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Glossary of Terminology

 
Below is a list of terminology that may be helpful as you navigate the information on this website:

 

0403T Code = A code developed to allow CDC-recognized national DPP providers to submit a claim for reimbursement based on negotiated agreements with local payers.

1115 Waiver = Section 1115 of the Social Security Act gives the Secretary of Health and Human Services the authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid program.

1915(b)(3) Waiver = Allow states to use the cost savings generated from managed care delivery systems to provide additional services to Medicaid beneficiaries such as maternity care programs, Nurse-Family Partnership programs, and other non-Medicaid services. The additional services are subject to CMS approval and must be for medical or health-related care or other services as described in federal regulation.

6|18 Initiative = This CDC initiative offers proven interventions that prevent chronic and infectious diseases by increasing their coverage, access, utilization, and quality. Additionally, it aligns evidence-based preventive practices with emerging value-based payment and delivery models.

A1C test = A blood test that measures an individual’s average blood sugar level over the previous three months. It is different from the daily blood sugar checks people with diabetes perform and is often used to diagnose prediabetes and diabetes.

Alternative services mechanism = A Medicaid managed care mechanism that allows “in lieu of services” to be offered in place of other services under Medicaid managed care organization (MCO) contracts if such alternative services or settings are medically appropriate, cost-effective, and are offered on an optional basis for both the MCO and its enrollees.

Application approval date = The date CDC approves an organization’s application for participation in the CDC DPRP. An organization may begin offering classes immediately after receiving their application approval date.

Applicant organization (organization) = An organization that offers the National DPP lifestyle change program and is in the process of applying for pending recognition from the CDC DPRP.

Budget neutral = Over the course of a demonstration (or 1115 waiver period), federal Medicaid expenditures will not be more than what federal spending would have been without the waiver.

CDC-recognized organization (recognized organization) = An organization that offers the National DPP lifestyle change program and has received either pending or full recognition from the DPRP.

CMS’ Preventive Services Rule = Allows state Medicaid agencies to reimburse for preventive services provided by professionals that may fall outside of a state’s clinical licensure system, as long as the services have been initially recommended by a physician or other licensed practitioner.

Cohort = A cohort is a set of participants in a lifestyle change program. A completed cohort is a cohort that has a fixed first and last session and runs for 12 months. An organization can have multiple cohorts running at the same time.

Community health workers (CHW) = A frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community they serve.

Cumulative diabetes incidences = The probability of developing diabetes over a stated period of time.

Current Procedural Terminology (CPT) = A medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations.

CPT Category I Codes = Five digit codes that describe a procedure or service.

CPT Category II Codes = These codes are used to track the performance of certain services and/or test results that contribute to quality patient care.

CPT Category III Codes = Used to designate newly emerging technologies and to track their usage in the medical community.

Data collection period = For the first data submission, the data collection period would include data from sessions held between the application approval date to the data submission due date, six months later. For subsequent submissions, the data collection period would include data from sessions between the previous due date and the data submission due date, six months later.

Delivery System Reform Incentive Payment (DSRIP) = A type of Medicaid reform project, included in 1115 waivers, that allows providers or payers participating in the demonstration to receive financial support from a pool of state and federal dollars for implementing delivery system or payment reforms in a designated region.

Diabetes Action Plan = Legislation passed to establish a collaborative process across state agencies to ensure state legislators and other policymakers are strategically taking steps toward reducing the prevalence of type 2 diabetes. Agencies typically involved include the Medicaid agency, the state department of health, and the agency responsible for state employee health benefits.

Diabetes Advocacy Alliance (DAA) = A coalition of 22 members, representing patient, professional and trade associations, other nonprofit organizations, and corporations, all united in the desire to change the way diabetes is viewed and treated in America. The DAA was formed and began activities in January 2010.

Diabetes Prevention Program (DPP) = The 2002 NIH original research study which showed that making modest behavior changes helped participants lose 5% to 7% of their body weight and reduced the risk of developing type 2 diabetes by 58% in adults with prediabetes (71% for people over 60 years old).

Diabetes Prevention Recognition Program (DPRP) = The quality assurance arm of the National DPP charged with evaluating organization performance in effectively delivering the lifestyle change program with quality and fidelity. The DPRP awards CDC recognition to organizations that are following a CDC-approved curriculum and achieving meaningful results with participants based on established evidence-based national standards.

DPP Lifestyle Intervention (lifestyle intervention) = The intervention developed for the 2002 DPP research study or replicated during further efficacy and implementation studies.

Effective date = The first day of the month following an organization’s application approval date.

EHR = Electronic health record systems, an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

Fasting plasma glucose = A simple blood test that is taken after fasting to measure the current level of blood glucose. Can be used to help diagnose pre-diabetes or diabetes.

Fee Schedule = A list of the maximum rate a payer will allow for services, with the definition of services based on CPT and ICD 10 codes.

Full recognition = The CDC recognition status that, like preliminary (see below), allows organizations to become Medicare Diabetes Prevention Program (MDPP) suppliers and to begin billing Medicare. Full recognition is required to remain a MDPP supplier after the 24 months of preliminary recognition expires. Organizations will be awarded full recognition when they meet the following criteria:

  • The 12-month data submission includes at least 5 participants who attended at least 3 sessions in the first 6 months and whose time from first session to last session of the lifestyle change program was at least 9 months.
  • They meet the requirements for pending and preliminary recognition.
  • They meet all requirements for documentation of body weight, documentation of physical activity minutes, weight loss achieved at 12 months, and the program eligibility requirement as defined in the DPRP Standards and Operating Procedures.

Health Care Innovation Awards = The Health Care Innovation Awards – Round Two – are awarded from the Center for Medicare and Medicaid Innovation, funding up to $1 billion in awards and evaluation to applicants across the country that test new payment and service delivery models that will deliver better care and lower costs for Medicare, Medicaid, and/or CHIP enrollees.

Healthcare Effectiveness Data and Information Set (HEDIS) = A tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service.

Health Information Technology for Economic and Clinical Health Act (HITECH Act) = Legislation created in 2009 to stimulate the adoption of electronic health records and supporting technology in the United States.

Health Insurance Portability and Accountability Act (HIPAA) = Legislation that provides data privacy and security provisions for safeguarding medical information.

International Classification of Diseases (ICD-10) = A system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care in the U.S.

Medicaid Federal Match = The federal government’s share of the cost of covered services in state Medicaid programs. Federal Medicaid match can be claimed for both direct service costs as well as administrative costs. On average, the federal share has been 57%, meaning states are responsible for cover 43% of Medicaid costs and the federal government covers the remaining 57%.

Medicaid Managed Care Organizations (MCO) = Provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations that accept a set per member per month payment for these services.

Medicaid Managed Care Performance Improvement Projects (PIPs) = Federally mandated quality improvement projects developed and conducted by Medicaid managed care organizations (MCOs). PIPs can focus on either clinical or nonclinical areas and topics range from improving diabetes care and management, to reducing unnecessary hospital readmissions and emergency department visits, to addressing substance use disorders.

Medicaid State Plan = A contract between a state and the Federal Government describing how that state administers its Medicaid program.

Medical Loss Ratio (MLR) = The percentage of insurance premium dollars spent on health care claims and expenses.

Medicare Access and CHIP Reauthorization Act (MACRA) = In April 2015, Congress enacted MACRA legislation that alters the method by which physicians and other health care providers are paid for Medicare Part B services.

National Committee for Quality Assurance (NCQA) = An independent non-profit organization in the United States that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation.

National Diabetes Prevention Program (National DPP) = A partnership of public and private organizations working collectively to establish, scale, and sustain an evidence-based lifestyle change program for people with prediabetes to prevent or delay onset of type 2 diabetes.

National Provider Identifier (NPI) = A unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).

Participants = Individuals who meet CDC-eligibility criteria for the National DPP lifestyle change program and elect to enroll.

Payers = Health plans or state agencies that contract with CDC-recognized organizations to provide the National DPP lifestyle change program for their members or beneficiaries.

Pending recognition = The CDC recognition status granted to all applicant organizations once an initial application is approved.

Preliminary recognition = The CDC recognition status that allows organizations to become MDPP suppliers and to begin billing Medicare. Organizations will be awarded preliminary recognition when they meet the following criteria:

  • The 12-month data submission includes at least 5 participants who attended at least 3 sessions in the first 6 months and whose time from first session attended to last session of the lifestyle change program was at least 9 months.
  • Of the participants, eligible for evaluation in #1, at least 60% attended at least 9 sessions in months 1-6, and at least 60% attended at least 3 sessions in months 7-12.

Preventive Services Rule = A rule change issued by CMS in April 2014 that allows states to offer Medicaid services that are provided by non-licensed staff.

Provider integrators = Entities that manage networks of CDC-recognized organizations as well as provide functions such as billing. Also, known as third-party administrators (TPAs). They are generally paid a percentage of claims.

RTI International = An independent nonprofit research institute dedicated to improving the human condition.

State plan amendment (SPA) = A change to the State Plan submitted to CMS for approval.

The National DPP lifestyle change program = The translated adaption of the DPP lifestyle intervention which includes all of the following:

  • is a year-long structured program (in-person group, online, or combination) consisting of:
    • an initial 6 month phase offering at least 16 sessions over 16–24 weeks and
    • a second 6 month phase offering at least 1 session a month (at least 6 sessions)
  • is facilitated by a trained lifestyle coach.
  • uses a CDC-approved curriculum.
  • includes regular opportunities for direct interaction between the lifestyle coach and participants.
  • focuses on behavior modification, managing stress, and social support.

Third-Party Administrator (TPA) = An organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.

Trained lifestyle coach = Individuals trained to use the CDC–approved curriculum. These individuals must have the knowledge and skills to effectively deliver the program. The coaches lead the lifestyle change program sessions and support and encourage participants.

United States Preventive Services Task Force (USPSTF) = An independent panel of experts that publishes recommendations for evidence-based clinical preventive services. The Affordable Care Act requires a subset of health plans to cover items and services with a grade A or B USPSTF recommendation without cost-sharing for the relevant member. Counseling requirements referenced in some of the recommendations can be met through coverage of the National DPP lifestyle change program.

Value-added services = Medical or nonmedical services provided by Medicaid MCOs that fall outside direct care costs. They are services MCOs use to attract Medicaid enrollees to their plans or improve health outcomes. Examples include health education classes, reduced limitations on medications, or incentive programs.

Waiver for 12-Month Continuous Eligibility = An 1115 waiver that would allow for 12-month continuous eligibility for Medicaid populations.