by Jared Staheli
December 12th, 2017
Diabetes treatment places an ever-increasing strain on the resources of the U.S. healthcare system. CMS estimated that in 2016 alone, Medicare incurred an additional $42 billion in costs due to the number of beneficiaries with diabetes. The best way to keep these costs down in the future is by preventing the development of diabetes in the first place. The Medicare Diabetes Prevention Program, which began as a pilot program under the CMS Innovation Center, aims to do just that through health behavior changes resulting in weight loss and therefore a lower risk of developing diabetes. From CMS:
“The Medicare Diabetes Prevention Program expanded model is a structured intervention with the goal of preventing progression to type 2 diabetes in individuals with an indication of prediabetes. The clinical intervention consists of a minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention (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 completing the core sessions, less intensive follow-up meetings furnished monthly will help ensure that participants maintain healthy behaviors. The primary goal of the expanded model is at least 5 percent weight loss by participants.”
How Does it Work?
MDPP is divided into two service periods. There is one year of “Core” services, with the first six months consisting of the more frequent “Core Sessions” followed by six months of “Core Maintenance Sessions.” Then, up to one more year of “Ongoing Maintenance Sessions” are covered. Eligibility for both the “Core” and “Ongoing” Maintenance Sessions will only be covered if the beneficiary attends two out of three maintenance sessions per three-month interval and for the “Ongoing” Maintenance Sessions, the beneficiary must also maintain their minimum 5% weight loss.
What did the 2018 Final Rule Change?
From the CMS Fact Sheet:
“The Calendar Year 2017 Medicare Physician Fee Schedule (CY 2017 PFS) final rule, published in November 2016, established the expansion and aspects of the expanded model policy framework. The CY 2018 PFS final rule finalizes additional policies necessary for suppliers to begin furnishing MDPP services nationally in 2018, including the MDPP payment structure, as well as additional supplier enrollment requirements and supplier compliance standards aimed to enhance program integrity. This final rule also finalizes amendments to policies in the CY 2017 PFS final rule regarding MDPP services and beneficiary eligibility.”
- MDPP services may begin being furnished on April 1, 2018
- Prospective MDPP suppliers may begin enrolling on January 1, 2018 on a rolling basis
Which Beneficiaries Does This Affect?
This program is not applicable to beneficiaries who already have diabetes, only those who are considered at-risk (i.e., prediabetic). The 2018 Final Rule did specify, however, that if a patient develops diabetes over the course of the program, they are still eligible to continue receiving the MDPP services.
Beneficiaries are only able to participate in this service once in their lifetime
What Types of Organizations can Participate?
There are no regulations on the type of organization, just requirements on “recognition.” From the CMS Fact Sheet:
“In this rule, we have finalized that an entity may be eligible to enroll in Medicare as an MDPP supplier if it has achieved MDPP preliminary recognition (either MDPP interim preliminary recognition or CDC preliminary recognition, when established) or CDC full recognition. Our intent with MDPP interim preliminary recognition is to bridge the gap until any CDC preliminary recognition standards are established and to allow organizations who have met this standard to enroll in Medicare.
Entities that have not yet reached CDC full recognition status may be able to enroll as an MDPP supplier if they meet MDPP interim preliminary recognition standards with a 12-month data submission to CDC. If CDC establishes its preliminary recognition standard through the 2018 Diabetes Prevention Recognition Program Standards, we intend to ensure the transition to CDC preliminary recognition does not disrupt MDPP supplier status.”
Note that an individual provider cannot enroll in this program, as enrollment is done only through the organization.
Click here for the CDC's Recognition Standards.
How Does Payment Work?
Payment is based on a performance structure which ties payment to the goals of attendance of the sessions and/or weight loss. The table below, adapted from the CMS Fact Sheet, explains further:
Performance Goal Performance Payment per Beneficiary WITH required minimum weight loss (5%) Performance Payment per Beneficiary WITHOUT required minimum weight loss (5%) 1st core session attended
4 total core sessions attended
9 total core sessions attended
2 sessions attended in first core maintenance session interval (months 7-9) of the MDPP core services period
2 sessions attended in second core maintenance session interval (months 10-12) of the MDPP core services period
2 sessions attended in ongoing maintenance session interval (4 consecutive 3-month intervals over months 13-24 of the MDPP ongoing services period)
*The required minimum weight loss from baseline must be achieved or maintained during the core maintenance session 3-month interval or maintained during the ongoing maintenance session 3-month interval.
*A beneficiary attends at least 1 core session during the core services period to initiate the MDPP services period; must attend at least 1 session during the final core maintenance session 3-month interval; and must achieve or maintain the required minimum weight loss at least once during the final core maintenance session 3-month interval to have coverage of the first ongoing maintenance session interval. Then, a beneficiary must attend at least 2 sessions and maintain the required minimum weight loss at least once during an ongoing maintenance session 3-month interval to have coverage of the next ongoing maintenance session interval.
There are some additional payments, which include:
- A one-time weight loss payments of $160 when 5% loss is achieved with a bonus of $25 if 9% is achieved. These payments can come at any time in the first year of “Core” services
- A “bridge” payment of $25 for a beneficiary switching MDPP providers during their services period
How do I Report Codes/Services?
There will be new G-codes released to report these services. They will likely be included in the 2018 Quarter 2 HCPCS update.
How do I Enroll my Organization?
MDPP suppliers will enroll through a new, MDPP-specific enrollment application, which will be available prior to January 1, 2018. For approved applications submitted prior to April 1, 2018, the effective date of billing privileges will be April 1, 2018. For all approved applications submitted after April 1, 2018, the effective date of billing privileges will be the date the application was submitted.