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Medicare Diabetes Prevention Program (MDPP)

Medicare Diabetes Prevention Program announcements, MDPP benefit details and more included below.

MDPP Announcements

The proposed beginning date is April 1, 2018, Medicare Part B insured participants will be able to attend the National DPP lifestyle change classes as a preventive benefit without a co-pay.

Medicare Diabetes Prevention Program (MDPP)

On March 23, 2016, the Department of Health and Human Services (HHS) announced that the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary (OACT) certified that the National Diabetes Prevention Program (National DPP) lifestyle change program would “reduce net-Medicare spending.” It reviewed results from the first two years of the YMCA of the USA (Y-USA) Health Care Innovation Award implementation, the original DPP randomized clinical trial, and a subset of National DPP lifestyle change programs recognized by the CDC.

New Announcement!

The Centers for Medicare and Medicaid (CMS) is in the process of setting up a support center to assist organizations that want to become MDPP suppliers. CMS will have a webinar, web site with tip sheets and more. The Medicare DPP rule won’t be finalized until November, therefore, CMS can’t announce these resources until then. More on this soon.

Payment for MDPP Services

  • MDPP services will be paid for through a performance-based payment methodology (final payment amounts announced soon)
    • A maximum of $810 per beneficiary will potentially be paid for the set of MDPP services, equating to approximately $18 per session if all goals are achieved.
    • MDPP payments will not be risk-adjusted for social risk factors or geography
  • 19 HCPCS codes have been established to submit claims for payment
  • If a beneficiary changes MDPP supplier mid-MDPP services period, the new supplier must obtain and maintain the beneficiary’s MDPP record from the previous supplier. A $25 bridge payment will be paid to the new supplier to cover initial administrative costs.

 

MDPP Requirements

The proposed beginning date is April 1, 2018, Medicare Part B insured participants will be able to attend the National DPP lifestyle change classes as a preventive benefit without a co-pay.

Requirements for Medicare DPP (MDPP)

In order to bill Medicare for reimbursement of the National DPP, the following must be met by your National DPP organization.

  1. Enroll as a Medicare provider and receive a National Provider Identifier (NPI) number.
  2. Have preliminary or full recognition status from the CDC’s DPRP program.
  3. Pay a proposed one-time $560 enrollment fee to Medicare (CMS).

Scholarship for Enrollment Fee

The Utah Department of Health, EPICC Program, is offering to pay for your organization's $500 enrollment fee to Medicare to become an MDPP provider. Please contact Celsa Bowman at cbowman@utah.gov or call (801) 538-6273 for details.

What Can Your Organization Be Doing Now?

  • Understand enrollment regulations
  • Understand Screening regulations set forth in 424.518(c) for “High Categorical Risk”:
    • Site visit by CMS
    • Fingerprints required from anyone who has 5% or more ownership interest in the organization
    • Background checks
  • Understand the application process to enroll in Medicare - Internet Based PECOS
  • Download free software to submit claims – PC-ACE Pro32
  • Review process for obtaining a National Provider Identifier (NPI)
  • Continue to work toward obtaining full-recognition from the CDC’s DPRP
  • Work with provider groups to encourage Medicare beneficiary referrals with blood-based values
  • Watch for the new DPRP Standards and the next final rule (round 2) to come out in Spring/Summer 2017

Additional Resources

MDPP Details

The proposed beginning date is April 1, 2018, Medicare Part B insured participants will be able to attend the National DPP lifestyle change classes as a preventive benefit without a co-pay.

Details of the MDPP Benefit

  • Core benefit is 12 consecutive months
  • Core sessions = at least 16 weekly core sessions over months 1-6
  • Core maintenance sessions = at least six monthly core maintenance sessions over months 6-12. Offered regardless of weight loss
  • CDC-approved core curriculum
  • Session duration requirement – approximately one hour
  • Ongoing maintenance sessions are offered monthly after the core benefit IF participants achieve and maintain the required minimum weight loss of five percent (5%)
    • “Maintenance of weight loss” – achieving the required minimum weight loss (5%) from baseline weight at any point during each 3 months of core maintenance or ongoing maintenance sessions
    • “Maintenance session bundle” – each 3-month interval of core maintenance or ongoing maintenance sessions

Beneficiary Criteria

  • Enrolled in Medicare Part B
  • BMI of at least 25 or at least 23 if self-identified as Asian
  • Have, within the 12 months prior to attending the first core session:
    • HgbA1c test with a value between 5.7 and 6.4 or
    • Fasting plasma glucose of 110 – 125 mg/dL or
    • 2-hour post-glucose challenge of 140-199 mg/dL
  • No previous diagnosis of type 1 or type 2 with the exception of gestational diabetes (GDM)
  • Do not have end-stage renal disease (ESRD)
  • No previous receipt of MDPP services

Beneficiaries who meet the eligibility criteria would only be able to receive MDPP services once in their lifetime.

MDPP Referral Options

  • Self-referral
  • Community-referral
  • Health care practitioner-referral (which includes non-physician practitioner referrals)

Who Can Be an MDPP Supplier?

  • An organization with preliminary or full recognition from the CDC’s Diabetes Prevention Recognition Program (DPRP). Prelimary recognition will require that an organization submit at least one year of class data to the CDC/DPRP.
  • Existing Medicare suppliers would have to enroll separately as MDPP suppliers and also pay a $560 enrollment fee to CMS.

What About Lifestyle Coaches?

  • Coaches need to obtain an CMS National Provider Identification (NPI).
  • National DPP organizations will need to submit a roster of coach NPIs, names and SSNs to CMS upon applying for enrollment as an MDPP supplier
  • Coaches cannot apply to be an MDPP supplier on their own
  • Just like the CDC DPRP’s definition of recognized programs, MDPP suppliers are at the organizational level
  • Any individual can become a Coach