CMS Finalizes Expanded Diabetes Prevention Program

Ken Terry

November 03, 2017

In its just-released final rule for the 2018 physician fee schedule (PFS), the Centers for Medicare & Medicaid Services (CMS) issued detailed regulations for the expanded model of the Medicare Diabetes Prevention Program (MDPP). Under this expanded model, which builds on an earlier test of MDPP and was announced in 2016, CMS will add MDPP as a covered benefit for Medicare beneficiaries who meet certain criteria, starting on April 1, 2018.

MDPP is designed to supply coaching services to prediabetic patients to help them lose weight and avoid developing type 2 diabetes. Community health workers and health professionals will supply these services in community and healthcare settings.

"The sessions provide practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to maintaining weight loss and a healthy lifestyle," the final rule said.

The set of MDPP services includes core sessions (first 6 months), core maintenance sessions (second 6 months), and ongoing maintenance sessions (second year). Sixteen weekly sessions must be completed within the first 6 months, when the likelihood of losing weight is greatest.

A key goal of MDPP is for beneficiaries to reduce their weight by at least 5% from baseline. They must achieve that goal by the end of the first year to be eligible for ongoing maintenance sessions in the second year.

In the 2018 PFS proposed rule, MDPP services would have been offered for up to 3 years, including 2 years of ongoing maintenance. The final rule settled on a total of 2 years.

Patients are eligible for MDPP only once in their lives. CMS said it believes that the one-time benefit will be more likely to motivate people than allowing them to re-enroll at any time.

Private plans that contract with Medicare, including Medicare Advantage plans, must also offer MDPP because it is a Part B benefit.

MDPP Criteria

To be eligible for MDPP, Medicare beneficiaries must be enrolled in Part B and have a body mass index of at least 25, or 23 if they identify themselves as Asian. They must also have a hemoglobin A1c value between 5.7% and 6.4% and a fasting plasma glucose of 110 to 125 mg/dL or a 2hour plasma glucose of 140 to 199 mg/dL (oral glucose tolerance test). They cannot have a previous diagnosis of type 1 or type 2 diabetes, other than gestational, and cannot have end-stage renal disease.

If a patient receiving MDPP services develops diabetes during the benefit period, they can keep receiving services.  However, MDPP suppliers are urged to refer the patient to an appropriate healthcare provider for treatment.

Patients can be referred to MDPP by a healthcare provider, or they can self-refer. If they refer themselves to an MDPP supplier, the latter must give them blood tests to determine their eligibility.

For a supplier to be eligible for the MDPP program, the Centers for Disease Control and Prevention (CDC), which provided the curriculum for MDPP, must recognize that provider as being qualified. According to the final rule, more than 1500 organizations are pursuing or maintaining this CDC recognition.

Regarding payment, the final rule said, "The proposed MDPP payment structure would incentivize MDPP suppliers to prioritize the achievement and maintenance of beneficiary weight loss by furnishing MDPP services, and provide a balance between performance-based payments related to weight loss and session attendance. We believed that it would be inappropriate for payment to be tied to attendance [at coaching sessions] alone because weight loss is more directly associated with a reduction in the incidence of type 2 diabetes than attendance at MDPP sessions."

The maximum total performance amount that can be paid to an MDPP supplier is $670, including attendance-based performance payments for core sessions that add up to $165.

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