This edition covers:
- Omada’s actionable recommendations to CMS and HHS in 2025
- Reimagining what healthcare could look like as Gen X ages into Medicare
- Modernizing and progressing healthcare through continuous dialogue
Since May of 2025, The U.S. Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) have been on a regulatory sprint, issuing multiple requests to solicit public information on top of normally scheduled rule-making. One example is CMS' May request for information on a health tech ecosystem. Another is HHS' request for Information on deregulation. The White House has also weighed in, including a statement on creating a patient-centric ecosystem.
As an organization that strives to be a thoughtful representative of the digital health sector in the healthcare ecosystem, Omada participated in this sprint by providing actionable recommendations for how CMS and HHS can take advantage of digital health to effectively bend the curve of chronic disease. Here are the top five, which are reflected in the Center for Medicare & Medicaid Innovation ACCESS Model announced December 1, 2025.
1. Embrace Virtual Care Modalities for the Medicare Population
First, CMS should embrace the ability of America’s seniors to get care outside of physician offices and hospital complexes. Hundreds of thousands, if not millions, of adults ages 18 to 64 regularly get care through virtual programs, but to date, these programs have largely gone unrecognized by CMS. However, for the first time in the Physician Fee Schedule (PFS), effective January 2026, CMS proposed to allow any modality of CDC Fully Recognized Diabetes Prevention Programs (DPP) to apply to serve the Medicare population.
Historically, video-based telehealth has been permitted for select services, and a few online components offered by in-person programs have been used to fill in gaps of in-person services since the pandemic; however, no 100% virtual programs have been allowed to serve the Medicare population until now. While that’s a step in the right direction, the Medicare Diabetes Prevention Program (MDPP) will be one of the only, if not the only, CMS benefit that is authorized to be offered 100% virtually.
For example, as a result of these laws, 90% of physicians offices and nearly 100% of hospitals now use certified electronic health records (CEHR). New modalities of care, like Omada’s virtual care model, wouldn’t exist without these laws either, not to mention the new level of patient empowerment that comes with new health technology. And given that 79% of American seniors use a smartphone regularly, it’s time to make healthcare innovation available to that population as well. In June of 2025, we made this point to the government:
We recognize that, in some respects, Congressional action may be required to update Title 42, US Code. But in other respects, where care is capable of being safely supplied through synchronous telehealth or asynchronous “virtual” care, Medicare should enable such care. In doing so, Medicare should expect that such types of care may have different, lower costs to operate and different, higher ability to scale and reach underserved and rural populations. (For example, enabling appropriate care without requiring transportation of seniors could benefit seniors and our environment.) There is a growing consensus that many types of care for seniors could be easily and effectively supplied outside of a physician’s office. (See e.g. Sachin Jain, MD and Sean Duffy, “To Integrate Virtual Care, Start By Redefining The ‘Visit’, Health Affairs Forefront July 6, 2022.)
Another example is Diabetes Self Management Training (DSMT), more generally known as diabetes education. Omada already supplies this service, accredited by the same organization and under the same protocol as DSMT offered in a clinic under 42 USC 1395x. The care meets the same standards. Why can’t it be offered by other methods, as long as quality is maintained?
What’s more, services delivered asynchronously via smart phones, not tethered to synchronous time, or “site of service” for video encounters, make care more accessible to seniors in rural communities.
2. Eliminate Coinsurance for Chronic Disease
Second, CMS should rethink where it charges coinsurance, or actively urge Congress to eliminate coinsurance for chronic disease, like diabetes. Coinsurance is a financial barrier to accessing services like DSMT, which is a well-known part of the standard of care for diabetes. Coinsurance is often used to reduce utilization, even of services that help people manage chronic conditions, improve their health, and save the taxpayers money by reducing the need for acute and emergent services.
The coinsurance requirement dates back to the mid 1970s when the per-capita rate of diabetes was less than 3%. Today, that rate is over 10%. Perhaps when type 2 diabetes was less common, it made more sense to charge coinsurance. But today, when the benefits of DSMT are well-known, and the disease is endemic, coinsurance doesn’t make sense. It’s hard enough to get people to sign up for a six or 12-month set of classes to learn new eating habits, and how to test glucose and administer insulin; coinsurance is one more unnecessary barrier.
This is especially true where DSMT in Medicare is available only in physical clinics and hospitals that people must drive to, pay parking, etc.
DSMT vs. MDPP:
DSMT or diabetes education is any educational program or session that educates people on managing their diabetes (type 1 or type 2).
- Generally requires co-insurance
MDPP is a structured, Medicare-covered program focused solely on preventing type 2 diabetes.
- Does not currently require co-insurance
The good news is, in 2019, the IRS approved DSMT and supplies without co-insurance, consistent with recommendations from the United States Preventive Services Task Force (USPSTF).
USPSTF is an independent volunteer panel of experts that makes evidence-based recommendations on the effectiveness of preventive services for purposes of when coinsurance must be waived. It has concluded that lifestyle behavior change to prevent or manage diabetes has enough evidence of efficacy that when it is a covered benefit, it must be offered without coinsurance.
Building on this guidance, Omada for Diabetes is also offered without coinsurance because Omada’s DSMT curriculum meets the USPSTF criteria for appropriate lifestyle behavior change for people with diabetes.
The IRS has updated its rules on coinsurance, and the USPSTF review of evidence supports the removal of coinsurance for DSMT. It is time for CMS to support congressional action to remove coinsurance from DSMT programs across the board, so people living with diabetes can manage their condition with fewer barriers. As an experiment, CMMI’s Access Model allows participants to waive coinsurance.
3. Develop Standardized Outcome-Based Reimbursement Pathways
Third: Current reimbursement standards for the vast majority of services depend on minutes spent on care. To truly modernize and take advantage of the power of digital health, CMS should develop new reimbursement pathways that do not depend on counting time, or paying healthcare professionals for the process of using state-of-the-art digital technologies, including AI.
Rather, CMS should rapidly develop standards for evidence of outcomes that digital technologies can effectively document, and financially reward desirable outcomes.
This may require a re-think of how CMS develops reimbursement policy, but the healthcare system we have today is dramatically different from the one we stood up in 1964.
4. Reimagine the Role of Technology in Medicare
Fourth: CMS must rethink the role of digital technology in Medicare overall, not just for the management of chronic conditions. Medicare beneficiaries should be able to choose how they receive healthcare, and it should be accessible in rural or underserved communities, and to beneficiaries with transportation challenges.
This issue goes beyond individual services that can be supplied asynchronously, like diabetes prevention programs or DSMT. We now have fast, near “super computers” in our pockets and purses; thanks to HITECH, physicians and care providers can securely message with their patients via an app.
