Policy to Payment Roadmap

Coalition Building and Stakeholder Engagement: Identify state public health priorities. Build or strengthen the relationship between public health and Medicaid. Engage relevant stakeholders (e.g., MCOs, legislators, state coalitions or advisory councils, ADA, health systems, associations, CDC-recognized organizations, tribes, etc.).

Research and Coverage Options: Study the prevalence of prediabetes and the impact of type 2 diabetes in the state and in Medicaid. Catalogue existing diabetes prevention and management efforts. Gather evidence on the National DPP lifestyle change program. Explore coverage options (e.g., state plan amendment, 1115 waiver, MCO pilot, etc.). Cost and Value Assessment: Create a budget projection to assess the costs of covering the National DPP lifestyle change program. Consider the return on investment (ROI) associated with the prevention of type 2 diabetes, as well as the overall value of investment (VOI).

Benefit Design: States have flexibility with how to implement the program as a Medicaid benefit and must determine the details of the benefit design, including:

• Will the benefit be offered to both fee-for-service and managed care beneficiaries?
• Will a new provider type be created?
• Will the delivery method be in-person, online, distance learning, or a combination?
• What will the Medicaid reimbursement rate be for the program?
• Will a physician referral be required?

Coverage Options: Obtain state coverage of the program in Medicaid through legislation, rulemaking, or another mechanism, such as a statewide MCO pilot. Federal Medicaid Matching Funds: Seek authorization for federal Medicaid matching funds through the Medicaid State Plan, an 1115 waiver, or another mechanism.

Medicaid and Public Health Collaboration: Create a shared work plan between Medicaid and public health to establish roles for benefit implementation and determine data, reporting, and evaluation mechanisms.

MMIS Development: A Medicaid Management Information System (MMIS) is an integrated group of procedures and computer processing operations. If creating a new provider type for the program, add the new provider type to the MMIS and make necessary modifications to the fee-for-service and managed care information system components to include the new benefit. Provider Network Evaluation and Development: Assess (e.g., survey) CDC-recognized organizations, MCOs, and other stakeholders in the state to determine network adequacy, technical assistance, and resource needs. Communication Documents: Create guidance documents, such as bulletins, policy transmittals, provider manuals, and FAQs for stakeholders.

Ongoing Communication: Formalize communication channels with stakeholders, including MCOs and CDC-recognized organizations. Develop a health care provider awareness campaign.

CDC-Recognized Organization Medicaid Enrollment: If a new provider type was created, enroll CDC-recognized organizations or other qualified program providers in Medicaid. Contracting: If covering the program in managed care, amend contracts between Medicaid and MCOs, as applicable. States may also support the establishment of contracts between MCOs and CDC-recognized organizations, as appropriate. Participant Recruitment and Enrollment: Engage health care providers for referrals, to identify eligible participants, and to outreach to participants. Participant Retention: Encourage stakeholders to implement effective retention strategies, including program supports* to overcome barriers to participation. *Program supports are items, services, and activities that:

• Reinforce information in the curriculum. Examples include measuring cups and cooking demonstrations.
• Remove barriers to participation. Examples include transportation vouchers, weight scales, mobile devices, and prepaid phone minutes or data.
• Address social determinants of health. Examples include access to healthy foods and referrals to community resources.
• Promote social support and connectedness. Examples include one-on-one meetings with the Lifestyle Coach and social media groups.

Benefit Evaluation: Evaluate program utilization, participant retention, and outcomes.

Benefit Scaling: Consider ways to scale the benefit and improve utilization, including increasing access to the program by aligning delivery methods with beneficiary preferences, establishing or expanding referral systems, increasing health care provider or Medicaid beneficiary outreach, and engaging new stakeholders.