Return to Decision Tree

 

Use an Existing Provider Type that Becomes or Affiliates with a CDC-Recognized Organization

 

States can elect to use an existing provider type that is already enrolled in Medicaid to deliver the National DPP lifestyle change program. States can allow licensed professionals (e.g., registered dieticians, certified diabetes educators, nurses, and pharmacists), unlicensed professionals (e.g., community health workers), and facilities (e.g., clinics and hospitals) to deliver and/or be reimbursed for the program. Leveraging existing provider types may mean the state will not need to pursue a State Plan Amendment (SPA) if the Medicaid State Plan already adequately addresses the required coverage and reimbursement topics. For more information about SPAs, see the Attaining Coverage Through a Medicaid State Plan page of the Coverage Toolkit. Although using an existing provider type means that provider type is already enrolled in Medicaid and therefore already eligible for Medicaid reimbursement, the state must ensure these providers are qualified (and willing) to provide the National DPP lifestyle change program sessions.

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 have lifestyle coaches who are trained to use the CDC-approved curriculum. 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.

 

Utilizing Community Health Workers

Community health workers (CHWs) are non-licensed providers and several states already allow Medicaid reimbursement of CHWs. This means CHWs can be a good fit to serve as lifestyle coaches for the National DPP lifestyle change program. For example, Minnesota was able to use CHWs as lifestyle coaches for its Medicaid population without the submission of a new SPA, because the Medicaid State Plan already included covered services provided by CHWs (see the Minnesota example on the Attaining Coverage Through a Medicaid State Plan page and the Minnesota State Story of Medicaid Coverage for more details). However, to evaluate the number of CHWs offering the National DPP lifestyle change program, it is necessary to ensure the billing codes used by the CHWs can be linked to the program.

States’ policies on reimbursement and certification for CHWs vary. Some states, like Minnesota, require CHWs to be certified for Medicaid reimbursement. To learn more about CHW certification, see the CDC’s Statewide Community Health Worker Certification: Key Questions.

To learn about CHWs generally, see these reports from the CDC and FAMILIESUSA. For a state-by-state review of CHW programs and funding, see the National Academy for State Health Policy’s State Community Health Worker Models.

 

"

 

The following paragraphs provide additional details about the steps in the above graphic.

 

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 specific codes associated with the National DPP lifestyle change program. Moreover, existing billing codes may not necessarily fit the specifications of the National DPP lifestyle change program schedule of sessions. 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.

 

Managed Care: CDC-Recognized Organization Enrolls with MCOs and Completes MCO Credentialing Process

Many 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 obtain an Organizational National Provider Identifier (NPI) and enroll with the state Medicaid agency. An NPI is a unique identification number that is needed to submit claims. Next, the CDC-recognized organization will likely enroll in one or more MCO networks and complete each MCO’s credentialing process. Some MCOs are pursuing a delegated credentialing process for lifestyle coaches. With delegated credentialing, the MCO is responsible for credentialing the CDC-recognized organization yet is not responsible for credentialing the individual lifestyle coaches (see section below). For more information on MCOs, please see the Medicaid MCOs page.

 

CDC-Recognized Organization Ensures Lifestyle Coaches Meet Requirements

Lifestyle coaches facilitate the National DPP lifestyle change program sessions. When a CDC-recognized organization becomes a Medicaid enrolled provider, the individual lifestyle coaches may not have to enroll with Medicaid. Instead, the CDC-recognized organization may be responsible for ensuring the lifestyle coaches have an individual NPI and are trained and qualified to facilitate the National DPP lifestyle change program. As the Medicaid-enrolled provider, the CDC-recognized organization may then need to provide updated rosters of its lifestyle coaches to Medicaid.

Content Last Updated: April 23, 2020