Use an Existing Provider Type that Becomes or Affiliates with a CDC-Recognized Organization
The following paragraphs provide additional details about the steps in the above graphic.
Existing Provider Type Becomes or Affiliates with a CDC-Recognized Organization
States must ensure existing Medicaid-enrolled providers are qualified (and willing) to provide National DPP lifestyle change program services. To deliver the National DPP lifestyle change program, a currently enrolled Medicaid provider must meet the Diabetes Prevention Recognition Program (DPRP) requirements to become a CDC-recognized organization and must provide or be aligned with Lifestyle Coaches who are trained to use the CDC-approved curriculum. For example, if the currently enrolled Medicaid provider is a licensed or non-licensed individual practitioner, that individual must be trained to use the CDC-approved curriculum and be affiliated with a CDC-recognized organization
Medicaid Determines if Billing Codes Fit National DPP Lifestyle Change Program Services and if not, Determines Codes
Even when Medicaid uses an existing provider type, these providers may not be authorized to bill for the codes associated with the National DPP lifestyle change program. Moreover, the codes that existing Medicaid enrolled providers can bill for may not necessarily fit the specifications of the National DPP lifestyle change program schedule of sessions. Finally, the use of codes not specified for the National DPP lifestyle change program services may make it impossible to effectively evaluate the utilization of the program. In these cases, it may be necessary for Medicaid to add or open a new code to the state system. For more information, please see the Coding and Billing page.
Communication to Providers About the National DPP Lifestyle Change Program Services
Communicating to providers (whether existing or new) that Medicaid has a provider type that can bill for National DPP lifestyle change program services is an important step in program implementation. For example, Maryland Medicaid developed a series of webinars to explain the process for how CDC-recognized organizations can enroll in Maryland’s electronic Provider Revalidation and Enrollment (ePREP) portal under its new provider type. Maryland Medicaid provides access to these webinars (both recordings and notices about upcoming webinars), the ePREP link, and other documents related to Medicaid coverage of the National DPP lifestyle change program on its HealthChoice Diabetes Prevention Program Information for Providers website.
Similarly, California created a website, hosted a webinar, and provided a FAQ document to communicate to CDC-recognized organizations how to enroll in Medi-Cal.
Pennsylvania Medicaid began its process of communicating the creation of a new Medicaid provider type through a Medicaid bulletin describing how CDC-recognized organizations can enroll in Medicaid. Pennsylvania also surveyed all CDC-recognized organizations in the state to assess the organizations’ knowledge of the new provider type and to understand what type of technical assistance would be most valuable to provide regarding Medicaid enrollment and delivering the National DPP lifestyle change program to Medicaid beneficiaries.
The Illinois Public Health Institute, who worked closely with Illinois Healthcare and Family Services and the Illinois Department of Public Health on the development and operationalization of their Medicaid National DPP benefit, developed training videos on how to enroll in and be reimbursed by Medicaid. They also released an FAQ document with information on enrolling in Medicaid through Illinois’ IMPACT system, obtaining a new NPI, and individual provider enrollment.
The Michigan Department of Health and Human Services compiled resources for CDC-recognized organizations on a central website, which includes Medicaid pre-enrollment resources (including MiDPP Guidance for CDC-recognized Organizations Applying to Become a Medicaid DPP Provider Handout) and information on enrolling in Michigan Medicaid’s CHAMPS system.
Managed Care: CDC-Recognized Organization Enrolls with MCOs and Completes MCO Credentialing Process
Most state Medicaid agencies contract with Medicaid managed care organizations (MCOs). In a managed care environment, the Medicaid agency contracts with and pays MCOs a capitated rate to deliver Medicaid covered services to beneficiaries. In these states, the CDC-recognized organization will likely enroll in one or more MCO networks and complete each MCO’s credentialing process.
Some MCOs may pursue a delegated credentialing process for Lifestyle Coaches. With delegated credentialing, the MCO is responsible for credentialing the CDC-recognized organization but is not responsible for credentialing the individual Lifestyle Coaches (see section below). See the MCO Contracting page of the Coverage Toolkit for more information on:
- Contracting between MCOs and CDC-recognized organizations
- MCOs’ credentialing CDC-recognized organizations
- Negotiating reimbursement for CDC-recognized organizations
The Coverage Toolkit’s Engaging MCOs page and Building Network Capacity page contain additional information on working with MCOs and Medicaid managed care network management rules.
CDC-Recognized Organization Ensures Lifestyle Coaches Meet Requirements
Lifestyle Coaches facilitate National DPP lifestyle change program sessions. When a CDC-recognized organization becomes a Medicaid enrolled provider, its individual Lifestyle Coaches may not have to enroll with Medicaid. Instead, the CDC-recognized organization would be responsible for ensuring the Lifestyle Coaches are trained and qualified to facilitate the National DPP lifestyle change program as well as meet all other Medicaid requirements. As the Medicaid-enrolled provider, the CDC-recognized organization may then need to provide updated rosters of its Lifestyle Coaches to Medicaid.
