UBCNews - Business - Medicare Changes Are Coming In 2026: Why You Should Seek Wound Treatment Now

Episode Date: December 12, 2025

Welcome back, everyone. Today we're tackling something that could seriously affect a lot of Medicare patients out there—especially if you're dealing with chronic wounds, diabetic foot ulcers, or venous leg ulcers. Starting January first, twenty twenty-six, Medicare is rolling out some pretty significant changes to its Local Coverage Determination for Cellular and Tissue-Based Products—CTPs—also known as skin substitutes. These are used in outpatient wound care specifically for diabetic foot ulcers and venous leg ulcers. So, why should patients seek treatment now, before these reductions take effect? KureCare a division of Veracor Group LLC City: Miami Address: 1150 NW 72ND AVE Website: https://curewounds.com

Welcome back, everyone. Today we're tackling something that could seriously affect a lot of Medicare patients out there, especially if you're dealing with chronic wounds, diabetic foot ulcers, or venous leg ulcers. Starting January 1st, 2026, Medicare is rolling out some pretty significant changes to its local coverage determination for cellular and tissue-based products, CTPs, also known as skin substitutes. These are used in outpatient wound care specifically for diabetic foot ulcers and venous leg ulcers. So, why should patients seek treatment now before these reductions take effect? Great question. The short answer is, timing matters. These new rules aren't just tweaks. They're a complete overhaul. You know, the skin substitutes used to treat those tough to heal wounds.

After January 1st, coverage becomes much more restrictive. Patients who wait could face denials, delays, or even gaps in care. So we're talking about real barriers to getting treatment. What exactly is changing? Well, first off, Medicare is now requiring that only CTPs with peer-reviewed clinical evidence will be reimbursed. If a product doesn't have solid research backing its effectiveness for diabetic foot ulcers or venous leg ulcers, it's all.

the table. Some products like Oasis Trilayer wound have been removed from coverage due to a lack of sufficient clinical evidence. On the flip side, products like Dermagide, Kerasis, and New Shield have been added to the covered list for diabetic foot ulcer indications. Kerasis is also covered for venous leg ulcers. Mm-hmm. Interesting. So evidence-based practice is the name of the game now. But there's more to it than just which products are covered, right? Exactly. Medicare is also tightening the clinical thresholds. Before a patient can even get a CTP applied, they have to go through a documented four-week trial of standard wound care first. That means regular wound checkups with precise measurements, consistent use of appropriate dressings, necessary

debridement to remove non-viable tissue, and managing any underlying health issues that affect the wound. And here's the kicker. After those four weeks, the wound has to show less than 50% reduction in ulcer area to qualify for advanced treatment. It's no longer just about whether the wound is failing to respond. There are now specific measurable criteria. So patients need documented proof that standard care isn't cutting it. What happens if someone waits until after these rules are in place? They could be looking at longer wait times, more paperwork, and potentially being denied coverage altogether if the documentation isn't perfect. Clinics and providers are going to be scrambling to adapt, and that means the whole system slows down.

If you're a Medicare patient with a chronic wound right now, getting evaluated and starting treatment before the new year gives you a much better shot at accessing the full range of therapies that are currently available. That makes sense. And I imagine this isn't only a question of access. There's a financial angle, too, right? You might say the wallet feels it just as much as the wound does. Ha ha, that's one way to put it. Yeah, the financial side is huge. That point about standard wound care documentation sets up our next piece.

The reimbursement changes. But first, a quick word from our sponsor. If you or a loved one is living with chronic wounds, diabetic foot ulcers, or venous leg ulcers, now is the time to find treatment options that work. CureCare is a national platform that combines advanced biologic wound care products with full Medicare billing support. We're a resource for patients seeking effective solutions for non-healing wounds. Learn more about how we can help you manage your care

by clicking the link in the description now. Picking up on that standard wound care documentation, how do the new reimbursement rules actually impact what patients can expect? Here's where it gets a bit tricky. Medicare is moving away from the average sales price reimbursement model for most skin substitutes. Instead, these products are being reclassified as what's called incident to supplies. That means they're bundled into the application procedure rather than paid separately.

Under the proposed rule, skin substitutes would be reimbursed at a flat rate of approximately $125. And 38 cents per square centimeter, regardless of the product type or complexity. Wow. So clinics are going to see a huge revenue hit? Definitely. And that financial pressure could lead some providers, to limit which products they offer, or even scale back, wound care services altogether. For patients, that translates to fewer options and potentially longer waits for appointments. Organizations that don't adapt quickly risk coverage denials and care delays. It's a ripple effect.

I actually had a patient recently, this was just last fall, who came in with a diabetic ulcer she'd been ignoring for months. We got her started on a CTP regimen under the current rules, and within weeks we saw a real improvement. But if she'd waited until 2026, the hoops we'd have to jump through would have been significantly tougher. Right. Makes sense. That's a powerful example.

And it speaks to the urgency here. There's also the issue of utilization limits, isn't there? Yes, under the new LCD, a CTP episode of care is limited to 12 to 16 weeks with a maximum of eight total applications. If you need more than four applications, your provider has to document healing progress and attest to medical necessity. Plus, if the wound shows infection, ischemia, or necrotic tissue, the application will be denied. The documentation burden is going to be enormous. So the key point is this.

If you delay, you're risking not just access, but the entire treatment pathway. So approval isn't a one-time thing. Providers have to prove progress every step of the way. How are these changes being rolled out nationwide? This LCD will be adopted by all seven Medicare administrative contractors, covering all 12 Medicare jurisdictions. That means nationwide consistency, which sounds good in theory, but it also means there's no wiggle room. Every provider, everywhere, has to follow the same strict rules.

A billing and coding article has been released to guide providers, but the learning curve is steep. And for patients, that consistency could mean consistency in barriers too. Have you ever wondered how much these policy changes will actually save Medicare? That's the big question. The stated goal is to decrease spending on skin substitutes and encourage price competition. By grouping products into categories based on FDA regulatory status, Medicare hopes to incentivize innovation while saving money for the Medicare Trust Fund.

But the real-world impact on patients, especially those with complex, hard-to-heal wounds, could be significant. We're talking about people who are already vulnerable. So the takeaway is clear. Don't wait. If you're a Medicare patient with a chronic wound, the time to act is now. Get evaluated. Start treatment if you're eligible.

And avoid the bottleneck that's coming in January. What's the one thing you want listeners to remember? Simple. Earlier is better. The clock is ticking and the regulatory environment is getting a lot more complicated. Proactive care now can prevent denials,

delays, and unnecessary suffering down the line. In other words, acting today protects your access tomorrow. Take control of your health while you still have full access to the options that are available. Couldn't have said it better. Thanks so much for breaking this down with us.

And to our listeners, don't let these changes catch you off guard. seek treatment now, ask questions, and advocate for your care. Until next time, stay informed and stay healthy.