I can’t wait to learn how this is going to affect DME stuff like pumps, insulin and infusion sets. Probably CGMs as well.
It also will affect choices of ostomy supplies. That means me.
One size doesn’t fit all. I tried 3 infusion sets until I found what works best for me. The same with Urostomy pouches.
2026 is going to be interesting to say the least.
I don’t think anything will change WRT what we do in 2026. The Wyden legislation is just expanding the bidding process to more than the initial 20, or was it 100?, pharmaceuticals.
The reference to DMEPOS in the rule changes is, so far as I can tell, to the change to move both pumps and CGMs to a rental model; don’t get a pump on Medicare until those rules go through unless you want to spend 5 years in obsolete pump hell! Or not; TL,DR,DL.
Anyway, here are the links:
This may be what you were referring too:
https://www.hmenews.com/article/cms-moves-forward-with-national-competitive-bidding
Perhaps:
In addition, the bidding system will contain a “country of origin” question to obtain information on where the product(s) is manufactured. Suppliers awarded a DMEPOS CBP contract will be listed on the Medicare Supplier Directory, along with its product(s) and country of origin information, allowing beneficiaries to have additional information about the product(s).
Obviously relevant to many people in the US.
So here’s the MAGIC from the above. @Chris, @Trying, @mohe0001 please read this; it does, in fact, answer some very important questions. (Though it is from a third party web site so it may be a false truth) :
Payment for CGMs and insulin infusion pumps will be made on a continuous, monthly rental basis with payment for all necessary supplies and accessories included in the monthly rental rates beginning on the first day of the contract period. Contract suppliers maintain ownership of the rental equipment and are allowed to bill for up to three months of rental in advance. Contract suppliers must furnish the brand of CGM or insulin pump ordered by the physician for the beneficiary. Beneficiaries who own their own CGM or insulin pump prior to the start of the contract period can continue to use their equipment until it needs to be replaced or they elect to switch to a rented device. Contract suppliers must furnish replacement supplies and accessories for the beneficiary-owned CGM or insulin pump.
YES. That’s what I wanted to hear (the bit in bold).
Now is it true?
I think they are limiting to 5 major suppliers/distributors. You read this when I originally posted it.
Let me see if I can pull info from a policy cat about the current state of this stuff. She might know something.
I think you can call ADA to ask specific questions.
The actual pdf is 700 pages long. https://public-inspection.federalregister.gov/2025-21767.pdf
So, I hear that the pump rental fee will be around $200/month. Nondurable medical (pump supplies) will be in addition to that. Highest monthly fee they expect is around $275/month for pump rental. Let me pull out my calculator. Worst case scenario might be $3,300.
@jbowler, I have a policy gal. I told her you wrote a letter and were excited to see the 5 year contract removed. She asked if she could read the letter you wrote, just to get broader perspective from the community. I said that I would ask.
@CarlosLuis, I think that the largest risk (until we see details on this) is that a selected supplier doesn’t provide your particular preferred infusion set and/or pump. Peoples largest concern, in general, is that there will be limitations on the types of pump equipment provided.
A second concern is that costs increase.
That’s not what we pay and, since the bidding process hasn’t completed or even started, it’s difficult to believe those numbers at all. See below for how it works for G7 on Part B this year. Bear in mind that at present insulin pump prices are pushing towards $10,000; the base price of the 780g is apparently $8,574. I couldn’t find Medicare approved pump prices, someone, perhaps, could post one, in the same manner as I posted prices for the G7 below?
Because the Medicare covered amounts for pumps and CGMs are so large they blow away the Part B deductible instantly; the deductible is $257. After that Medicare covers 80% of the covered/approved amounts. The DME supplier has to accept the approved amount (significantly less than the billed amount) as full payment.
The deductible and the 20% co-insurance are covered first by supplemental insurance. 89% of Original (“Traditional”) Medicare enrollees have supplemental insurance. Some supplemental insurance imposes a higher “deductible”, this ends up similar to a Part C out-of-pocket maximum.
Most (89%) of Part B enrollees have supplemental insurance of one form or another. I give the breakdown for what happens with Medigap supplemental insurance below. However, in practice every T1d needs supplemental insurance to afford a CGM or a pump.
With my supplemental insurance (Plan G) I pay the premium ($2,251.80) plus $257 per year for everything. That’s it; nothing else. This covers endos, vaccinations, doc visits, CGM, non-disposable pump 80% of extra-US emergency care, physician rip-off charges.
For those with Medigap exact coverage depends on the plan letter (A-N) and ever plan covers at least some of the 20%. I give a more detailed breakdown of Medigap plans by letter below.
The actual costs for those on Medicare without supplemental insurance, pretty much under 6% of enrollees as half of the people on Medicare use Part C, not “traditional” are certainly getting more significant in every area; there is no limit to the 20% copay. This is a problem, but it’s not relevant to pumps; CGMs are more important and people faced with that 20% copay are going to have very real problems (see my G7 numbers below).
This table is derived from the table in Oregon’s SHIBA document; I dropped the information about hospital services and gave explicit personal co-insurance amounts rather than tabulating the amount of the original 20% the plan pays. Notice that with Medigap the co-insurance is $0 for everything except K (10%) and L (5%); never 20%.
| Plan(s) | Co-insurance coverage before deducible | Coinsurance after deductible | Annual deductible |
|---|---|---|---|
| A,B,D,G,M,N | 0% | 100% | $257[1] |
| G-high | 0% | 100% | $2,870[1] |
| C,F,[2] | 100% | 100% | $0 |
| F-high[2] | 0% | 100% | $2,870[1] |
| K | 10% after $257[1] | 100% | $7,220[1] |
| L | 5% after $257[1] | 100% | $3,610[1] |
[1] These are the 2025 figures.
[2] These plans are no longer available for new enrollees.
Some things bypass the deductible and the supplement kicks in immediately, for example insulin should cost $0 except on K ($3.50/month) and L ($1.75/month). The required endo appointments will still blow away the $257 though, so it doesn’t matter at all.
Looking at CGMs (I don’t have a Part B pump) these are the actual amounts I paid
| Item | Billed amount (EHCS) | Approved amount (Medicare) | Mediare payment(80%) | Remainder (20%) |
|---|---|---|---|---|
| G7(10 sensors) | $1,050.00 | $790.90 | $630.15 | $160.75 |
| G7 receiver | $400.00 | $266.69 | $212.48 | $54.21 |
I had already met the $257 Part B deductible however you can see that a single month supply, at $263.63, would have wiped out the deductible anyway.
Had I received the full year supply (4 3-month deliveries) the Medicare approived amount would have been $3,163.6 and the after-Medicare amount would be $838.32, included $257 for the deductible.
The approved amount is 75% of the billed amount for the G7 sensors and 2/3 for the G7 receiver.
We can see what happens without supplemental insurance for just the G7:
| Item | cost | notes |
|---|---|---|
| G7 sensors | $838.32 | includes $257 Part B deductible |
| G7 receiver | $18.07 | based on 3 year life |
| Insulin | $420 | $35/month, no deductible, assume a pump but cost is the same on Part D |
| ===== | ||
| Total | $1,276.39 | Total cost without a pump |
Compare this with the $2,508.80 I pay total; a total that would cover a Part B pump (and insulin) if I had one. So that leaves $1,232.41 for a pump, pump supplies, both the doc/endo appointments, my retinal photographs etc.
My “Plan G” medigap supplement is also top-of-the-letters; so long as I hadn’t chosen plan K or L the math above would be the same but premiums would be lower.
Of course for a T1D to get Medigap after the initial enrollment period is likely to be very difficult. For T1s who didn’t get Medigap at the start Medicare Advantage seems to be the only option.
My understanding (now) is that the next round of competitive bidding for Part B DMEPOS is only just starting up and it won’t complete/come into effect until 2028. That’s based on a rapid reading of the second link I posted before.
This seems to be because there was a gap in competitive bidding after the pre-2021 round; the results kicked in in 2021 and expired in 2023:
As of this moment the bidding process has not yet started.
MA plans (Part C) seem completely different and I don’t think any of this except, maybe, the change to rental affects people on MA. This is because Part C covers Part A, Part B and, optionally, Part D and has its own competitive bidding process. Part C provides supplemental insurance and participants are not eligible to use Medigap.
I don’t think Part C plans typically given any choice about the DME provider to use; moda didn’t when I had private insurance it was use EdgePark or lose it.
Copy that.
@jbowler this is the best post I have read on the subject. Thank you!
@jbowler Thanks for taking the time to develop the information provided. The only thing I know enough about to comment on is your comment “…in practice every T1d needs supplemental insurance to afford a CGM or a pump. …” For most rules there are exceptions and as one I’ve found for most military retirees regular Medicare (no Medigap or Advantage Plan) along with Tricare for Life is about as good as it gets, particularly if what you need/use is in the Tricare formulary. (This years Tricare ruling retirees can’t get GLP-1s, but active duty can, is a troubling precedent and opens the door for further limitations for military retirees.)
That said, I don’t question the information you provide. I do take issue with the mental gymnastics and perseverance needed to determine who is paying for what. It shouldn’t be this difficult, particularly for the elderly (myself included). My concern is cost transparency. Saying “insurance covers it” or “Medicare/Medicaid covers it” just hides the actual cost from those that are paying, in one form or another, and transfers individual costs to all of us unknowingly. It lets the medical community, PBMs, and manufacturers charge what they want without our knowledge. We, the actual payers, don’t know what we’re actually paying for medical care thru direct payments, insurance payments, Medicare costs, and taxes, etc. As a personal example, I moved financial savings I made throughout my career into a 401Ks to Roths, completing the process this year and started on my wife’s savings doing the same thing. Because of that, we’re both paying over $800 per month to Medicare instead the $268 we should be paying because our perceived “income” is over Medicare allowable amounts, even though we’re not benefiting from the “calculated” income. It will likely be like that for years to come. I laud your ability to work the figures (you and my wife would get along), but the ability for the average American to understand medical costs and tax codes is long dead and needs to be restored.
Yes. The KFF webpage did it’s calculation of the number of Medicare enrollees without “additional coverage” (which is what I meant by “supplemental insurance”) this way:
- Nearly 90% of people in traditional Medicare had some form of additional coverage, such as Medigap (42%), employer or union-sponsored retiree health benefits (31%), or Medicaid (16%), but 11% (three million Medicare beneficiaries) had no additional coverage.**
Tricare is certainly part of the second entry, TFL is effectively equivalent to Medigap. Medigap, TFL and retirement benefits plans should all be “for life”. Medigap insurers cannot cancel a plan at all; all they can do is close it to new enrollees (Cigna is doing that to my Medigap Plan G).
From other people I know on Medicare the VA hospitals are also particularly important; my table doesn’t show the Part A coverage (I factored that out to simplify the table) and the Part A coverage (Part A covers hospitals) is strictly limited. Long term care is another big issue, indeed that issue is not specific to the US; in most countries “LTC” requires children.
I found one conversation on the topic. I haven’t listened to it yet, but it’s on the topic of CMS rule changes. The Capitol Hill Policies Shaping Diabetes Care
If that link doesn’t work for you, try this one. Inside Capitol Hill’s Fight for Diabetes Care: What These Advocates Need You to Know - Diabetes Connections
@jbowler Thank you for your post. As someone who is close to navigating the Medicare waters any clear explanation is helpful.
This link will take you to the “SHIP” web site, implemented by HHS, which gives links to the various (54 apparently) local state assistance programs. That leads to local advisors who can give you assistance over the telephone or face-to-face (probably depends on location) and so on. There are state specific rules for Medicare, for example rules which allow Medigap policies to be changed vary on a state-by-state basis.
These guys are pretty clear (most of the time) and much more likely to be correct than I am, particularly as the eligibility rules change in 2026.
Thanks @jbowler . I’ve been lurking all the Medicare posts for a bit. I’m not quite there yet, but soon and I want to be prepared. As an added complexity, my spouse won’t be eligible for an additional 3 years after I am.
My child bride was born in 1964 so for a few years I’m battling the twin dragons of Medicare and the ACA at once. It doesn’t help having an eligible spouse; the costs of Medicare are not altered, it’s a simple sum.
What does matter for spousal coverage is individual eligibility. Either spouse can claim the other spouse’s eligibility. This creates a conundrum for some of us; we can’t get married, because getting married voids both spouses eligibility for the prior spouses’ eligibility. That was a serious consideration for my third girlfriend, eventually we parted ways but there was no way we could get married (I did ask and she quite reasonable refused, voiding her Medicare eligibility was not the only reason.)
If that might be an issue for you, if either of you have previously been married, BE VERY CAREFUL.
Apart from that I’m not aware of any spousal issues that affect Medicare enrollment. There are complexities for sure; it may be better to stay on a spouses spousal coverage but, so far as I can tell (it was not an issue for me so I didn’t do the research) it doesn’t affect Medicare enrollment. That is because if you don’t do it when you turn you will suffer bad consequences.
SHIP probably won’t say this but don’t think to skip Part B. Yeah, it costs money, but so far as I can tell there is no way to skip it, even with spousal coverage, without incurring later costs. That is a truly complicated equation.
Thx for the advice @jbowler, 1 question though, when you said. “Either spouse can claim the other spouse’s eligibility” , does that mean that if I am eligible than my spouse who is not eligible for another 3 years can claim eligibility alongside me? If so, I would not need to shop in the ACA marketplace for my spouse when I am eligible.
No. I believe the 2026 status is as follows. I’m assuming the apparent intent of the recent changes and I’m assuming that the very well paid lawyers got it all right (unlikely), but I’ll try to explain the ambiguities afterward:
A person who turns 65 and meets the eligibility requirements for Medicare (2025, a legal resident, 2026 a green card holder or citizen) may claim Medicare on the basis of 5 quarters of payments in which case Part A requires additional monthly premiums or 40 quarters of payments in which case Part A is “free”.
If the claimant does not have 40 quarters the claimant may supplement them using tax treaty provisions for “totalization”; using equivalent payments from a foreign country to “top up” the Medicare quarters as allowed by the relevant US tax treaty.
If the claimant has had a spouse the most recent spouse’s own Medicare eligibility may be used to claim Medicare in place of the person’s own eligibility. This is the marriage trap; marry someone else and the rights to the eligibility from the prior spouse disappear.
Ambiguities: I haven’t seen anything at present to clarify if a resident who has Medicare eligibility, either the 5 quarter or 40 quarter (free Part A) version endows a spouse who is a green card holder or citizen with the quarters. The ambiguity is because the resident may not be eligible for Medicare as a result of not being a GCH/C but the spouse may well be a GHC/C but not have the quarters.
Full disclosure: I have 39 quarters, my wife 37. There is no totalization agreement for Medicare for the UK (me) and there is no treaty whatsoever with Taiwan (my wife)[:colon:]
Broadly similar rules apply to “social security”, aka the state pension in UK terms, however both countries don’t endow the pension until the age of 67 (for men, in the case of the UK). There is a totalisation agreement in the UK-US tax treaty for “social security/pension”, but that happens in two years and still does not cover Medicare.
This is just me, it’s much, much, much simpler for most Americans but the system complexity invariably singles someone out, so, if there is one thing I want to say to my fellow Americans, don’t assume it isn’t you.
I asked about CMS bidding during this session in an effort to drum up information.
They basically said that the last time there was competitive bidding on glucometers, it was a disaster. Everyone lost access. I’ve heard that before from a variety of policy cats.
People often say the government lacks any knowledge of how healthcare works, so it never works well when they insert themselves into the process. They have a tendency to break stuff instead of fix stuff.
They talk about CMS, specifically, at min 32.
Thanks for digging this YouTube forum up @mohe0001 and keeping the greater discussion on track. #points@self
The strangest response was at the end when I asked them about OTC sales of insulin and CGMs. I keep trying to make a play to get insulin over the counter. They really didn’t love that idea. But, I have heard that response more than once now - that running meds OTC just allows insurance to reap all the benefits of improved health outcomes without any effort on their part. That perspective is floating around in connection tot GLP-1.
I would like that connivence, but besides the danger of insulin to the uninformed, there are idiot muscle heads, excuse me, body builders using insulin to increase their muscles.