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Attaining Coverage Through a Medicaid State Plan
After a state has made the decision to cover the National DPP lifestyle change program in Medicaid, either through legislation or administrative rules, the state will determine how to claim federal Medicaid matching funds for the program. The most common way to claim federal Medicaid matching funds is by including the benefit in the Medicaid State Plan. If the policies or processes the state intends to implement for the National DPP lifestyle change program cannot be accomplished through the Medicaid State Plan, the state may choose to use a section 1115 demonstration waiver or another mechanism (see the Medicaid Managed Care Options page for examples of other mechanisms).
What is a Medicaid State Plan and a State Plan Amendment?
A Medicaid State Plan is a written agreement between a state and the federal government outlining the details of the state’s Medicaid program, including benefits, provider rate methodologies, and who is eligible for coverage. It gives an assurance that a state will abide by Federal rules, which allows the state to claim federal Medicaid matching funds. See California’s Medicaid State Plan for an example of how a Medicaid State Plan is organized.
To make changes to the Medicaid State Plan, a state submits a State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS) for review and approval. An approved SPA results in permanent changes to the state’s Medicaid program, and may include content such as the addition of new populations or providers, changes in benefit coverage, changes in what administrative expenditures the state expects the federal government to pay for (such as processing claims, care coordination, risk stratification, transportation, etc.), and changes in reimbursement methodologies.
CMS’ SPA review and approval process can be relatively quick for standard changes, most of which are enacted by the state in advance of formal approval by the federal government. These changes are effective back to the first day of the quarter in which the SPA was submitted. For less common changes, a state can support the likelihood of a SPA being approved in a timely way by engaging in calls with CMS prior to submission. This allows the state and CMS to discuss potential concerns with the SPA and gives the state the opportunity to make changes. The pre-SPA submission calls New York held with its regional CMS representatives aided in the expedited approval of the SPA, which took just over two months after the SPA was submitted.
It is important to note that CMS’ approval of SPAs is guided by the statutory and regulatory terms and conditions of the Medicaid program including, but not limited to:
- Comparable benefits must be available to all eligibility groups to which the benefit package applies; and
- Benefits must be offered statewide.
- Beneficiaries must have the freedom to choose their provider (some exceptions exist with managed care);
A searchable list of SPAs that have been approved by CMS can be found here.
What are Federal Medicaid Matching Funds?
Medicaid services are paid for through funding from both state and the federal governments, where the federal government matches state Medicaid spending according to a formula set in federal Medicaid law.
Federal Medicaid matching funds can be claimed for both direct service costs as well as administrative costs. The amount the federal government reimburses direct service costs ranges from 50% to 100%, depending on the state’s Federal Medical Assistance Percentage (FMAP), the type of service delivered, and the location where the service is provided. Administrative costs are generally shared between the federal government and the state at a rate of 50/50, or in some cases at a higher rate of 75/25 or 90/10.
To claim federal Medicaid matching funds for the National DPP lifestyle change program, a state must have approval from the federal government through a Medicaid State Plan, a section 1115 demonstration waiver, or another mechanism (see Medicaid managed care options).
A state could also choose to provide Medicaid coverage of the National DPP lifestyle change program using only state funds.
When is a State Plan Amendment Needed?
A state that wants to use a Medicaid State Plan to claim federal Medicaid matching funds for covering the National DPP lifestyle change program must determine whether:
- There is existing language in the Medicaid State Plan that would include the National DPP lifestyle change program in the way the state intends to implement it.
- E.g., Minnesota did not need a new SPA because the Medicaid State Plan already included language defining preventive services that was broad enough to encompass the National DPP lifestyle change program and covered services provided by community health workers (CHWs).
- Changes need to be made to the Medicaid State Plan to include the National DPP lifestyle change program in the way the state intends to implement it.
- E.g., See the State Plan Amendment Examples section below for details on California’s, Montana’s, and New York’s approved SPAs.
There are a variety of reasons why a state may need to make changes to the Medicaid State Plan through a SPA to claim federal Medicaid matching funds. Two of the most common are:
- The Medicaid State Plan does not include language on services that would allow for coverage of the National DPP lifestyle change program for the target population(s).
- The Medicaid State Plan does not currently permit Medicaid reimbursement of the health care providers or organizations that the state intends to allow to deliver the National DPP lifestyle change program to Medicaid beneficiaries.
Other information that would be detailed in a National DPP lifestyle change program SPA includes the reimbursement rate, the date program coverage becomes effective, and program training requirements.
1. The Medicaid State Plan does not include language on services that would allow for coverage of the National DPP lifestyle change program for the target population(s)
If there is not an existing preventive service in the Medicaid State Plan that would incorporate the National DPP lifestyle change program for the desired populations, a SPA may be needed to claim federal Medicaid matching funds.
In Medicaid, “preventive services” are defined as services recommended by a physician or other licensed practitioner to:
- Prevent disease, disability, and other health conditions or their progression;
- Prolong life; and
- Promote physical and mental health and efficiency. (42 CFR 440.130(c))
To qualify for Medicaid coverage, preventive services must be medical or remedial in nature, i.e.:
- Involve direct patient care; and
- Be for the express purpose of diagnosing, treating or preventing illness, injury, or other impairments to an individual’s physical or mental health.
Preventive services must also meet additional provisions outlined in the State Medicaid Manual, Chapter 4, Section 4385. For example, nonmedical preventive services that are applied at the community level or that address broader social or environmental concerns are not covered by Medicaid (e.g., counseling on the importance of smoke detectors, dust-mite proof bedding, lead abatement activities, and community water fluoridation).
Qualifying National DPP Lifestyle Change Program Services
Services provided through the National DPP lifestyle change program that qualify for Medicaid coverage as preventive services include:
- Intensive behavioral counseling; and
- Other preventive services for the express purposes of preventing type 2 diabetes.
California’s SPA and New York’s SPA are examples of how the National DPP lifestyle change program aligns with 42 CFR 440.130(c).
Preventive services are subject to the general terms and conditions of the Medicaid program including, but not limited to:
- Comparable benefits must be available to all eligibility groups to which the benefit package applies;
- Benefits must be offered statewide; and Beneficiaries must have the freedom to choose their provider (some exceptions exist with managed care).
Coordinating with Public Health
Coordinating the provision of preventive services with other state and federal programs, like public health, can help avoid duplication of services. Generally, coordination can be achieved through the establishment of interagency agreements, informal cooperative arrangements, and increased referrals between the Medicaid agency and other programs that offer preventive care.
2. The Medicaid State Plan does not currently permit Medicaid reimbursement of the providers or organizations that the state intends to allow to deliver the National DPP lifestyle change program to Medicaid beneficiaries.
A state will need to seek a SPA if the Medicaid State Plan does not currently permit Medicaid payment to the health care providers or organizations the state intends to reimburse for delivering the National DPP lifestyle change program to Medicaid beneficiaries.
Both health professionals and non-licensed personnel can be National DPP lifestyle change program lifestyle coaches. However, the types of providers and organizations that can become Medicaid enrolled providers and be reimbursed by Medicaid is determined by each state. Some states use existing Medicaid enrolled provider types, such as Community Health Workers (CHWs), nurses, registered dieticians, clinics, or hospitals (see the Minnesota example below). Other states create a new provider type (see the New York SPA below for an example).
For more information on using an existing provider type or creating a new provider type, see the Determining the Medicaid Enrolled Provider Type page. Additional information on utilizing CHWs as lifestyle coaches can be found on the Use an Existing Provider Type page.
State Plan Amendments: Preventive Services Rule Change
In states where it is necessary to change or broaden the state Medicaid authority to cover non-licensed personnel to serve as lifestyle coaches, states could consider a SPA based on CMS’ Preventive Services Rule Change.
Under the Preventive Services Rule Change to 42 CFR 440.130(c) issued by CMS in 2013, states can offer Medicaid services that are provided by non-licensed staff. Under the old rules, preventive services could only be provided by a physician or “other licensed practitioner (OLP) of the healing arts” to qualify for Medicaid reimbursement. The amended rule allows other practitioners to provide and be reimbursed as long as they are furnishing preventive services “recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice.” How the term recommended is interpreted will vary on a state-by-state basis and be defined through SPA language. Some states may require that the services be ordered by licensed health professionals, while others may require some type of supervision by a physician or nurse practitioner.
States pursuing a SPA based on the Preventive Services Rule Change will need to define the preventive services being covered, the provider qualifications, the process for ensuring that appropriate services are being delivered by qualified providers, and the reimbursement methodology. Any required education, training, experience, credentialing or registration information should also be included. For an example, see New York’s SPA below.
For more information about the Preventive Services Rule Change, see the Center for Medicaid & CHIP Services (CMCS) Information Bulletin and a presentation prepared by CMS entitled Medicaid Preventive Services: Regulatory Change.
State Plan Amendment Examples
California submitted a SPA to CMS on December 26, 2018 to secure federal Medicaid matching funds for the National DPP lifestyle change program. The SPA was approved by CMS on October 24, 2019, with an effective date of January 1, 2019. The SPA creates a new provider type to allow CDC-recognized organizations to be reimbursed by Medicaid. To learn more about how California is covering the National DPP lifestyle change program in its Medicaid program (Medi-Cal), visit the California State Story page of the Coverage Toolkit.
California’s SPA Language:
- National DPP lifestyle change program description
DPP services are a set of medically necessary services recommended by a physician or other licensed practitioner or the healing arts to prevent or delay the onset of type 2 diabetes for beneficiaries with indications of prediabetes, in accordance with 42 CFR 440.130(c).
DPP services provide a variety of behavioral and nutritional interventions identified as evidence-based by clinical research or studies and/or nationally recognized organizations specializing in disease control and prevention.
Medically necessary DPP services are provided during sessions that occur at regular, periodic intervals over the course of one year, and, if eligible based upon individual measurable health-outcomes, additional ongoing maintenance sessions at regular, periodic intervals for another year. At these sessions, DPP services include:
- Individual or group nutrition or behavioral counseling.
- Physical activity and fitness assessments.
Comparable services are available to children under age 18, pursuant to EPSDT.
- Lifestyle coaches
A DPP services provider must be an organization enrolled in Medi-Cal and must have either pending, preliminary, or full recognition by the Centers for Disease Control and Prevention (CDC) for DPP. DPP services providers use lifestyle coaches for delivery of DPP services.
DPP services are delivered by lifestyle coaches and must have completed nationally-recognized training for delivery of DPP services. Lifestyle coaches may be:
- Licensed nonphysician practitioners, such as nurses, and physical therapists.
- Unlicensed practitioners under the supervision of a DPP services provider or a licensed Medi-Cal practitioner.
For DPP services delivered by unlicensed lifestyle coaches, the supervising Medi-Cal practitioner will assume professional liability for care of that patient and furnish services within its scope of practice according to state law.
All lifestyle coaches must complete at least 12 hours of training in DPP services from an organization recognized by the CDC for DPP. All lifestyle coaches must be trained to the specific curriculum being used by the recognized organization before offering their first class.
1) Effective January 1, 2019, the reimbursement rates for Diabetes Prevention Program (DPP) services will be set at no more than 80 percent of the corresponding Medicare rate for the same or similar service. Any rate reflected at or below 80 percent will not be decreased until federal approval is obtained.
2) Except as otherwise noted in the State plan, state-developed fee schedules are the same for both governmental and private providers of DPP services. The department’s fee schedule rates were set as of January 1, 2019 and are effective for services provided on or after that date. All Medi-Cal Fee-for-Service rates are published at: http://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp.
On January 1, 2016, Minnesota began offering the National DPP lifestyle change program as a covered benefit for Medicaid beneficiaries under existing Medicaid State Plan authority. The state was able to claim federal Medicaid matching funds for including the program without the submission of a new State Plan Amendment (SPA), an 1115 demonstration waiver, or another mechanism. Minnesota’s Medicaid State Plan already included language defining preventive services that was broad enough to encompass the National DPP lifestyle change program and covered services provided by community health workers (CHWs).
In Minnesota, a lifestyle coach may be a licensed health professional, a CHW, or an unlicensed individual trained in the CDC curriculum. Minnesota CHWs are trained health educators who have received a valid certificate by completing a statewide 14-credit CHW curriculum at one of seven schools that offer the certificate program.
Minnesota Medicaid requires the following of CHWs to deliver the National DPP lifestyle change program:
- CHWs must work under the supervision of a physician, dentist, advanced practice registered nurse (APRN), certified public health nurse (PHN), mental health professional, or registered nurse to provide patient education for health promotion and disease management services.
- CHWs must have a valid certificate from the Minnesota State Colleges and Universities (MnSCU), demonstrating that the applicant has completed an approved community health worker curriculum.
- CHWs must be affiliated with a CDC-recognized organization and trained as a lifestyle coach.
CHW services are diagnosis-related medical interventions, not social services. Medicaid coverage includes diagnosis-related patient education services, including diabetes prevention and pediatric obesity treatment under specified criteria, including:
- The service involves teaching the patient how to self-manage their health effectively in conjunction with the health care team; and
- The service is provided face-to-face with the recipient (individually or in a group) in an outpatient, home, clinic, or other community setting.
For more information about the Minnesota’s benefit see:
- Minnesota’s State Story of Medicaid Coverage
- Minnesota Medicaid National DPP Lifestyle Change Benefit
- Minnesota Medicaid CHW benefit, Provider Manual
- Minnesota CHW Toolkit
Montana’s approved SPA allows the delivery of its type 2 diabetes prevention program through several provider types.
- Montana’s SPA Language:
- A. Services to prevent diabetes and cardiovascular disease provided to people at risk for diabetes and cardiovascular disease:
- Group nutrition counseling to prevent diabetes and cardiovascular disease
- B. Providers
- Mid-level practitioners,
- Registered dieticians who also hold a current Montana license as a nutritionist,
- Federally Qualified Health Centers,
- Rural Health Clinics,
- Indian Health Services/Tribal Health Services,
- Groups/Clinics, or
- Public Health Departments.
- A. Services to prevent diabetes and cardiovascular disease provided to people at risk for diabetes and cardiovascular disease:
Listed providers will provide services for reimbursement under the diabetes and cardiovascular disease prevention program. Services for the program are limited to group nutrition and lifestyle counseling to prevent diabetes and cardiovascular disease.
A physician or mid-level practitioner supervising a provider not listed above, such as a licensed nurse, a certified diabetes educator, or an exercise physiologist, will assume professional liability for care of the patient and will furnish services within his or her scope of practice under State law.
For more information on Montana Medicaid’s implementation of the National DPP lifestyle change program, see the Montana’s State Story of Medicaid Coverage.
New York State
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 SPA on June 28, 2019, which was approved by CMS on September 4, 2019. Pre-SPA submission calls with NYS’s regional CMS representatives may have expedited its approval.
New York State’s SPA covers the National DPP lifestyle change program as a preventative service. Only organizations that have achieved CDC recognition can be enrolled in Medicaid to bill for providing the National DPP lifestyle change program to Medicaid members.
New York State’s SPA Language
For dates of service on or after July 1, 2019. Medicaid will begin covering diabetes prevention services as outlined in the Centers for Disease Control and Prevention (CDC)-recognize National Diabetes Prevention Program (NDPP). The NDPP is an evidence-based, educational and support program designed to assist at-risk individuals from developing Type 2 diabetes. Diabetes services are provided as preventive services pursuant to 42 C.F.R. Section 440.130(c) and must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice under state law to prevent diabetes, prolong life, and promote the physical and mental health of the beneficiary.
The CDC grants NDPP recognition only to organizational entities. Therefore, only organizations that have achieved CDC recognition can be enrolled in Medicaid as an NDPP provider. Individuals who wish to participate in the Medicaid NDPP program may do so as a trained “Lifestyle Coach” once they meet the standards and guidelines specified in the CDC’s Diabetes Prevention Recognition Program (DPRP). Only the organizations that are enrolled in Medicaid as NDPP providers may bill for NDPP services. The CDC-recognized organization will supervise Lifestyle Coaches and must ensure that the individual Lifestyle Coaches providing NDPP services on behalf of the organization have been formally trained and have complied with the requirements outlined by the CDC.
A Lifestyle Coach may be a physician, non-physician practitioner, or an unlicensed person who has received formal training on a CDC-approved curriculum for at least 12 hours and is recognized as having met the NDPP requirements specified in the CDC’s Diabetes Prevention Recognition Program (DPRP) standards and guidelines.
Lifestyle Coaches will work with Medicaid members to provide them with a practical understanding of the positive impacts of healthier, sustained dietary habits; increased physical activity; and behavior change strategies for weight control; and will offer the following services with the goal to prevent Type 2 diabetes:
- Counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control;
- Counseling and skill building to facilitate the knowledge, skill, and ability necessary to prevent the onset of Type 2 diabetes; and
- Nutritional counseling.
Reimbursement Methodology: Attachment 4.19-B Effective July 1, 2019, the Medicaid rate for NDPP services will be set at 80 percent of the corresponding 2019 Medicare NDPP rate for the same or similar service.
Beginning in January 2020, Wyoming Medicaid began a one-year trial allowing registered dieticians to be reimbursed for offering the National DPP lifestyle change program to Medicaid beneficiaries. Because registered dieticians offering dietician services was already included in Wyoming’s Medicaid State Plan, a SPA was not needed to begin reimbursement.
There were no registered dieticians who were Medicaid enrolled providers at the beginning of the trial, so Wyoming will use the trial to assess registered dietician interest in being lifestyle coaches and overall network adequacy. The registered dieticians do not need to be affiliated with a CDC-recognized organization to be reimbursed.
Other Program Costs
It is important to note that other services and costs associated with the National DPP lifestyle change program will not qualify as preventive services and may or may not be eligible for drawing down federal Medicaid matching funds.
A list of additional services and costs associated with the National DPP lifestyle change program and whether they are eligible for federal Medicaid matching funds is provided below.
*In certain cases a higher administrative FMAP is allowed for medical professionals, which may be how a state chooses to administer the National DPP lifestyle change program. If a state contracts with Medicaid managed care organizations (MCOs) under a risk contract, amounts paid to the managed care plan to cover administrative functions are matched as a medical assistance cost at the applicable FMAP, not as an administrative cost (42 CFR 438.812). For more information, see MACPAC Federal Medical Assistance Percentage.
**Qualifying situations must follow federal regulations regarding NEMT.
Obtaining an Additional 1% Federal Medicaid Match: U.S. Preventive Services Task Force (USPSTF)
States can obtain a one percentage point federal match rate increase for covered preventive services when covering and reimbursing all USPSTF grade A and B preventive services and approved vaccines recommended by ACIP, and their administration, without cost-sharing. If the state utilizes a managed care delivery system, it must also make these services available to those enrolled in managed care and the one percentage point increase will be applied to the managed care expenditures.
Covering the National DPP lifestyle change program at no cost to members may also aid states in securing this additional 1% federal Medicaid match. For states pursuing the one percentage point increase in their FMAP per Section 4106(b) of the ACA, the counseling requirements referenced in the following recommendations can be met through coverage of the National DPP lifestyle change program.
Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening. The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.
Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Factors: Behavioral Counseling. The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. Impaired fasting glucose is listed as one such risk factor.
Coverage of the National DPP lifestyle change program is also indirectly related to two additional USPSTF grade A and B preventive services. These services reference National DPP lifestyle change program inclusion criteria.
Gestational Diabetes Mellitus: Screening. The USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation. Note: You cannot participate in the National DPP lifestyle change program if you are pregnant, but you are eligible if you were previously diagnosed with GDM.
Obesity in Adults: Screening and Management. The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.
As stated in the Medicaid.gov Questions & Answers on ACA Section 4106 “All USPSTF grade A and B preventive services, Advisory Committee on Immunization Practices (ACIP) recommended vaccines, and their administration, must be covered without cost-sharing in order to be eligible for the one percentage point FMAP increase.”
In managed care environments, states will need to work with their MCOs to establish special codes and protocols to allow for an audit trail to determine the additional 1% is being properly claimed and that the costs are appropriately accounted for in rate setting for the MCOs.
For more information, see the quality metrics page or view the complete list of USPSTF grade A and B recommendations. For more information and details about Section 4106(b), see CMCS State Medicaid Letter RE: Affordable Care Act Section 4106.
Content Last Updated: March 27, 2020