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.
On July 7, 2016, the administration proposed to expand the Medicare Diabetes Prevention Program (MDPP) to eligible Medicare Part B beneficiaries, and issued a final rule to implement aspects of the MDPP expanded model as part of the CY17 Physician Fee Schedule (PFS) in November 2016. In July 2017, additional rules and details about the expanded program were proposed. The proposed details will be finalized after public comments have been received and reviewed.
The benefit is proposed to take effect on April 1, 2018. It is expected that Medicare Advantage (MA) plans will also be required to offer the benefit to its members; additional information is expected to be released that will provide details on how MA plans will cover the program. For more information, visit the Center for Medicare and Medicaid Innovation or see CMS MDPP Expanded Model Fact Sheet.
The MDPP: Summary of Rules
The MDPP expanded model will be implemented through several rounds of rule-making. The first round of rule-making (finalized and published in November 2016) focuses on enabling organizations to prepare for enrollment, and includes details about the MDPP benefit, beneficiary eligibility criteria, authorized referrals, and MDPP supplier eligibility and enrollment. The second round of proposed rule-making (published in July 2017) has not yet been finalized. It focuses on the payment structure, beneficiary engagement incentives, MDPP supplier standards, and clarifications regarding MDPP services and beneficiary eligibility.
There are some aspects of the program that have not yet been finalized and will be detailed in further rulemaking. Some of the policies that will be addressed in future rules include:
- Virtual or remote program delivery – CMS is considering implementing a separate model under CMS’ Innovation Center to test and evaluate virtual DPP services. The model would run in parallel with the MDPP Expanded Model.
- Program integrity safeguards
It is important to note that there are some key differences between the National DPP lifestyle change program and the MDPP, including:
- Age of beneficiaries (limited to those enrolled in Medicare Part B)
- Beneficiary eligibility criteria
- National DPP CDC-recognized organization eligibility criteria vs. MDPP supplier eligibility criteria
- The MDPP will be covered under Medicare Part B as a preventive service once per lifetime.
- Medicare cost sharing does not apply to MDPP services.
- Benefit description:
- Core benefit is 12 months
- 16 weekly core sessions over months 1-6
- 6+ monthly core maintenance sessions in months 6-12, regardless of weight loss
- Access to 24 months of ongoing maintenance sessions after the core benefit if 5% weight loss is achieved and maintained and attendance requirements are met
- Sessions are approximately one hour
- No minimum or maximum number of beneficiaries
- Limited in-person and virtual makeup sessions may be provided
- MDPP suppliers can use any curriculum approved by the CDC.
- Although virtual makeup sessions are approved, virtual DPP services are not currently included.
Beneficiary Eligibility Criteria and Referrals
- Eligibility criteria:
- Are enrolled in Medicare Part B;
- BMI ≥ 25; ≥ 23 if self-identified as Asian;
- A1c (HgA1c) between 5.7 and 6.4%, or a fasting plasma glucose of 110-125 mg/dL, or a 2-hour post-glucose challenge of 140-199 mg/dL (oral glucose tolerance test) within the previous 12 months;
- Have no previous diagnosis of type 1 or type 2 diabetes with the exception of a previous diagnosis of gestational diabetes; and
- Does not have end-stage renal disease (ESRD) at any point during the MDPP services period.
- The MDPP benefit is available for coverage only once per lifetime.
- The following referrals are allowed, as long as blood test results indicate eligibility:
- Community referral
- Self referral
- Physician referral
- Other health care practitioner referral
MDPP Supplier Eligibility and Enrollment
- MDPP suppliers must 1) enroll under Medicare; and 2) have full CDC recognition or 3) meet the MDPP interim preliminary recognition standard. For more information on full CDC recognition see Requirements for CDC Recognition. CMS provided interim preliminary recognition standard requirements in the second round of rule-making. It includes:
- MDPP suppliers must have pending CDC recognition,
- Follow 2015 CDC DPRP standards for data submission, and
- Submit 12 months of performance data to CDC on at least one completed cohort of at least 5 participants who attended at least 3 sessions in the first 6 months. At least 60 percent of the participants eligible for evaluation must have attended at least 9 sessions in months 1–6 and at least 3 sessions in months 7–12.
- MDPP suppliers must also maintain at least one administrative location—a non-private residence—and a primary business telephone number.
- All coaches (who are employed by an MDPP supplier) must obtain an NPI, which will be reported with Medicare claims
- To be eligible to provide MDPP services, coaches may not have had Medicare billing privileges revoked or have been convicted of a felony within the last 10 years.
- Individual coaches cannot apply to be an MDPP supplier.
- All CDC-recognized organizations must enroll in Medicare as MDPP suppliers to furnish and bill for MDPP services.
- Existing Medicare suppliers must enroll as MDPP suppliers to offer the program.
- If an MDPP supplier’s Medicaid billing privileges are revoked, Medicare billing privileges will also be revoked.
- MDPP suppliers must submit a roster of coach NPIs, names, and social security numbers upon application for enrollment.
- MDPP supplier enrollment will not begin until after the next round of rule-making has been released, but January 1, 2018 is the proposed date stated in the current proposed rule.
Payment for MDPP Services
- MDPP services will be paid for through a performance-based payment methodology (see table below)
- A maximum of $810 per beneficiary will be paid for the set of MDPP services, equating to ~$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.
Beneficiary Engagement Incentives
- If an MDPP supplier offers an in-kind incentive, the item or service must be provided during the MDPP services period and must have a reasonable connection to the CDC-approved curriculum.
- Cost of incentives must not be shifted to another Federal health care program
- MDPP suppliers must maintain documentation of incentives that individually exceed $25 in retail value; incentives involving technology may not, in aggregate, exceed $1,000 in retail value for any one MDPP beneficiary.