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Medicare Diabetes Prevention Program

Background

Diabetes affects more than 25 percent of Americans aged 65 or older and its prevalence is projected to increase approximately two-fold for all U.S. adults (ages 18–79) by 2050 if current trends continue. We estimate Medicare spent $42 billion more in the single year of 2016 on beneficiaries with diabetes than it would have spent if those beneficiaries did not have diabetes; per beneficiary, Medicare spent an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes (estimates based on fee-for-service, nondual eligible, over age 65 beneficiaries).

Fortunately, type 2 diabetes can usually be delayed or prevented with health behavior changes. The MDPP expanded model is a structured behavior change intervention that aims to prevent the onset of type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. This model is an expansion of the DPP model test, which was tested through the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards.

The final rule establishing the expansion was finalized in the CY 2017 Medicare PFS final rule published in November 2016. On 11/2/2017, CMS issued the CY 2018 PFS Final Rule, which established policies related to the set of MDPP services, including beneficiary eligibility criteria, the MDPP payment structure and supplier enrollment requirements and compliance standards aimed to enhance program integrity.

What is the Medicare Diabetes Prevention Program?

The MDPP expanded model is a structured intervention with the goal of preventing type 2 diabetes in individuals with an indication of prediabetes. The clinical intervention consists of a minimum of 16 intensive “core” sessions of a CDC-approved curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity and behavior change strategies for weight control. After the completing the core sessions, less intensive follow-up meetings furnished monthly help ensure that the participants maintain healthy behaviors. The primary goal of the expanded model is at least five percent weight loss by participants. The National DPP is based on the results of the DPP study funded by the National Institutes of Health. The study found that lifestyle changes resulting in modest weight loss sharply reduced the development of type 2 diabetes in people at high risk for the disease.

Overview of MDPP

The MDPP expanded model includes an evidence-based set of services aimed to help prevent the onset of type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. MDPP services will be available to eligible beneficiaries nationwide beginning 4/1/2018 under a performance-based payment model through the CMS Innovation Center.

What is Covered Through the Model?

  • Structured sessions with a coach, using a CDC-approved curriculum to provide training in dietary change, increased physical activity and weight loss strategies
  • 12 months of core sessions for beneficiaries with an indication of prediabetes, and an additional
  • 12 months of ongoing maintenance sessions for participants who meet weight loss and attendance goals

How Does the Model Pay for MDPP Services?

MDPP suppliers are paid performance-based payments through the CMS claims system. Medicare payments to suppliers will range, and can be up to $670 per beneficiary over two years, depending on beneficiaries’ attendance and weight loss.

What Does this Mean for Beneficiaries?

Beginning 4/1/2018, eligible beneficiaries have coverage of MDPP services with no cost-sharing through Medicare-enrolled MDPP suppliers.

Eligible beneficiaries are those who:

  • are enrolled in Medicare Part B’
  • have a BMI of at least 25 or at least 23 if self-identified as Asian,
  • meet one of the following three blood test requirements within the 12 months of the first core session:
    • a hemoglobin A1c test with a value between 5.7 and 6.4% or
    • a fasting plasma glucose of 110–125 mg/dL or
    • a two-hour plasma glucose of 140–199 mg/dL (oral glucose tolerance test)
  • have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes) and
  • do not have ESRD.

What Does this Mean for Providers?

Although a referral from a physician is not required for beneficiaries to participate in MDPP services, clinicians have an important role to play in helping beneficiaries understand their risk of diabetes and their treatment options. This is particularly important because only 14% of adults aged 65 and older with prediabetes are aware of their condition. Clinicians may help Medicare patients obtain the blood tests they need to become aware of their risk and recommend they participate in MDPP services.

What Does this Mean for Organizations that Wish to Deliver MDPP Services?

Organizations who wish to furnish MDPP services to beneficiaries and bill Medicare for those services must enroll in Medicare as an MDPP supplier. To enroll as an MDPP supplier, organizations must:

  • have MDPP preliminary recognition or full CDC DPRP recognition,
  • have an active and valid TIN or NPI,
  • pass enrollment screening at the high categorical risk level,
  • on the MDPP enrollment application, submit a list of MDPP coaches who will lead sessions, including full name, date of birth, SSN, and active and valid NPI and coach eligibility end date (if applicable),
  • meet MDPP supplier standards and requirements, and other requirements of existing Medicare providers or suppliers and
  • revalidate its enrollment every five years.

Key Dates

  • January 2018 – MDPP supplier enrollment begins
  • April 2018 – Enrolled MDPP suppliers may begin furnishing services and billing Medicare

Preparing to Enroll as an MDPP Supplier

Eligible organizations may enroll as a MDPP supplier beginning in January 2018. Your organization may enroll as an MDPP supplier if it meets certain criteria and applicable Medicare enrollment requirements. There are certain steps you can take to prepare for enrollment in Medicare.

Take Steps Now to Prepare to Enroll as an MDPP Supplier

You must complete the following required steps before submitting an enrollment application:

  1. Create an I&A account (for online applications only).
  2. Obtain an NPI through the NPPES.
  3. Learn how to submit an enrollment application through the PECOS.
  4. Learn about MACs, the contractors that process Medicare enrollment applications and claims, among other activities.
  5. Check out available resources and help desks.

MDPP Billing

Using MDPP HCPCS G-Codes

  • HCPCS G-codes are used when submitting claims to bill Medicare for payment. MDPP HCPCS G-codes may be used only one time per eligible beneficiary (except for G9890 and G9891)
  • The initial session (G9873) or bridge payment (G9890) claim must be submitted before any other claims will be paid
  • MDPP suppliers should submit claims when a performance goal is met
  • Use the non-payable G-code (G9891) to report attendance at sessions that are not associated with a performance goal. These codes should be listed on the same claim as the payable code with which they are associated (e.g., report G9891 for sessions two and three if you are reporting G9874 for session four attendance)
  • Each HCPCS G-code should be listed with the corresponding session date of service and rendering coach NPI
  • If a beneficiary switches suppliers, the new supplier may receive a bridge payment (G9890) for the first MDPP session furnished to that beneficiary. More than one supplier may claim a bridge payment for the same beneficiary
  • The virtual modifier, “VM,” should be appended to the end of any G-code that is associated with a session that was furnished as a virtual make-up session (e.g., G9891VM)

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