Medicare Diabetes Prevention Program (MDPP) Expanded Model
BACKGROUND
Diabetes affects more than 25 percent of Americans aged 65 or older[1] and its prevalence is projected to increase approximately 2 fold for all U.S. adults (ages 18-79) by 2050 if current trends continue.[2] We estimate that Medicare will spend $42 billion more in the single year of 2016 on fee-for-service, non-dual eligible, over age 65 beneficiaries with diabetes than it would spend if those beneficiaries did not have diabetes -- $20 billion more for Part A, $17 billion more for Part B, and $5 billion more for Part D. On a per-beneficiary basis, this disparity is just as clear. In 2016 alone, Medicare will spend an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services, and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes.[3] Fortunately, type 2 diabetes is typically preventable with appropriate lifestyle changes.
The Medicare Diabetes Prevention Program (MDPP) expansion was announced in early 2016, when the Secretary of Health and Human Services determined that Diabetes Prevention Program model test met the statutory criteria for expansion. The final rule establishing the expansion was finalized in the Calendar Year 2017 Medicare Physician Fee Schedule (PFS) Final Rule published in November 2016.
WHAT IS THE MDPP EXPANDED MODEL
The MDPP expanded model is a structured behavioral change intervention that aims to prevent the onset of type 2 diabetes among Medicare beneficiaries diagnosed with pre-diabetes. The MDPP expanded model is a CMS Innovation Center model test expanded in duration and scope under section 1115A(c) of the Social Security Act and will be covered as an additional preventive service with no cost-sharing under Medicare. Beginning on January 1, 2018, eligible beneficiaries will be able to access MDPP services in community and health care settings and furnished by coaches that are trained community health workers or health professionals.
OVERVIEW OF WHAT IS IN THE 2017 PFS FINAL RULE
The 2017 PFS rule finalizes aspects of the expansion that will enable organizations, including those new to Medicare, to prepare for enrollment into Medicare as MDPP suppliers. Finalized policies include the definition of the MDPP benefit, beneficiary eligibility criteria, and supplier eligibility and enrollment criteria. Future rulemaking will address policies related to payment, virtual providers, and other program integrity safeguards.
DESCRIPTION OF THE MDPP BENEFIT
The MDPP core benefit is a 12-month intervention that consists of at least 16 weekly core hour-long sessions, over months 1-6, and at least 6 monthly core maintenance sessions over months 6-12, furnished regardless of weight loss. In addition, beneficiaries have access to three month intervals of ongoing maintenance sessions after the core 12-month intervention if they achieve and maintain the required minimum weight loss of 5 percent in the preceding three months. Medicare cost-sharing will not apply to MDPP services.
ELIGIBLE BENEFICIARIES
Coverage of the MDPP services will be available for beneficiaries who meet the following criteria:
- Enrolled in Medicare Part B;
- Have, as of the date of attendance at the first core session, a body mass index (BMI) of at least 25 if not self-identified as Asian or a BMI of at least 23 if self-identified as Asian;
- Have, within the 12 months prior to attending the first core session, a hemoglobin A1c test with a value between 5.7 and 6.4 percent, a fasting plasma glucose of 110-125 mg/dL, or a 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test);
- Have no previous diagnosis of type 1 or type 2 diabetes with the exception of gestational diabetes; and
- Do not have end-stage renal disease (ESRD).
SUPPLIER ELIGIBILITY AND ENROLLMENT
MDPP supplier enrollment in Medicare is expected to begin following rulemaking in 2017, and ahead of implementation of the MDPP expanded model on January 1, 2018. Additional rulemaking is required to finalize enforcement activities related to supplier enrollment. In this rule, we finalize the following policies specific to organizations seeking to enroll as MDPP suppliers:
- MDPP suppliers are obligated to comply with all statutes and regulations that establish generally applicable requirements for Medicare suppliers.
- At the time of enrollment, organizations must have full recognition by the CDC Diabetes Prevention Recognition Program (DPRP).Due to timing issues with CDC standards updates, we are not finalizing any proposals for preliminary recognition at this time. We intend to address this issue in future rulemaking.
- All coaches who will be furnishing MDPP services on the organization’s behalf must obtain and maintain active and valid NPIs.
- Organizations must submit a roster of all coaches who will be furnishing MDPP services. The roster will include the coaches’ first and last names, SSN, and NPI.
- Upon enrollment as an MDPP supplier, organizations must pass application screening at a high categorical risk level per 42 CFR 424.518(c).
- All existing Medicare providers and suppliers are required to adhere to the same enrollment requirements as MDPP suppliers.
PAYMENT STRUCTURE
We expect to finalize the payment structure for the MDPP expanded model in rulemaking during 2017 and expect to begin payment for MDPP services in 2018.
ADDITIONAL INFORMATION
Have additional questions? Please visit: https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/
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[1] Centers for Medicare & Medicaid Services, “Chronic Conditions Among Medicare Beneficiaries, Chartbook: 2012 Edition,” Centers for Medicare & Medicaid Services, 2012, https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf.
[2] James Boyle, et al., “Projection of the Year 2050 Burden of Diabetes in the US Adult Population: Dynamic Modeling of Incidence, Mortality, and Pre-Diabetes Prevalence,” Population Health Metrics 8, no. 29 (2010): 1-12.
[3] Erkan Erdem and Holly Korda, “Medicare Fee-For-Service Spending for Diabetes: Examining Aging and Comorbidities,” Diabetes & Metabolism 5, no. 3 (2014); The Boards of Trustees: Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, “2016 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” Centers for Medicare & Medicaid Services, 2016, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/downloads/tr2016.pdf.; and CMS estimates.