Building Network Capacity and Supporting CDC-Recognized Organizations

Within Medicaid, states must ensure adequate access to providers (i.e., CDC-recognized organizations). The “equal access provision” outlined in Title 42 of the Code of Federal Regulations (CFR) requires that state Medicaid reimbursement ensures that program enrollees have the same access to care that is available to the general population (42 CFR 447.204).

Additionally, states must monitor access to care through an access monitoring review plan. “The access monitoring review plan and analysis must, at a minimum, include: The specific measures that the state uses to analyze access to care such as, but not limited to:

• Time and distance standards,
• Providers participating in the Medicaid program,
• Providers with open patient panels,
• Providers accepting new Medicaid beneficiaries,
• Service utilization patterns,
• Identified beneficiary needs,
• Data on beneficiary and provider feedback and suggestions for improvement,
• The availability of telemedicine and telehealth, and
• Other similar measures…”. (42 CFR 447.203)

The Medicaid managed care rule finalized in April 2016 and updated in 2020 includes several provisions related to network management that will need to be followed when contracting with CDC-recognized organizations.

First, all MCO contracted providers (i.e., CDC-recognized organizations) are required to enroll with the state as Medicaid providers, even if they do not deliver services to Medicaid fee-for-service beneficiaries. As Medicaid enrolled providers, these organizations will need to comply with Medicaid program integrity rules such as confidentiality, screening, and disclosure standards.

Second, states must set a quantitative network adequacy standard for certain classes of provider types contracting with MCOs. States can choose which quantitative standard they use (e.g., minimum provider-to-enrollee ratios, maximum travel time or distance to providers, a minimum percentage of contracted providers that are accepting new patients, maximum wait times for an appointment, hours of operation requirements, or a combination of these quantitative measures). While CDC-recognized organizations are not one of the designated classes of providers subject to these standards, MCOs might consider using similar types of quantitative standards when developing their National DPP lifestyle change program networks.

Beyond state and federal rules, some key issues MCOs may want to consider when establishing a network of CDC-recognized organizations for the National DPP lifestyle change program include:

• Geographic dispersion to ensure adequate access and availability of programs;
• The data tracking processes and mechanisms to be used by the covered providers; Standards for claims submission processes; etc.

Nearly every state has flexible qualitative network adequacy standards such as requiring networks to be “sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without reasonable delay.” For more information see Regulation of Health Plan Provider Networks.

However, more than half of states have also implemented objective quantitative tests of network adequacy. Common quantitative standards include:

• Maximum time and distance enrollees travel to access services
• Types of providers available to enrollees
• Maximum length of time enrollees wait for appointments for nonemergency services
• Ratios of providers to enrollees

Commercial plans, self-insured employers, and the CDC-recognized organizations they contract with to provide the program should be aware of all state network adequacy statutes and regulations in states where they operate. For quick reference, a summary of network adequacy standards developed by the National Conference of State Legislatures is available here (dated 02/01/2018).

Section 1311(c) of the Affordable Care Act (ACA) introduced federal network adequacy standards for individual market and small group commercial plans that are Qualified Health Plans.
Qualified Health Plans are required to have a provider network that:

1. Includes essential community providers in accordance with 45 CFR 156.235;
2. Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay; and
3. Is consistent with the network adequacy provisions of section 2707(c) of the Public Health Service Act.

A Center for Medicare & Medicaid Services (CMS) letter describing how this standard will be applied in 2017 is available here.

These federal rules serve as a “regulatory floor,” but states have the latitude to retain authority over enforcing network rules. Therefore, state network standards also apply to Qualified Health Plans.

An initial strategy for states in assessing network capacity may be to map or otherwise represent existing CDC-recognized organizations to show the number and location within a state. This information can be used to identify gaps according to different filters, such as areas with elevated diabetes prevalence and/or obesity, low socioeconomic levels, and at-risk populations. For example, the location of CDC-recognized organizations (shown for Minnesota in Figure 1 below) could be overlayed with other factors, such as adult diabetes prevalence (shown for Minnesota in Figure 2 below). States can use this information to guide decisions on where and how to prioritize support for new and existing CDC-recognized organizations.

A list of CDC-recognized organizations that is filterable by state, city, or organization can be found here.
 

Figure 1. Minnesota CDC-Recognized Organizations, 2019

 

 

Figure 2. Minnesota Adult Diabetes Prevalence by County Overlayed
with National DPP CDC-Recognized Organization Sites, 2016

 

 

A useful resource to track and map state and local data can be the CDC’s United States Diabetes Surveillance System, an interactive web application that compiles diabetes data and trends at national, state, and county levels. The Surveillance tool provides estimates and trends of diabetes prevalence, risk factors, preventive care practices, and complications. The system also includes a Social Determinants of Health tool that provides county-level estimates of diabetes, physical inactivity, and obesity within the context of important social factors.

Study authors from the CDC’s Division of Diabetes Translation have published information regarding program availability by county-level diabetes incidence and by disadvantaged socioeconomic status. Disadvantaged status is measured using the Area Deprivation Index (ADI) score. According to CDC, “ADI is a geographic area-based measure of the socioeconomic disadvantage experienced by a community. The index uses various markers of socioeconomic status including level of education, housing value, family income, and unemployment status. High disadvantage is associated with a higher risk for poor health, as well as poorer health care outcomes.” For example, Figure 3 below shows the publicly available in-person National DPP lifestyle change program classes compared to the ADI Score in Minnesota. This article includes similar maps of the United States that can help assess the presence of publicly available National DPP lifestyle change program classes as of March 1, 2017. Organizations could use maps like these to understand the counties most in-need of new programs.
 

Figure 3: Publicly Available In-Person National DPP Lifestyle Change Program Classes Compared to ADI Score, 2017

 

 

Beyond the statewide distribution of CDC-recognized organizations, it can be important to understand the realities of the different entities, including:

• Delivery mode (in-person, online, distance learning, or combination)
• Level of DPRP recognition (preliminary, pending, or full)
• Populations being served
• Language(s) for delivery and program materials (both current programming and capabilities)
• Program saturation (e.g., Do they find it difficult to fill classes or is there a wait list?)
• Capacity for expansion (through adding locations, classes, trained lifestyle coaches, language or cultural adaptations, or additional delivery modes)
• Billing/reimbursement mechanisms in place (such as managed care organizations (MCOs), Medicaid, or commercial/employer contracts)
• Access to bi-directional referral systems
• Technical assistance needs

It can also be helpful to identify MDPP suppliers within a state. This information can help states better understand how potentially sustainable their existing network is, and where to focus efforts on capacity building and expansion. To become an MDPP supplier, CDC-recognized organizations must enroll in Medicare and must have capabilities to submit claims to Medicare for reimbursement (these capabilities could be applied to other payer types).

• A list of current MDPP suppliers can be found here.
• A map of current MDPP suppliers by zip code or region is available here.

For more information about the MDPP, see the MDPP page of the Coverage Toolkit.

To better understand the capacity and technical assistance needs of current CDC-recognized organizations, several states have conducted research through surveys, focus groups, barrier analyses, and other mechanisms. The identification of technical assistance needs helps states develop training opportunities, resources, ongoing communications, and support that states provide to CDC-recognized organizations. For additional information on providing technical assistance to CDC-recognized organizations, see the Providing Technical Assistance and Building Core Business Skills section below.

Surveys

Surveys can be a convenient way to learn more about the CDC-recognized organizations in the state. Surveys have the advantage that they can be administered remotely to a large number of organizations.

Focus Groups

Another approach to gathering information about technical assistance needs is by asking questions to a focus group. This approach gives the interviewer the opportunity to adapt questions and to ask follow-up questions. Focus groups can also allow responders to build on each other’s answers.

Barrier Analysis

Barrier Analysis is a model used to identify root causes of a particular behavior or trend in order to develop effective social and behavioral change messages, strategies, and activities to address positive change or uptake.

Accountable care organizations (ACOs) are groups of providers who are responsible for the cost and quality outcomes of a defined population of patients. ACOs and other types of alternative payment arrangements (also called value-based payment arrangements) are meant to reward health care providers for keeping patients healthy. Given these incentives, ACOs can be important partners in the effort to advance the National DPP lifestyle change program by becoming CDC-recognized and delivering the program, making referrals to existing programs, or becoming champions of type 2 diabetes prevention within their networks.

More information can be found on the How to Engage ACOs in the National DPP Lifestyle Change Program page of the Coverage Toolkit.

Diabetes Self-Management Education and Support (DSMES) programs may be a key resource for expanding the network of CDC-recognized organizations in many states, as there is significant geographic coverage of existing locations across the United States. These programs are also generally equipped to handle systems such as privacy compliancy, data sharing, and billing, and have an intact program infrastructure with coordinators and staff (who could potentially be trained as lifestyle coaches).

DSMES programs are often linked into physician referral systems and may already be connected to potential participants. They are also well-positioned to transition potential or existing participants who are identified as having type 2 diabetes (either before, during, or after participating in the National DPP lifestyle change program) to appropriate alternative services.

Both the Association for Diabetes Care and Education Specialists (ADCES) and the American Diabetes Association (ADA) share information about their accredited and recognized programs with CDC, and that data informs the map on ADCES’ website DiabetesEducator.org/Find. The map is searchable and updated quarterly with CDC data from both organizations. Figure 4 below identifies each ADA-recognized and ADCES-accredited DSMES program site in the mainland US as of January 1, 2021.
 

Figure 4: ADA-Recognized and ADCES-Accredited DSMES Program Sites, 2021

Licensed professionals, including registered dietitians (RDs), registered nurses (RNs), certified diabetes care and education specialists (CDCES), physical therapists, and chiropractors, may share many of the same advantages as DSMES programs, especially related to familiarity with reimbursement systems and access to populations at high risk for type 2 diabetes.

To learn more about the roles of licensed professionals in delivering the National DPP lifestyle change program in Medicaid, see the Determining the Medicaid Enrolled Provider Type page of the Coverage Toolkit.

Pharmacists may also be helpful in promoting and delivering the National DPP lifestyle change program and engaging with payers. The CDC has compiled resources for pharmacists to promote engagement in the program. The CDC has also released an Action Guide that includes case studies and promotes pharmacist participation on three tiers: promoting awareness; screening, testing, and referral; and delivering the program. To learn more, visit the Engaging Pharmacists page of the Coverage Toolkit.

A community health worker (CHW, also known as promotores and promotoras de salud, community health representatives, and community health advisors) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community they serve. CHWs are generally non-licensed health workers; however, some state agencies certify them through accredited CHW training programs. CHWs may be trained on the National DPP lifestyle change program curriculum and become Medicaid-enrolled providers (if allowed through state rules) or affiliate with Medicaid-enrolled providers.

To learn more about CHWs, see the Use an Existing Provider Type that Becomes or Affiliates with a CDC-Recognized Organization page of the Coverage Toolkit.

MCOs may become CDC-recognized and deliver the National DPP lifestyle change program directly to their members. MCOs can identify members with prediabetes or who are at high risk for type 2 diabetes, use established communication channels to outreach to their members about the program, and track referral and program outcomes through their internal systems.

Health care systems and hospitals are also uniquely positioned to help build state capacity for the National DPP lifestyle change program, increase patient engagement, and engage with payers. These facilities can become CDC-recognized and offer classes taught by hospital-employed lifestyle coaches at the hospital and affiliated sites. Many hospitals already offer DSMES classes and may cross-train registered nurses, dietitians, nutritionists, health educators, or CHWs to be lifestyle coaches and deliver the program.

Hospitals and health care systems can also contract with a local CDC-recognized organization and host classes at the hospital or at affiliated sites. This may help expand an organization’s reach as well as shift administrative responsibilities from a community-based organization to a hospital system. Hospitals can also act as a referral hub in their community and refer patients to available National DPP lifestyle change programs.

FQHCs are comprehensive, community-based primary care providers that offer affordable care in areas with high need for health care. Their location in communities and their accessibility to patients makes FQHCs good candidates to deliver the National DPP lifestyle change program to their patient populations.

FQHCs receive payment and support from Medicaid, Medicare, private insurance, self-pay, Health Resources and Services Administration (HRSA) grants, and a variety of other grant funding sources.

FQHCs are reimbursed by Medicaid using an encounter-based prospective payment system (PPS), which is calculated on a per-visit basis and is designed to cover all qualifying services and supplies provided during the visit. For states that have established Medicaid coverage for the National DPP lifestyle change program, reimbursement of the program would either be rolled into existing FQHC PPS rates, or it would be reimbursed separately (i.e., FQHCs would bill the Medicaid agency directly for the service under a separate billing code).

Additionally, MCOs have more flexibility in how they pay for FQHC services; however, plans are required to pay FQHCs at least what they would pay non-FQHC providers in their network for the same medical services. If total MCO payments to an FQHC are less than what the center would have been paid under the PPS, the state Medicaid agency must pay the difference.

For additional information on Medicaid and Medicare reimbursement of FQHCs delivering the National DPP lifestyle change program, including state examples, see the Engaging Federally Qualified Health Centers page of the Coverage Toolkit and the FQHCs: Medicaid and Medicare Reimbursement for the National DPP Lifestyle Change Program document.

The CDC has many available resources through their National DPP Customer Service Center (CSC) to support CDC-recognized organizations engaging with payers.

• The Working with Employers and Insurers Guide provides information for CDC-recognized organizations on recruiting, engaging, and retaining people with prediabetes who have health insurance coverage into their programs. This guide also includes information on different types of insurance plans and guidance for reaching employers and insurers.

CSC also has resources on covering the National DPP lifestyle change program as a wellness/insurance benefit, and promotional materials for employers and insurers.

NACDD and Leavitt Partners have created the following resources, which are intended to support MCOs, CDC-recognized organizations, and referral organizations around Medicaid coverage of the National DPP lifestyle change program. These documents can be tailored to include state-specific information.

• Steps for Community-Based Organizations to Provide the National DPP Lifestyle Change Program in Medicaid: A visual overview for achieving CDC-recognition, enrolling in Medicaid, contracting with MCOs, and becoming credentialed in an MCO’s network. This document provides CDC-recognized organizations that are new to interacting with Medicaid and MCOs with a clear guide for the steps they need to take to receive Medicaid reimbursement for delivering the program to Medicaid beneficiaries.
• Tips for Contracting with Medicaid Managed Care Organizations: A two-page document that lists tips for community-based organizations that wish to contract with Medicaid MCOs.
• Self-Reflection and Capacity Discussion Questions: This document can primarily be used in two ways: (1) As a self-reflection exercise for CDC-recognized organizations, MCOs, referral organizations, and organizations in the delivery planning process to assess their own organizational capacity to support the National DPP lifestyle change program. (2) As a tool to generate discussions between different types of organizations; for example, a CDC-recognized organization could begin a conversation with an MCO by asking the MCO the questions listed in the MCO section.

Additional pages of the Coverage Toolkit that may be of use include:

• The MCO Contracting with CDC-recognized Organizations page, which contains sample language for common contract elements in contracts between MCOs and CDC-recognized organizations.
• The Commercial Payer Contracting with CDC-recognized Organizations page, which contains sample language for common contract elements in contracts between commercial payers and CDC-recognized organizations.
• The Data, Reporting, and Evaluation page, which describes the types of data involved with the National DPP lifestyle change program and the processes and protocols by which that data is shared among parties.

The American Medical Association (AMA) also has many resources on their Prevent Diabetes website to support health care providers and CDC-recognized organizations. For example, AMA offers a budget considerations tool for health care organizations or CDC-recognized organizations considering delivering the National DPP lifestyle change program. The AMA website also includes other helpful resources such as a sample business associate agreement and CPT code guidance.

CDC-recognized organizations may benefit from collaborating with a third-party organization that can assist with the administration of the National DPP lifestyle change program and other chronic disease prevention and management programs. Third-party organizations can be national or local entities that provide outsourced specialized services to community-based organizations, health care providers, and payers. These organizations may offer expertise and scale to groups of CDC-recognized organizations, providing functions such as claims processing and billing, data and reporting, eligible participant lists, and referral management. Existing entities that offer similar services include:

• Third-party administrators (TPA): TPAs are typically defined as companies that administer self-funded employee benefit plans (such as health welfare, workers’ compensation and retirement plans) on behalf of an employer or health plan sponsor.
• Management service organizations (MSO): organizations that provide services to providers, which may include claims processing; electronic health record management; fiscal management; referrals and participant identification; human resources; contract management; operations; data, reporting, and analytics; and sometimes clinical, social, and behavioral health program supports.
• Administrative services organizations (ASO): organizations that generally provide payroll, employee benefits, human resource guidance, and workers’ compensation insurance coverage.
• Provider integrators: a new term describing an organization serving to connect health systems, payers, patients or members, and CDC-recognized organizations.

Third-party organizations can assist CBOs offering the National DPP lifestyle change program in meeting administrative and programmatic needs, including:

• Verification of billing and claims-based reimbursement by public and commercial insurers
• Support in achieving CDC-recognition and managing MDPP supplier regulations
• Contracting and negotiation support
• Data collection, analysis, storage, security, management, and submissions
• Legal support on HIPPA and HITECH; data use agreements
• Multi-partner convening, governance, and technical support
• Plan member identification; recruitment and secure referral of at-risk individuals

CDC-recognized organizations can also partner with other organizations to form an umbrella hub arrangement for the purposes of obtaining sustainable reimbursement from payers and sharing the infrastructure costs needed to scale the National DPP lifestyle change program. This concept stems from the discussion earlier on this page capturing the many ways in which CDC-recognized organizations’ roles are expanding, including organizations having to develop and expand business skills; utilize technology in new ways; enroll, contract, and credential with payers; and engage in communication and marketing campaigns. Umbrella hub arrangements are intended to allow CDC-recognized organizations to receive support for these new responsibilities. Additionally, umbrella hub arrangements may serve to increase community-based organizations’ attractiveness to payers that may prefer to enter into a single contract with a network of CDC-recognized organizations rather than many different contracts with separate organizations.

To learn more, see the Umbrella Hub Arrangements page of the Coverage Toolkit.

Another consideration when working with a range of organizations is the potential for orchestrating “delivery-only” models. In a delivery-only model, a community-based organization or program has a relationship with a provider in which the CDC-recognized organization is only responsible for the delivery of the program, and the provider is responsible for the administrative responsibilities (such as recruitment, referral, reimbursement, data collection, reporting, etc.).

An example of a delivery-only model could be a YMCA contracting with a larger health system, in which the YMCA is responsible for delivering the program, while the health system assumes a range of administrative responsibilities. This would minimize the need for an organization to take on significant technological, financial, and administrative responsibilities associated with engaging with payers and health systems.

In Medicaid, this model may be tied to the concept of billing and rendering providers. Some states may choose to utilize different billing and rendering providers to support National DPP lifestyle change program delivery. Billing providers are reimbursed by Medicaid and rendering providers are typically licensed, credentialed, or other designated Medicaid enrolled provider types that do not have the authority to bill Medicaid but can offer a service under the supervision of the billing provider. More information on billing and rendering providers can be found on the Determining the Medicaid Provider Type page of the Coverage Toolkit.