Umbrella Hub Arrangements → Reimbursement for Umbrella Hub Arrangements
Reimbursement for Umbrella Hub Arrangements
Having multiple health care payers for the National Diabetes Prevention Program (National DPP) lifestyle change program is essential for the sustainability of an umbrella hub arrangement (UHA). Umbrella hub organizations (UHOs) are encouraged to enroll in the Medicare Diabetes Prevention Program (MDPP), Medicaid (if applicable), and contract with Medicaid managed care organizations (MCOs), Medicare Advantage (MA) plans, commercial health plans, and self-insured employers.
This page provides an introduction into the components of the MDPP supplier application followed by information on other payer types. For more information on the MDPP, please visit the MDPP Basics and MDPP Implementation Resources pages of the Coverage Toolkit. For additional guidance on completing the MDPP supplier application and submitting MDPP claims as a UHO, please reference the UHO MDPP Supplier Enrollment Guide. Additional learnings related to enrolling the UHA with various payers will be added to this page as they become available.
Learnings from the Umbrella Hub Demonstration that correlate with this Coverage Toolkit page (learnings related to UHA reimbursement) are in the document titled, Learnings from the Umbrella Hub Demonstration – Reimbursement. For all of the learnings from the Umbrella Hub Demonstration refer to the full document, Learnings from the Umbrella Hub Demonstration.
Enrolling in Medicare as an MDPP Supplier
UHAs interested in becoming a MDPP supplier need to apply through the Centers for Medicare and Medicaid Services (CMS). After an organization is approved by CDC to become a UHA, the UHA will submit a single MDPP supplier application on behalf of all the subsidiary organizations in the UHA. If your UHA spans multiple states or multiple MAC jurisdictions, please refer to the Multiple Medicare Administrative Contractor Jurisdictions section of the UHO MDPP Supplier Enrollment Guide.
MACs
Medicare Administrative Contractors (MACs)
For UHOs, Medicare Administrative Contractors (MACs) approve MDPP applications and process Medicare fee-for-service (FFS) claims. MACs are multi-state, regional contractors responsible for administering Medicare FFS claims. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers (including MDPP suppliers) enrolled in the program. For more information on MACs, see CMS’ What’s a MAC webpage. UHOs will develop a relationship with their MAC that starts with the MDPP application and extends through the claims submission and reimbursement process. Different regions across the United States have different MACs. UHOs can find out in which MAC region they operate here.
PECOS
Provider Enrollment Chain and Ownership System (PECOS)
The Provider Enrollment Chain and Ownership System (PECOS) is where organizations manage the details of their MDPP supplier application. For a subsidiary organization to be recognized as a part of the UHA, it will need to be listed on the UHA’s MDPP application in PECOS. To provide timely payment of claims, UHOs are responsible for keeping PECOS updated, including additions to the lifestyle coach roster and location changes for community settings or administrative sites. UHOs are encouraged to create a plan with their subsidiary organizations for communicating any changes to their coach roster so that the UHO may make necessary changes in PECOS. Claims will not be paid for any sessions delivered by a coach not listed on the roster. The Claims Submission Components of the MDPP supplier application will require UHOs to establish themselves as a business entity, which involves acquiring and understanding several business components. These include National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), Legal Business Names (LBNs), and Tax Identification Numbers (TINs). For more information on these components and how they relate to the MDPP application and claims submission, please see the UHO MDPP Supplier Enrollment Guide.
MDPP Supplier Application
MDPP Supplier Application
It is a best practice to review the CMS MDPP Enrollment Preparation Guide to become familiar with requirements, documents, and additional details needed to enroll as an MDPP supplier. Maintaining a folder with required documents may assist in completing this multistep process prior to submitting your application.
Once the UHA has established a business entity and understands the unique considerations for a UHO to enroll as an MDPP supplier, it is time for the UHO to submit a MDPP supplier application on behalf of all the subsidiaries in the UHA. For a step-by-step guide to filling out your MDPP supplier application, please reference the CMS Online MDPP Application Tutorial.
The Umbrella Hub Demonstration organizations obtained valuable learnings related to the challenges and requirements of submitting the MDPP supplier application. For more information on these learnings and other MDPP considerations, please reference the Learnings from the Umbrella Hub Demonstration.
Contracting with Additional Health Care Payers
Since the inception of the National DPP lifestyle change program in 2012, CDC and its partners have focused on expanding the reach and coverage of the program so that all payers are involved – Medicare, Medicaid, state employee benefit plans, commercial health plans, and employers. A growing number of state Medicaid agencies offer coverage, and so do an increasing number of commercial and employer payers. For information on states and organizations that offer coverage of the National DPP lifestyle change program, please visit the Participating Payers page.
Because many health care payers are unfamiliar with UHAs, UHOs may need to have multiple conversations with health care payers before securing a commitment to the UHA. The state health department may be able to convene stakeholders, including payers, for a meeting or webinar that features the UHA. Considering the novelty of the UHA approach, plan to spend time educating state health departments or other stakeholders on the basics of a UHA. For additional resources direct the stakeholders to the UHA Basics webinar and other resources on the Umbrella Hub Arrangements Overview page.
Medicaid and MCOs
If the National DPP lifestyle change program is a covered Medicaid benefit in their state and UHOs wish to obtain reimbursement from Medicaid, UHOs can consider enrolling as a Medicaid provider. Even if a state has not achieved Medicaid coverage for the National DPP lifestyle change program, opportunities may be present to contract with MCOs offering reimbursement for the program. Umbrella Hub Demonstration organizations and other emerging UHAs are currently in the process of contracting with MCOs to obtain sustainable reimbursement for their respective UHAs. Information on connecting and engaging with MCOs is available on the Engaging MCOs to Attain Coverage page of the Coverage Toolkit. Additionally, considerations for MCO contract type and provisions are available on the MCO Contracting page of the Coverage Toolkit.
Additional Payers
UHOs can also contract with Medicare Advantage plans, commercial health plans, and self-insured employers. Enrollment, contracting, and certification requirements will vary between each payer type, institution, and state. UHOs are encouraged to discuss reimbursement requirements with each individual payer prior to beginning the enrollment or contracting process.
Resources for Umbrella Hub Arrangements – Reimbursement
