Medicaid AgenciesMedicaid CoverageState Stories of Medicaid Coverage → Pennsylvania

 

Pennsylvania’s State Story of Medicaid Coverage

 

Overview

 
Pennsylvania currently offers the National Diabetes Prevention Program (National DPP) lifestyle change program to Medicaid beneficiaries. Effective 2020, all of Pennsylvania’s managed care organizations (MCOs) are required to offer the National DPP lifestyle change program to their beneficiaries. Pennsylvania hopes to make the program a Medicaid covered benefit for both managed care and fee-for-service (FFS) delivery systems in the near future.

 


 

Establishing Coverage

 

Initial Steps Towards Medicaid Coverage

  • 2014: The Pennsylvania Department of Health (PADOH) was awarded a CDC Preventive Health and Health Services Block Grant (PHHSBG) of $915,000. PADOH worked in four under-served and/or rural regions (South West, South Central, South East, North East) and during subsequent years expanded statewide to provide technical assistance support to organizations obtaining their CDC recognition. Through the work of the CDC PHHSBG funding the number of CDC-recognized organizations grew from 13 in 2015 to 54 in 2017, and to 69 in 2018. In addition to technical assistance support for organizations seeking their CDC recognition, the PHHSBG also funded lifestyle coach trainings and certified four master trainers until 2018, when PADOH began supporting the lifestyle coach trainings solely with 1815 Grant funds.
  • 2015: PADOH provided a cost benefit analysis for diabetes prevention to the Pennsylvania Medicaid Director. PADOH and the Pennsylvania Department of Human Services (PADHS) (Medicaid) continued collaborations and incrementally added information about the National DPP to quarterly Medicaid MCO meetings.
  • 2016: The Pennsylvania legislature mandated that the Joint State Government Commission complete an ongoing study of the public health challenges and financial burden related to increased diabetes rates. The Commission recommended that the General Assembly support mandates related to coverage for diabetes prevention and management programs in the state regulated insurance plan. To learn more about the legislation that mandated this study, see the Pennsylvania example on The Role of the State Legislature in Medicaid Coverage page of the Coverage Toolkit.
  • 2017: The PADHS Medical Director committed to a statewide National DPP Medicaid MCO pilot at the Pennsylvania National DPP State Engagement Meeting (this meeting was supported through funding from CDC and technical assistance from NACDD).

 

Piloting the National DPP Lifestyle Change Program through MCOs

In January 2018, PADHS launched a pilot requiring all MCOs in the state to provide a diabetes prevention offering to their Medicaid enrollees. Because over 93% of Pennsylvania Medicaid beneficiaries are enrolled in managed care, this pilot captures most of the Medicaid population. Initially, it was not mandated the diabetes prevention offering be delivered through CDC-recognized organizations. However, Pennsylvania incorporated language in its 2020 managed care contracts requiring MCOs to refer eligible members to CDC-recognized organizations.

Pennsylvania chose to pursue a pilot initially, rather than requiring coverage of the National DPP lifestyle change program for all Medicaid enrollees, to ensure that enough CDC-recognized organizations were available to deliver the program throughout the state. PADHS created a new provider type for CDC-recognized organizations to enroll in Medicaid, which allows the state to map where CDC-recognized organizations are located. Once PADHS confirms that there is sufficient access to CDC-recognized organizations across the state, they intend to make the National DPP lifestyle change program a Medicaid covered benefit, including coverage for Medicaid beneficiaries in the FFS delivery system, and to pursue a State Plan Amendment (SPA). To learn more about SPAs, visit the Attaining Coverage Through a Medicaid State Plan page of the Coverage Toolkit.

 

Webinars to Support the Engagement about the Pilot

PADOH and PADHS are planning a series of webinars in 2020-2021 for National DPP stakeholders, including CDC-recognized organizations, MCOs, and lifestyle coaches, to share information about the pilot. These interactive webinars will cover how CDC-recognized organizations can enroll in the Pennsylvania Medicaid program, contracting between MCOs and CDC-recognized organizations, network adequacy, and considerations for successfully recruiting, enrolling, and retaining Medicaid beneficiaries. Webinars such as these provide a way for partners to interact and to disseminate information on the program; they also serve as a way to engage key stakeholders and build new or strengthen existing relationships between the individuals and organizations who implement the program.

Pennsylvania’s pathway to coverage continues to be supported by CDC and NACDD through grant funded intensive technical assistance and support for the statewide meeting. This award enables Pennsylvania to have visibility of the National DPP coverage landscape and critical resources to enable successful implementation.


 

Implementing Coverage

 

Pilot Breakdown

Delivery Methods CDC-recognized organizations offering the National DPP lifestyle change program through in-person, online, distance learning, and combination delivery options can enroll in Medicaid.
Participant Eligibility Medicaid beneficiaries may need to have a referral from a physician to be eligible for the National DPP lifestyle change program. Each MCO determines whether a referral is required.
Lifestyle Coaches A lifestyle coach may be a licensed health professional, a community health worker, or an unlicensed individual trained in the CDC curriculum.
Eligible Providers Pennsylvania has created a new provider type that allows CDC-recognized organizations to be enrolled in Medicaid. The CDC-recognized organization must have Preliminary or Full Recognition, or be a Medicare Diabetes Prevention Program (MDPP) Supplier.
Program Parameters National DPP lifestyle change program services are provided over a 12-month period. They are not limited to once in a lifetime for Medicaid beneficiaries.
Reimbursement, Coding, and Billing MCOs receive a per member per month payment from Pennsylvania Medicaid; however, Pennsylvania Medicaid is not determining reimbursement rates for this pilot. Instead, because the MCOs are paying the CDC-recognized organizations, the MCOs are determining the reimbursement rate for this program.

 


 

Program Features Unique to Pennsylvania

 

Creating a New Provider Type

In 2019, PADHS created a new provider type that allows CDC-recognized organizations to enroll in Medicaid. Pennsylvania’s MCOs must contract with Medicaid-enrolled CDC-recognized organizations. Pennsylvania released a bulletin for CDC-recognized organizations that explains how to enroll, federal resources, enrollment procedures, and requirements. To learn more about why a state would create a new provider type, visit the Determining the Medicaid Enrolled Provider Type page of the Coverage Toolkit.


 

Lessons Learned

 

Pilot Before Required Coverage

To set the National DPP lifestyle change program up for success in Pennsylvania, the state chose to first pursue a pilot within the Medicaid managed care program. Pennsylvania’s pilot of the National DPP lifestyle change program has several advantages. First, it allows Medicaid to evaluate the network adequacy of its CDC-recognized organizations. Second, by initially requiring the MCOs to provide diabetes prevention services—but not mandating that those services be delivered through CDC-recognized organizations—PADHS allowed the MCOs time to prepare. Finally, it has allowed PADHS to provide support to CDC-recognized organizations. For example, shortly after PADHS created the new provider type, Pennsylvania asked CDC-recognized organizations in a survey about their knowledge of the new provider type, the challenges with enrolling in Medicaid, and their technical assistance needs.


 

Additional Resources

 
Pennsylvania CDC-recognized Organization Enrollment in Medicaid Bulletin

 

 

Content last updated: September 15, 2020