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. The benefit will take effect on January 1, 2018. It is expected that Medicare Advantage (MA) plans will also be required to offer the benefit to its members.
CMS is currently in the second round of the rule-making process and additional details about the program and how MA plans will cover the program are being finalized. The first round of rule-making was finalized and published in November 2016. The second round of rule-making is expected to be released in the summer of 2017.
The MDPP: Summary of First Final Rule
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 and summarized below) 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.
There are many 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:
- Payment model
- Virtual or remote program delivery
- Standards for preliminary CDC recognition
- 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.
- 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 ongoing maintenance sessions after the core benefit if 5% weight loss is achieved
- Sessions are approximately one hour
- No minimum or maximum number of beneficiaries
- MDPP suppliers can use any curriculum approved by the CDC.
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).
- 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 preliminary or full CDC recognition. For more information on preliminary or full CDC recognition see Requirements for CDC Recognition (an interim definition of preliminary recognition will be provided in the second round of rule-making).
- All coaches (who are employed by an MDPP supplier) must obtain an NPI.
- 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.
- MDPP suppliers must submit a roster of coach NPIs, names, and social security numbers upon application for enrollment.
- There are not restrictions on who can become a coach, but individual coaches cannot apply to be an MDPP supplier.
MDPP supplier enrollment will not begin until after the next round of rule-making has been released (summer 2017).
This website will be updated once additional rule-making is complete and new information becomes available.