As part of the efforts of working towards population health, in April of this year, Medicare launched coverage for the extended module of the Medicare Diabetes Prevention Program(MDPP). This program was designed to act as a behavioral change intervention aimed to prevent or delay the onset of type 2 diabetes among Medicare beneficiaries. Unsurprisingly, a program such as this comes with it a fair number of questions about eligibility, available services, requirements and more. In today’s blog, we attempt to answer all you may need to know about Medicare covering behavioral therapy for prediabetics.
Who are eligible to avail MDPP services?
To be eligible, an individual must meet the following criteria –
- Be enrolled in Medicare Part B
- BMI ≥ 25 or ≥ 23 if self-identified as Asian
- A1c (HgA1c) of 5.7 – 6.4%, or a fasting plasma glucose of 110-125 mg/dL, or a 2-hour post-glucose of 140-199 mg/dL (oral glucose tolerance test) within the previous 12 months
- No previous diagnosis of type 1 or type 2 diabetes except for a previous diagnosis of gestational diabetes
- Does not have an end-stage renal disease (ESRD) at any point during the MDPP services period.
These benefits are available for coverage only once in a lifetime and do not require referrals as long as the above-stated criteria are met.
What are MDPP services?
- Core services – A CDC-approved lifestyle change program curriculum run for 1 year
- Maintenance Program – After core services, an additional 1-year program for participants that achieve attendance requirements and maintain at least 5% weight loss in each 3-month interval during the ongoing maintenance period.
What are the MDPP Supplier Eligibility Requirements?
- The organization must be enrolled under Medicare
- Have CDC full recognition or CDC preliminary recognition
- All MDPP supplier must have a National Provider Identifier(NPI) number
- MDPP suppliers must always maintain at least one non-private administrative location and a primary business telephone number
Read the CMS/CDC Roles Fact Sheet (Outlines Roles of CMS/CDC) for more information
How do I enroll my Organization as an MDPP Supplier?
Below are the steps to become an MDPP supplier-
- To enroll as an MDPP supplier you need an NPI unique identification number. Acquire your NPI by an online application using NPPES website or a paper-based application by using this form.
- There are two ways to enroll as an MDPP supplier. Submit a paper-based application to MAC, or make an online application using PECOS.
- Medicare Administrative Contractor (MAC) – MAC is a regional contractor that process enrollment applications, claims, account payments and address queries for the Medicare FFS program. If your MDPP services are located in different regions, you will deal with multiple MACs.
- Provider Enrollment, Chain, and Ownership System (PECOS) – PECOS is an Internet-based system using which you can submit your enrollment application online, get it verified and sent to MAC electronically. For the online form, you need an Identity and Access (I&A) Account to connect you electronically to the CMS system.
Read the MDPP Enrollment Guide for more information.
What is the Payment Process for MDPP Services?
- Payment is made through a performance-based payment methodology with a maximum $670 per beneficiary
- 15 HCPCS codes have been developed to submit claims for MDPP services
- Refer the Reference Guide to Payment and Billing for more information.
For more information call MDPP Help Desk at 1-877-906-4940 or email at email@example.com
Additional Resources –
Taking on a new program, such as the Medicare Diabetes Prevention Program, at your facility can be disruptive from both a operations standpoint as well as to your staff. Suddenly there’s more to do, and new processes and rules to learn. In such instances, proper and thorough training is critical. Doing so can help you illustrate the change in this new program will cause to their day to day workflow, and reinforce what needs to be done to ensure compliance.