Updates for Medicare Diabetes Prevention Program Expanded Model:

With the intent of lowering the rate of progression to Type II diabetes and improving overall health, the CMS has finalized the Medicare Diabetes Prevention Program (MDPP) expanded model, which will allow qualified providers to begin furnishing MDPP services this year.

The MDPP expanded model allows Medicare beneficiaries to access diabetes prevention services consisting of a minimum of 16 intensive core sessions approved by the CDC. These core sessions occur in a classroom-style setting. Through this program, beneficiaries will be provided with strategies for weight control and training in long-term dietary change, with the goal of improving overall health and preventing the onset of Type II diabetes. A key program measurement is for patients to achieve at least a 5% weight loss. After completion of the core sessions, monthly follow up meetings are scheduled to help participants continue to practice healthy behaviors.

Billing Dates:

Potential MDPP providers can begin the enrollment process on January 1, 2018 through the new, MDPP-specific enrollment application.  Providers whose applications are submitted and approved before April 1, 2018 may begin billing for services as of this date.  Approved applications submitted after April 1, 2018 will receive billing privileges on the date of submission. MDPP providers must furnish services in person, with the exception of limited virtual makeup sessions.

Criteria for Beneficiaries:

The CY 2018 PFS final rule modified the prior eligibility criteria for beneficiaries established in 2017. Beneficiaries with a previous diagnosis of diabetes are not eligible to receive MDPP services. However, the new 2018 rule states that if a beneficiary develops diabetes during the MDPP services period, they may continue to receive MDPP services. The total MDPP service period is two years, made up of one year of core sessions and a second year of ongoing maintenance sessions. Throughout the ongoing maintenance session period, beneficiaries must attend 2 out of the 3 required monthly sessions and maintain the 5% weight loss requirement.

Payment Structure:

The payment structure is performance based and payment is based on whether the attendance and/or weight loss goals are met; with more emphasis placed on weight loss. If the required minimum weight loss of 5% is achieved, providers will receive a performance payment of $160. When the attendance requirement is met in addition to the weight loss performance goals, providers may be reimbursed up to a total of $670. If only the attendance requirement is met, then providers will receive $195.  The chart below provides additional detail on the service codes and reimbursement amounts:

For additional information on the 2018 updates to the MDPP, check out the MDPP fact sheet.