Medicare Diabetes Prevention Program (MDPP)
The Center for Medicare and Medicaid Innovation Medicare Diabetes Prevention Program (MDPP) site is the primary source for information and resources regarding the MDPP. A brief overview of the MDPP is provided below.
The 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. MDPP suppliers began enrolling in Medicare on January 1, 2018, and began furnishing MDPP services and billing Medicare for MDPP services on April 1, 2018.
Medicare Advantage plans are also required to offer the benefit to their members. To learn more please see the Medicare Advantage Plans and the MDPP section below.
Some key differences between the CDC Recognition requirements and the MDPP benefit should be noted, including:
- Age of beneficiaries (limited to those enrolled in Medicare Part B)
- CDC-recognized organization eligibility criteria versus MDPP supplier organization eligibility criteria
- Required length of the program (2 years for MDPP versus 1 year for the National DPP lifestyle change program)
CMS has provided an interactive map showing MDPP Suppliers in the United States. Use the map to help find MPDD Suppliers in your area.
- The MDPP is covered under Medicare Part B as a preventive service once per lifetime.
- Medicare cost sharing does not apply to MDPP services.
- Benefit description:
- Core services period is 12 months: 16 weekly core sessions over months 1-6, and 6 monthly core maintenance sessions in months 6-12
- After the core services period, an additional 12 months of ongoing maintenance sessions (one per month) is available for participants that achieve attendance requirements and maintain at least 5% weight loss in each 3-month interval during the ongoing maintenance period.
- Sessions are approximately one hour each
- No minimum or maximum number of beneficiaries per session
- Limited in-person and/or remote makeup sessions may be provided
- MDPP suppliers may use any CDC-approved lifestyle change program curriculum
- Although virtual makeup sessions are approved, 100% virtual delivery of DPP services is not currently approved.
- MDPP suppliers must apply for and receive MDPP supplier status prior to receiving reimbursement for MDPP services.
- MDPP suppliers must currently have either CDC Preliminary Recognition or CDC Full Recognition prior to applying.
Beneficiary Eligibility Criteria & Referrals
- Eligibility criteria:
- Are enrolled in Medicare Part B;
- BMI ≥ 25; ≥ 23 if self-identified as Asian;
- A1c (HgA1c) between 5.7 and 6.4%, or a fasting plasma glucose of 110-125 mg/dL, or a 2-hour post-glucose challenge of 140-199 mg/dL (oral glucose tolerance test) within the previous 12 months;
- Have no previous diagnosis of type 1 or type 2 diabetes with the exception of a previous diagnosis of gestational diabetes; and
- Does not have end-stage renal disease (ESRD) at any point during the MDPP services period.
- The MDPP benefit is available for coverage only once per lifetime.
- Although referrals are not required, the following referrals are allowed, as long as blood test results indicate eligibility:
- Self-referral from participant
- Community referral
- Physician referral
- Other health care practitioner referral
MDPP Supplier Eligibility & Enrollment
MDPP suppliers must 1) enroll under Medicare; and 2) have CDC full recognition or CDC preliminary recognition. For more information on full and preliminary CDC recognition see Requirements for CDC Recognition.
- MDPP suppliers must also maintain at least one administrative location—a non-private residence—and a primary business telephone number.
- All “lifestyle coaches” (who are employed by an MDPP supplier) must obtain an NPI, which will be reported with Medicare claims
- To be eligible to provide MDPP services, coaches may not have had Medicare billing privileges revoked or have been convicted of a felony within the last 10 years.
- Individual coaches cannot apply to be an MDPP supplier.
- Individual coaches should be compliant with the CDC Recognition Standards coach requirements
- All CDC-recognized organizations must enroll in Medicare as MDPP suppliers to furnish and bill for MDPP services.
- Existing Medicare suppliers must enroll as MDPP suppliers to offer the program.
- If an MDPP supplier’s Medicaid billing privileges are revoked, Medicare billing privileges will also be revoked.
- MDPP suppliers must submit a roster of coach NPIs, names, and social security numbers upon application for enrollment.
- MDPP supplier enrollment began January 1, 2018.
More CMS resources for MDPP Supplier enrollment, located on the Center for Medicare and Medicaid Innovation MDPP site, include:
- MDPP Supplier Roadmap (Overview of the MDPP Supplier Journey)
- MDPP Enrollment (How to Prepare for Enrollment)
- CMS/CDC Roles Fact Sheet (Outlines Roles of CMS/CDC)
MDPP Orientation Video: Provides a 5-minute overview of MDPP, including introductory information on enrollment and MDPP services.
Payment for MDPP Services
- MDPP services are paid for through a performance-based payment methodology (see table below) that will be updated annually for inflation.
- A maximum of $702 per beneficiary will be paid for the set of MDPP services.
- MDPP payments are not risk-adjusted for social risk factors or geography.
- 15 HCPCS codes have been established to submit claims for payment.
- If a beneficiary changes MDPP suppliers during the MDPP services period, a $26 bridge payment can be paid to the new supplier to cover initial administrative costs. In addition, the new supplier must obtain and maintain the beneficiary’s MDPP record from the previous supplier.
Beneficiary Engagement Incentives
- If an MDPP supplier offers an in-kind incentive, the item or service must be provided during the MDPP services period and must have a reasonable connection to the CDC-approved curriculum.
- Cost of incentives must not be shifted to another Federal health care program or to a beneficiary.
- MDPP suppliers must maintain documentation of incentives that individually exceed $25 in retail value; incentives involving technology may not, in aggregate, exceed $1,000 in retail value for any one MDPP beneficiary.
Medicare Advantage Plans and the MDPP
All Medicare beneficiaries have access to MDPP services. There are two ways in which Medicare beneficiaries can receive these benefits:
- Through original Medicare, which is comprised of Part A (hospital services) and Part B (outpatient medical services), or
- Through Medicare Part C, also known as Medicare Advantage.
Original Medicare is administered directly by the federal government, and beneficiaries may receive care from any provider that accepts Medicare. Medicare Advantage (MA) provides Medicare benefits through approved private insurance companies, rather than directly through the federal government, and generally receive care from a specific network of providers. MA plans must provide enrollees with all Medicare Part A and Part B services, but they may also cover additional benefits, such as dental or vision care.
CMS has released guidance for Medicare Advantage plans, including an MA Fact Sheet and document that contains Medicare Advantage-related extracts from the MDPP Calendar Year 2018 Physician Fee Schedule Final Rule. For more information, visit the Center for Medicare and Medicaid Innovation MDPP site.
It is important to note that there are some aspects of the program that have not yet been finalized or that CMS is continuing to monitor. It is expected that additional guidance on these elements will be detailed in future rulemaking. Some of the policies that may be forthcoming include:
- Virtual delivery – CMS is considering implementing a separate model under CMS’ Innovation Center to test and evaluate virtual DPP services. The model would run in parallel with the MDPP Expanded Model.
- Program integrity safeguards
- Verification processes used by MDPP suppliers to determine whether beneficiaries have enrolled in the program in the past
- Application processes and ongoing technical support of MDPP suppliers
If you have any further questions, please contact the MDPP Help Desk at 1-877-906-4940 or visit the MDPP Supplier Support Center.
Content last updated: January 7, 2020