Reimbursement Models for Medicaid Agencies and MCOs

The Community Epidemiology and Program Evaluation Group conducted a cost analysis of the National DPP lifestyle change program at Denver Health in 2015, which was compiled in a report prepared for the State of Colorado. Micro-costing and program information for the Denver Health National DPP lifestyle change program was provided by Denver Health for costs incurred from October 2012 to the end of calendar year 2014. Nearly half of the program participants were Medicaid beneficiaries. Component costs included the following:

• Community health worker (CHW)/lifestyle coach staffing
• Program management and supervision
• Other program support staff
• Training
• HR costs
• Other direct costs
• Facility and other indirect costs
• Program development costs

The evaluation authors estimated that costs equaled $552 per participant who attended at least one session, and $1,428 per participant who attended at least nine sessions. About 50% of the cost was attributable to coach staffing, and another 19% to program management and supervision. The remaining 25% was attributable to facility and other indirect costs. Program development costs constituted a relatively small percentage.

During the Medicaid Coverage for the National DPP Demonstration Project, a cost study of state agency, managed care organization (MCO) or coordinated care organization (CCO), and CDC-recognized organization costs were completed. A breakdown of the percentage of costs that were associated with administrative, recruitment, retention, data collection, and delivery activities for the National DPP lifestyle change program can be found here. The average cost to established CDC-recognized organizations to deliver the program was $1,529 per program participant and the average cost to new CDC-recognized organizations was $1,704 per program participant. The average cost to online CDC-recognized organizations to deliver the program was $556 per program participant.

A program manager from the Montana Department of Public Health and Human Services (Montana DPHHS) indicated the following about their reimbursement rate relative to actual cost:

“The $500 covers the basic education, the facility cost, and interactions between the coach and the participants. It may not cover some extra services which may be financed by in-kind contributions or donations. A lot of the DPP provider organizations add different value-added services such as a gym membership. Montana Medicaid has a benefit so that a beneficiary can call to get a ride or can secure reimbursement for gas. To address child care needs, we have not yet found a universal solution, but some facilities have onsite child care (e.g., YMCA). A few sites have provided incentives.”

Direct medical costs for the original DPP clinical trial were $2,780 per participant over three years. However, this featured an individual (rather than group) coaching model facilitated by case managers.

The YMCA program fee is $429 for the yearlong program. Consumers pay in a variety of ways, and YMCAs work with them if financial assistance is needed. Some payers pay a flat $429 fee regardless of how much of the program a participant completes. For claims-based reimbursement, a performance-based fee schedule is used, and payers pay claims based on the achievement of specific milestones. Average cost for the program are comprised of fixed and variable costs. When there are more participants in the program to absorb the fixed costs, the average cost can be substantially lower, but volume is key.

Under certain circumstances, individuals may be able to cover their portion of participation costs with their Health Savings Account (HSA). See the tab titled “Using HSA Dollars to Pay for the Program” in the About Employer Health Insurance section on the Coverage in Practice page for more information.

In the fee-for-service and managed care delivery systems of Medi-Cal, Californa uses a combination of an attendance milestone and performance-based approach to reimburse for the National DPP lifestyle change program as outlined below. The Healthcare Common Procedure Coding System (HCPCS) codes are listed in parenthesis (for more information about HCPCS codes, see the Coding and Billing page). California also covers the program in Medi-Cal through the managed care delivery system. For more information, see the California State Story.

For a Medi-Cal eligible participant in the National DPP lifestyle change program that attends all sessions for the two-year program and attains all the weight loss goals, the CDC-recognized organization would receive a total reimbursement of $536.

Sessions:

• Core Sessions Months 1-6:
  • (G9873) 1st session attended – $20
  • (G9874) 4 sessions attended – $40
  • (G9875) 9 sessions attended – $72
• Core Maintenance with 5% weight loss:
  • (G9878) 2 sessions attended in months 7-9 – $48
  • (G9879) 2 sessions attended in months 10-12 – $48
• Core Maintenance without 5% weight loss:
  • (G9876) 2 sessions attended in months 7-9 – $12
  • (G9877) 2 sessions attended in months 10-12 – $12
• Ongoing Maintenance Months 13-24: Maintained 5% weight loss and attended 2 sessions every 3 months
  • (G9882) Months 13-15 – $40
  • (G9883) Months 16-18 – $40
  • (G9884) Months 19-21 – $40
  • (G9885) Months 22-24 – $40

Weight Loss Performance:

• (G9880) achieved 5% weight loss OR had absolute reduction of waist circumference by 3.2 cm during months 1-12 – $128
• (G9881) achieved 9% weight loss during months 1-24 – $20

Bridge Payment for Transitioning from a Different DPP Provider:

• (G9890) Months 1-24 for first DPP core session, core maintenance session, or ongoing maintenance session – $20

Effective August 1, 2021, the National DPP lifestyle change program is available to eligible Medicaid beneficiaries in Illinois between the ages of 18 – 64. On February 4, 2022, CMS approved the state plan amendment (SPA) that includes the National DPP lifestyle change program and Diabetes Self-Management Education and Support (DSMES) services in the Illinois Medicaid State Plan.

The Illinois Medicaid rates for reimbursement for the National DPP lifestyle change program are session and performance-based for both in-person and online programs. For virtual or telehealth sessions a GT modifier can be used as well as a VM modifier for make-up sessions. The billing codes can only be used once every 365 days. Maximum Medicaid reimbursement for the National DPP lifestyle change program in Illinois is $670 per member.

The reimbursement is broken down by a series of milestones as follows:

For further information reference the Provider Notice. To learn more about Illinois’ Medicaid coverage for the National DPP lifestyle change program, visit the Illinois State Story of Medicaid Coverage page of the Coverage Toolkit.

Effective January 1, 2024, MaineCare (Maine’s Medicaid program), reimburses for the National DPP lifestyle change program in-person, online, and via distance learning. MaineCare’s benefit manual details that reimbursement is based on a session-based rate and a performance payment, as follows:

Session Rate. The allowed amount for each National DPP LCP session is 100% of Medicare’s current total reimbursement for all sessions without weight loss included in the MDPP divided by the total number of sessions required by the most current version of the DPRP Standards.

• Per session reimbursement without performance-based payments: $25/session
• Total reimbursement per client per one-year program of 22 sessions without performance-based payments: $550

Performance Payment. The allowed amount for each performance payment is 100% of Medicare’s current maximum reimbursement for additional payments related to weight loss in the MDPP divided by two (2).

• Per session reimbursement when performance payments are factored in: $34.91/session
• Total reimbursement per client per one-year program of 22 session with performance-based payment: $768

Effective September 1, 2019 the National DPP lifestyle change program is available through the HealthChoice Diabetes Prevention Program for Medicaid managed care members in Maryland. To learn more about their benefit please visit the HealthChoice Diabetes Prevention Program site.

Two reimbursement models are available to MCOs in Maryland.

1. Session and Performance Based Reimbursement Methodology – Available when the program is delivered in-person, online, or through distance learning.
2. Milestone/Bundled Reimbursement Methodology (only available when the program is delivered online, or through distance learning).

Maryland Department of Health intends to require MCOs to pay contracted CDC-recognized organizations that administer the National DPP lifestyle change program at least the minimum rates listed below, which are outlined in the Policy Transmittal and the HealthChoice Diabetes Prevention Program Manual. The HCPCS codes are listed in parenthesis (for more information about HCPCS codes, see the Coding and Billing page).

Under the minimum rates for both reimbursement models in Maryland, if a participant in the National DPP lifestyle change program attended all sessions and met all performance outcomes, the total reimbursement the CDC-recognized organization would receive is $670.

Session and Performance Based Reimbursement Methodology (available when the program is delivered in-person, online, or through distance learning)

Sessions:

• (G9873) Session 1, 1st core session attended: $100
• (G9874) Sessions 2-4, 4 total core sessions attended: $120
• (G9875) Sessions 5-9, 9 total core sessions attended: $140
• Sessions 10-19, 2 core maintenance sessions attended in months 7-9:
  • (G9876) Reimbursement if 5% weight loss goal is not achieved or maintained: $40
  • (G9878) Enhanced reimbursement for performance if 5% weight loss goal is achieved or maintained: $80
• Sessions 20-22, 2 core maintenance sessions attended in months 10-12:
  • (G9877) Reimbursement if 5% weight loss goal is not achieved or maintained: $40
  • (G9879) Enhanced reimbursement for performance if 5% weight loss goal is achieved or maintained: $80

Weight loss performance:

• • (G9880) 5% weight loss from baseline achieved: $100
  • (G9881) 9% weight loss from baseline achieved: $50

Milestone/Bundled Reimbursement Methodology (only available when the program is delivered online, or through distance learning)

Maryland Department of Health permits flexibility in bundled payment distribution across milestones 1-3 and the 5% and 9% performance payouts under this methodology, so long as the total payment per enrollee meets or exceeds $670. Below lists the recommended payment distributions.

Milestones:

• Milestone 1: May be billed at enrollment or initiation into program (0488T); scale is issued (E1639); or 1st core session attended (G9873): $220
• Milestone 2: Billed at 4 core sessions attended (G9874): $160
• Milestone 3: Billed at 9 core sessions attended (G9875): $140

Weight loss performance:

• (G9880) 5% weight loss from baseline achieved: $125
• (G9881) 9% weight loss from baseline achieved: $25

Effective July 2023, the Michigan Department of Health and Human Services set the following fee schedule to reimburse for the Michigan Diabetes Prevention Program (MiDPP):

• G9873 1 Em Core Session $38.00
• G9874 4 Em Core Sessions $115.00
• G9875 9 Em Core Sessions $191.00
• G9876 2 Em Core Ms Mo 7-9 No Wl $76.00
• G9877 2 Em Core Ms Mo 10-12 No Wl $76.00
• G9878 2 Em Core Ms Mo 7-9 Wl $101.00
• G9879 2 Em Core Ms Mo 10-12 Wl $101.00
• G9880 Em 5 Percent Wl $184.00
• G9881 Em 9 Percent Wl $38.00
• G9890 Em Bridge Payment $38.00

Total possible reimbursement per participant: $768 (not including Bridge payment)

For more information, see Michigan’s State Story of Medicaid Coverage on the Coverage Toolkit.

The Minnesota Department of Human Services reimburses for the National DPP lifestyle change program for fee-for-service beneficiaries according to the following schedule:

$13.62/session (core and maintenance) ($300 for 22 sessions)

To learn more about Minnesota’s coverage of the National DPP lifestyle change program, visit the Minnesota State Story of Medicaid Coverage.

On September 1, 2020, the Missouri HealthNet Division (MHD) instituted coverage of the National DPP lifestyle change program for eligible Medicaid beneficiaries age 21 or older. Reimbursement is set at $19.23 per session.

In year one, there can be up to a maximum of 26 sessions for months 1 through 12 (a total Medicaid reimbursement of $499.98). In year two, there can be up to a maximum of four sessions for months 13 through 24 (an additional Medicaid reimbursement of up to $76.92).

The reimbursement is broken down as follows:

• Core Services Sessions
  • (0403T) $19.23 per session/unit – Preventive behavior change, intensive program of prevention of diabetes using a standardized National DPP curriculum, provided to individuals in a group setting, minimum sixty (60) minutes, per day.
• Ongoing Maintenance Services Sessions
  • (99412) $19.23 per session/unit – Preventive Medicine Service, group counseling for ongoing maintenance.

To learn more about their benefit please reference the Provider Notice and the Missouri example on the Attaining Coverage through a Medicaid State Plan page of the Coverage Toolkit.

Montana Medicaid reimburses for the National DPP lifestyle change program according to the following schedule:

• $29.10 per weekly session in first six months ($465.60 total for completion of all 16 weekly sessions)
• $29.10 per monthly session in last six months ($174.60 total for completion of all 6 monthly sessions)

For a Medicaid eligible participant that attended all sessions, the CDC-recognized organization would be reimbursed $640.20. To learn more about Montana’s approach to coverage of the National DPP lifestyle change program, visit the Montana State Story page.

On April 12, 2019, the New York State (NYS) legislature amended its social services law to include the National DPP lifestyle change program within the definition of “standard coverage” for medical assistance for needy persons. Amending the social services law also authorized CDC-recognized organizations to enroll in NYS Medicaid and receive Medicaid reimbursement.

To secure federal Medicaid matching funds for the program NYS Medicaid submitted a Medicaid State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS) on June 28, 2019, which was expeditiously approved by CMS on September 4, 2019. To learn more about NYS’s pathway to Medicaid coverage, visit the New York’s State Story of Medicaid Coverage page of the Coverage Toolkit.

The NYS SPA outlines that the Medicaid fee-for-service (FFS) rate for the National DPP lifestyle change program is 80 percent of the max 2019 two-year Medicare National DPP lifestyle change program rate ($689). This results in a maximum reimbursement of $551 per member over 22 total sessions. However, NYS has rounded each session payment up to the nearest dollar, resulting in a maximum reimbursement amount of $554 per member. The $554 is broken down in as follows:

• (0403T) – This is a $22.00 per-member, per-session reimbursement for members who attend in-person National DPP lifestyle change program group sessions. This reimbursement is not tied to weight loss benchmarks.
• (G9880) – This is a $70.00 incentive payment that is awarded to providers for members that have achieved at least 5% weight loss from their baseline. This provider incentive payment is available only once to the provider over the course of the 22 sessions when the member first achieves the 5% weight loss from baseline. If the Medicaid member re–enrolls in a new National DPP lifestyle change program cohort at a later time, this incentive payment will be available again to the provider when the member achieves at least a 5% weight loss from the new baseline.

Additional information on NYS related to reimbursement can be found in the New York State Medicaid DPP FFS Policy and Billing Guidelines.

Reimbursement Models in Practice

Effective January 1, 2022, the National DPP lifestyle change program is a Medicaid covered benefit in Ohio.

Ohio Department of Medicaid reimburses for the in-person and online delivery of the National DPP lifestyle change program in fee-for-service Medicaid according to the fee schedules below, with a lifetime maximum of 52 billable, one-hour sessions. The standard reimbursement the CDC-recognized organization would receive for in-person delivery over a two-year period is $920, and over a one-year period it is $644. For online delivery, maximum reimbursement over a two-year period is $1,176, and over a one-year period is $588.

In-Person (CPT 0403T):

• Year One
  • Months 1-6 (16 sessions): $23.00 per day/per session
  • Months 6-12 (12 sessions): $23.00 per day/per session
• Year Two
  • Months 1-12 (12 sessions): $23.00 per day/per session

Online (CPT 0488T):

• Years One & Two
  • Months 1-24: $49.00 per month

Services furnished by a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) are paid under the Prospective Payment System at the FQHC’s or RHC’s pre-established per visit payment amount in accordance with Chapter 5160-28 of the Ohio Rule. Additional information on the benefit reimbursement can be found in the Ohio Department of Medicaid Transmittal Letter No. 336-24-15.

Effective January 1, 2019 the National DPP lifestyle change program is a Medicaid covered benefit in Oregon. To learn more about their benefit please visit the Oregon Medicaid National DPP benefit site and Oregon’s Requirements for National Diabetes Prevention Program Reimbursement document.

Oregon’s Health Authority (OHA) reimburses for the in-person, distance learning (a remote two-way telehealth class), and online delivery of the National DPP lifestyle change program in fee-for-service Medicaid according to the fee schedules below. The maximum reimbursement the CDC-recognized organization would receive for in-person or distance learning delivery over a two-year period is $1,196, and over a one-year period it is $644. For online delivery, the maximum reimbursement over a two-year period is $1,176, and over a one-year period is $588.

In-Person or Distance Learning:

Online:

OHA also produced a guide for coordinated care organizations (CCOs) to implement the National DPP lifestyle change program, which includes recommendations for determining a reimbursement methodology for CCOs (see pages 28-30).

Effective April 1, 2019, the National DPP lifestyle change program is a reimbursable service through Community Health Worker (CHW) Services within South Dakota Medicaid. Lifestyle Coaches seeking reimbursement are required to be employed and supervised by a South Dakota Medicaid-enrolled CHW agency. The National DPP lifestyle change program sessions are billed using the following CPT codes:

• 98960 – Self-management education & training 1 patient, 30 minutes: $30.89
• 98961 – Self-management education & training 2-4 patients, 30 minutes: $15.45/patient
• 98962 – Self-management education & training 5-8 patients, 30 minutes: $10.81/patient

One unit is equal to 30 minutes. When sessions are one hour in length, which is typical of the National DPP lifestyle change program, two units can be billed. Reimbursement is not tied to weight loss benchmarks and the program can be delivered in-person or online. To learn more on National DPP reimbursement and CHW services see South Dakota’s Medicaid Billing and Policy Manual.

Since reimbursement in South Dakota is based on length of time and the number of beneficiaries served, the following example offers a likely scenario for a typical cohort convening for 22 total sessions (16 weekly sessions, 6 monthly sessions).

• Seven patients served and one hour total instruction time, on average: $10.81 x 2 units x 7 patients x 22 sessions = $3,329.48 = $475.64 per participant

Effective July 1, 2022, Utah Medicaid reimburses for the National DPP lifestyle change program online and in-person according to the following schedule:

• $26.45 per session ($581.90 for 22 sessions)

Beginning in January 2020, Wyoming Medicaid opened codes allowing registered dieticians to be reimbursed for delivering the National DPP lifestyle change program to Medicaid beneficiaries. Wyoming is a fee-for-service (FFS) state and reimburses for the National DPP lifestyle change program according to the following schedule:

$19.00/session (core and maintenance) ($418 for 22 sessions)

To learn more about Wyoming’s reimbursement of the National DPP lifestyle change program, see the Wyoming example on the Attaining Coverage through a Medicaid State Plan page of the Coverage Toolkit.

The Medicare Diabetes Prevention Program (MDPP) expanded model allows Medicare beneficiaries to access evidence-based diabetes prevention services with the goal of a lower rate of progression to type 2 diabetes, improved health, and reduced spending. To learn more, please visit the Center for Medicare and Medicaid Innovation MDPP site. Additional information is also available on the MDPP Basics page of the Coverage Toolkit.

MDPP services are paid for using both a fee-for-service and performance-based payment methodology that is updated annually for inflation. The current payment rates can be found here: CMS Calendar Year MDPP Payment Rates.