situation will look very different.

That point about coverage timing really sets up our next piece, the payment structure changes. But first, a quick word from our sponsor. Managing Medicare changes can feel overwhelming, especially for wound care coverage. CureCare, a division of Veracore Group LLC, offers Medicare billing support and provider training. Their platform helps patients access regenerative medicine therapies

with 95% of qualified patients receiving full coverage from their federal health programs. If you're looking for guidance before the 2026 changes take effect, visit curewounds.com. Picking up on that coverage timing question, how does this payment methodology shift actually change what providers can offer? It's a fundamental shift. Previously, many skin substitutes were reimbursed based on average sales price, which often resulted in higher payments. Now they're being paid at that flat national rate,

$127.28 per square centimeter. For providers, this means the economics of offering these treatments changes completely. Some may stop offering certain advanced options because the reimbursement doesn't cover their costs. So we're potentially looking at reduced access, not just from the patient side with those waiting periods, but also because providers might opt out of offering these treatments altogether.

Definitely. And there's another layer, CMS finalized a 2.5% efficiency adjustment for non-time-based services, which reduces the work relative value units for certain procedures. Physicians are facing lower reimbursement across the board, which compounds the problem for wound care specifically. You know, it's almost like CMS is saying, we'll pay you less to do more paperwork. Not exactly a winning formula for provider enthusiasm. Right, exactly. What about the types of products that will still be covered? Are there any criteria for that? Yes, CMS is implementing changes to the local coverage determination for cellular and tissue-based products.

Only products with peer-reviewed clinical evidence supporting efficacy in diabetic foot ulcers or venous leg ulcers will be reimbursed. So there's an evidence bar that products have to meet now. In other words, products need solid proof they work, not just marketing claims. That sounds reasonable on paper, requiring evidence, but I imagine it still limits options for patients and doctors, right? It does. And the challenge is that innovation in wound care often happens faster than the peer-reviewed literature can keep up. So newer therapies that might be effective could be excluded simply because the clinical trials haven't been published yet. Uh-huh, I understand. So to everyone listening, if you or someone you care for has a chronic wound, What are the key action steps you'd recommend taking before the end of this year?

Three things. First, schedule an evaluation with a wound care specialist now. Don't wait. Second, ask your doctor about your treatment options under the current coverage rules. And third, document everything. Keep records of your wound assessments, treatments tried, and any doctor recommendations. This documentation could be critical when working through the new requirements in 2026. Great advice. And for caregivers, this is obviously going to create some additional administrative burden too, right? Absolutely. Caregivers should familiarize themselves with the new prior authorization requirements and the documentation standards. There will be more paperwork, more back and forth with Medicare, and potentially longer wait times for approvals.

Being prepared and organized will make a huge difference. Have you noticed if there are particular states where these changes might have a bigger impact? Well, the changes are nationwide, but they're happening alongside other Medicare initiatives. For example, six states are participating in a prior authorization pilot program for certain procedures, Arizona, Washington, New Jersey, Texas, Ohio, and Oklahoma. Patients in those areas are dealing with multiple policy shifts at once. It sounds like 2026 is going to be a year of adjustment for a lot of people. What's your overall take?

Is there a silver lining here? or are we looking at a net negative for patient care? I mean, the goal of reducing fraud and ensuring appropriate use of resources is valid. Nobody wants taxpayer dollars wasted on unnecessary procedures, but the concern is that we're using a blunt instrument that could harm patients who genuinely need these advanced therapies. Put another way, we're trying to stop fraud, but we might be blocking legitimate care in the process.

The key will be monitoring outcomes, watching amputation rates, infection rates, healing times, and being willing to adjust the policy if we see negative trends. That's a really balanced perspective, and I think it highlights why awareness is so important right now. People need to understand what's coming and plan accordingly. Have you ever had to help a family member work through Medicare coverage issues? Exactly. Knowledge is power in this situation.

The more informed patients and caregivers are, the better they can advocate. for themselves within the new system. Well said. Thank you so much for breaking all this down for us today. This is complex stuff, but you've made it really accessible. To everyone listening, if you found this helpful, please share it with anyone you know who might be affected by these changes. Time is really of the essence here.

Until next time, take care of yourselves and each other.