Medicare Diabetes Prevention Program (MDPP) - Frequently Asked Questions

Below is a list of common questions the Centers for Medicare and Medicaid Services (CMS) has received about the Medicare Diabetes Prevention Program (MDPP). The questions are grouped by topic: Recognition and enrolling in Medicare; billing and claims; MDPP set of services and beneficiary eligibility; coach requirements and supplier standards; and Medicare Advantage. Information about additional resources is also included on this page.

For additional questions, contact the MDPP team.

Contents

• CDC Recognition and Enrollment in Medicare
• Fingerprinting FAQs
• Billing and Claims
• MDPP Set of Services and Beneficiary Eligibility
• Coach Requirements and Supplier Standards
• Medicare Advantage (MA)
• Crosswalk File Submission
• MDPP PHE Flexibilities
• Additional Resources
• Help Desk Support

CDC Recognition and Enrolling in Medicare

1. How long does it take to obtain CDC preliminary or full Diabetes Prevention Recognition Program (DPRP) recognition?

   Please see the CDC Diabetes Prevention Recognition Program (DPRP) Standards or contact the CDC National DPP Customer Service Center (CSC) for questions related specifically to recognition.

   It typically takes a minimum of 12 months to obtain CDC Preliminary Recognition, and up to 24 additional months to achieve Full Recognition. All requirements for achieving CDC Full Recognition status are listed in the CDC DPRP standards. They include using a CDC-approved curriculum, meeting attendance-based requirements, and meeting standards related to the rate at which participants achieve the final 5 percent (or more) weight loss goal.

2. How will our organization know if we have received MDPP Interim Preliminary Recognition in order to apply as an MDPP supplier?

   CMS began notifying organizations who received MDPP Interim Preliminary Recognition by email on January 1, 2018. Now that the CDC’s 2018 Diabetes Prevention Recognition Program (DPRP) standards are effective, any organization that received MDPP Interim Preliminary Recognition will automatically qualify as having CDC Preliminary Recognition. Organizations that have MDPP Interim Preliminary Recognition will not have to take any additional action to apply for CDC Preliminary Recognition, and should receive notification of their transitioned DPRP recognition status from the CDC on or after March 1, 2018. After March 1, organizations that apply for Medicare enrollment as an MDPP supplier should use their notification from CDC of achievement of CDC Preliminary Recognition for their MDPP enrollment application.

3. Does each site under an “umbrella” / larger organization need its own CDC recognition?

   Please see the CDC Diabetes Prevention Recognition Program (DPRP) standards and contact the CDC National DPP Customer Service Center (CSC) for questions related specifically to recognition.

   To enroll in Medicare as an MDPP supplier, the enrolling organization must meet certain CDC DPRP recognition criteria. As part of the Medicare enrollment application for MDPP, your organization may list multiple locations under the enrolling organization.

4.  Can an organizational code have more than one administrative location?

   Yes. MDPP suppliers can have multiple administrative locations and those locations can have different organizational codes, or they may all share a Diabetes Prevention Recognition Program organizational code. This will depend on how your organization has decided to structure its CDC recognition and its Medicare enrollment. Remember that MDPP suppliers may list one or more administrative locations located within the same state on the same enrollment application. In this case, these administrative locations can share an organizational code or they may each have their own. You may also recall that MDPP suppliers must submit an enrollment application for each state in which they have an administrative location. In this case, even though the organization will need to submit more than one enrollment application, the same organizational code can be listed on both applications.

5. How do I make changes to my organization’s information (the coach roster, supplier locations, or authorized/delegated officials)?

   To make updates to your organization's MDPP coach roster and supplier locations, please use this tutorial, which provides step-by-step instructions on updating or changing information for an existing enrollment. The tutorial can also be found on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). 

   All changes should be reported through the enrollment application form including: changes of ownership or to the coach roster, or new final adverse action history of any individual or required entity. These changes should be reported within 30 days of their occurrence.

   All other changes related to required information must be made within 90 days of the reportable event. The enrollment application can be found here. 

   For more information on how to update an enrollment application, please refer to the Calendar Year 2018 Physician Fee Schedule Final Rule. 

6. Can a group of healthcare providers apply for an NPI instead of applying individually?

   Yes, a health care provider or group of health care providers can have a particular organization apply for an NPI on their behalf by a process called Electronic File Interchange (EFI), also referred to as bulk enumeration. Rather than a provider or group of providers submitting a paper or web NPI application, the EFI provides another alternative to health care providers to obtain an NPI via the submission of an electronic file. For additional information about EFI, please click on this link.

7. If we are a group of organizations (e.g., health system, hospital system), do we need separate applications for the individual entities (e.g., sites, hospitals)? Do we need a separate application for different sites?

   No. Separate applications are not required. Instead, suppliers may provide multiple locations on the same Medicare supplier enrollment application within a given state. Please note that suppliers must include all required information for each location.

   Suppliers may list multiple sites as either administrative locations or community settings under a single or multiple DPRP recognition status(es)/organizational code(s), depending on how each organization structures its MDPP enrollment application. Please note that organizations may list one or more administrative locations within the same state on the same MDPP enrollment application. In these instances, these administrative locations can share an organizational code, or they may each have their own.

   MDPP suppliers must submit an enrollment application for each state in which they have an administrative location. For example, even though the organization will need to submit more than one enrollment application, the same organizational code can be listed on multiple MDPP enrollment applications for the same organization.

8. If an organization has obtained both distance learning and in-person Diabetes Prevention Recognition Program (DPRP) organizational codes, which should be included on the MDPP application?

   Suppliers may include their in-person organization code, or both their in-person and distance learning DPRP organizational codes when submitting or updating their MDPP enrollment application in PECOS. 

   MDPP suppliers must maintain at least one active, in-person CDC DPRP organizational code to enroll and remain enrolled in Medicare as an MDPP supplier. 

9. If an applicant receives a letter from a Medicare Administrative Contractor (MAC) stating that they need to be fingerprinted as part of the MDPP enrollment process, will this delay the MDPP enrollment application being processed?

   In some cases, Medicare Administrative Contractors (MACs) will notify suppliers if individuals in their organization must submit fingerprints. Individuals with at least a 5% direct or indirect ownership of the organization must submit fingerprints. Please review the Fingerprinting FAQ for more information. 

   Applications take approximately 80-90 days for MACs to process, and may extend beyond this period, if additional information is needed or there are identified issues with an application. An applicant’s designated MAC will notify applicants on the status of their applications.

   To check the status of an MDPP enrollment application, please contact the MAC that serves the pertinent geographical area.

10. If an application is denied because for non-compliance with MDPP supplier standards, what options are available?

    If an organization’s enrollment is denied or revoked for non-compliance, the organization may submit a Corrective Action Plan (CAP). The CAP allows organizations to demonstrate the actions taken to correct the identified deficiencies. The CAP must be submitted within 30 calendar days from the date of the denial/revocation notice. 

    CMS will review the CAP and determine if the organization has provided sufficient evidence that it has complied fully with the Medicare requirements. Within 60 calendar days of receipt of the CAP, CMS will issue a written decision to the organization either reversing or upholding the denial/revocation of enrollment. If the CAP is denied and the denial/revocation is upheld, the decision letter will outline any appeals rights the supplier may have. If the CAP is approved, the denial/revocation will be reversed, and the enrollment application will be processed, or billing privileges will be re-instated.

11. How long does the supplier have to fix noncompliance issues (i.e., ineligible coach) when notified by CMS?

    A supplier has a maximum of 30 calendar days from the date of its denial/revocation notice to fix noncompliance issues that resulted in its denial or revocation.  For a supplier’s enrollment denial/renovation to be reversed, the MDPP supplier must submit a corrective action plan (CAP) that includes sufficient evidence to show that it has corrected each deficiency listed in the denial/revocation notice within 30 calendar days from the date of its denial or revocation notice from CMS.

12. Can individuals/coaches enroll in Medicare as MDPP suppliers? Does the answer differ if the individual has a certification or licensure (e.g., pharmacists, nurse practitioner, certified diabetes educator, etc.)?

    No. The CDC only grants recognition to organizational entities. Therefore, organizations, not individuals, may enroll in Medicare as an MDPP supplier if they meet the conditions for enrollment. Individuals who wish to participate in MDPP may do so as a coach.  An MDPP supplier must submit and maintain a roster of all coaches who will be furnishing MDPP services as part of its supplier enrollment application in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).

13. What NPI taxonomy type should prospective coaches use??

    Coaches may use a taxonomy type when applying for an NPI that fits their natural designation based on any certifications or licensures they may have (e.g. “Nurse”). Coaches may choose “Health Educator” in cases where no other taxonomy is applicable.

14. Why are coaches subject to screening?

    CMS established eligibility requirements to help prevent MDPP suppliers from allowing coaches to furnish MDPP services when certain adverse histories may indicate potential to harm Medicare beneficiaries or undermine program integrity.

15. Is there a fee associated with enrollment as an MDPP supplier?

    Per the finalized Calendar Year 2022 Physician Fee Schedule (PFS) at the Medicare enrollment application fee does not apply to all MDPP suppliers that submit an enrollment application on or after January 1, 2022.

16. How can we locate enrolled MDPP suppliers?

    A map of enrolled MDPP suppliers can be found on the interactive MDPP supplier Map. Alternatively, a list of all currently enrolled MDPP suppliers is available, including supplier location and contact information. 

Fingerprinting FAQs

1. If an organization is a non-profit community-based organization, is there a fingerprinting requirement?

   If the non-profit organizations (NPOs) does not have an owner, applicants do not need to list any owners in section 6 of CMS-20134, and as such there is no need to submit fingerprints. 

   To be considered an NPO an organization must obtain either 501(c)(3) certification from the IRS or acquire a comparable tax-exempt certification from the State where it is located. 

2. Are board members of an organization required to be included on the application and/or fingerprinted?

   Members of an organization’s board of directors only need be disclosed in section 6 of the form if: 

• The enrolling entity is classified as a corporation, OR
• The board member qualifies as a managing employee, owner, or other type of individual who is required to be reported in section 6. 
  
  Only board members with a 5% or greater direct or indirect ownership interest in the organization are required to submit fingerprints.

3. When and why were fingerprint-based background checks for certain Medicare providers and suppliers implemented?
4. Fingerprint-based background checks were implemented as part of the enhanced enrollment screening provisions required by Section 6401 of the Affordable Care Act. To implement this requirement, CMS published a final rule with comment period, entitled, “Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers” (CMS-6028-FC) in the February 2, 2011 “Federal Register.” The fingerprint-based background check implementation has been phased in beginning in 2014. The fingerprint-based background check must be completed on all providers or suppliers that are designated under the high-risk screening category for all individuals with a 5 percent or greater direct or indirect ownership interest in a Medicare-enrolled provider or supplier.

5. Does the fingerprint-based background checks apply to MDPP suppliers?

   Yes. The calendar year (CY) 2017 Medicare Physician Fee Schedule (PFS) designated MDPP suppliers as “high” categorical risk. 

6. When would individuals of an organization (applying to be an MDPP supplier) have to submit fingerprints?

   In the  CY 2017 Medicare PFS Final Rule, CMS finalized a rule that organizations applying to be MDPP suppliers are designated under the high-risk screening category. Suppliers under the high–risk screening category must submit fingerprints for a national background check for all individuals who maintain a 5percent or greater direct or indirect ownership interest in the provider or supplier. Therefore, all individuals with a 5 percent or greater direct or indirect ownership interest in an organization applying to be an MDPP supplier must submit fingerprints upon request of the Medicare contractor as a part of their enrollment application.

7. How does CMS define an "owner"?

   As laid out in 424 CFR 424.502, an owner means any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of the provider or supplier as defined in sections 1124 and 1124A(A) of Social Security Act. The Act defines the term “person with an ownership or control interest”, with respect to an entity, as a person who—

   • has directly or indirectly an ownership interest of 5 per centum or more in the entity; or
   • is the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by the entity or any of the property or assets thereof, which whole or part interest is equal to or exceeds 5 per centum of the total property and assets of the entity; or
   • is an officer or director of the entity, if the entity is organized as a corporation; or
   • is a partner in the entity, if the entity is organized as a partnership.

   For further information on owners and ownership interest, please refer to Chapter 15, sections 15.5.5 and 15.5.6 of Pub 100-08, the Medicare Program Integrity Manual.

8. Do shareholders of publicly traded companies need to submit fingerprints?

   Shareholders of publicly traded companies would need to submit fingerprints only if they owned 5 percent or more of the shares.

9. Would every organization have an individual that meets the definition of “ownership or investment interest?”
   
   Depending on the ownership structure, there may not be any individual who meets this definition. For example, non-profit organizations (NPOs) generally do not have owners and typically only have individuals with managing control. In this scenario, NPOs typically only disclose their board of trustees or other governing body, as noted in the Program Integrity Manual, Pub 100-08 15.2.F. These individuals are considered managing members, but not considered owners, and therefore, would not be subject to the fingerprint requirement.
    
10. Who will evaluate whether an applicant has an individual who meets the definition of “ownership or investment interest?” 
    
    The Medicare Administrative Contractors (MACs) will evaluate whether the applicant has an individual who meets this definition based on the information and supporting documentation that are submitted in an MDPP supplier’s enrollment application (e.g., non-profit organizations are required to submit a copy of 501(c)(3) forms to verify their non-profit status).

11. If I believe that I or individuals in my organization meet the definition of an owner, when do I submit fingerprints? Along with my application?

    Organizations interested in applying for MDPP supplier enrollment will complete the appropriate enrollment application and may submit fingerprints at the request of the Medicare Administrative Contractors (MACs) during the application process. MACs will then evaluate whether the applicant has an individual who meets this definition based on what is submitted in their enrollment application and will send fingerprint requests to the applicant based on this evaluation.

Billing and Claims

1. Do suppliers use CPT codes to bill for MDPP services? 

   No, MDPP suppliers use Healthcare Common Procedure Coding System (HCPCS) G-codes to bill for MDPP services.

2. Where are the MDPP HCPCS G-codes listed?

   The final 2024 Healthcare Common Procedure Coding System (HCPCS) G-codes can be found on page 79252 of the CY 2024 final rule. 

3. Can MDPP suppliers bill Medicare for services furnished before April 1, 2018?

   No, enrolled MDPP suppliers can only bill Medicare for MDPP services furnished on or after April 1, 2018 according to their effective date of billing privileges. For approved enrollment applications submitted prior to April 1, 2018, the effective date of billing privileges will be April 1, 2018. For all approved applications submitted after April 1, 2018, the effective date of billing privileges will be the date the application was submitted, in the event that the MDPP supplier’s enrollment is subsequently approved. If the MDPP supplier’s enrollment application was denied for non-compliance, and a corrective action plan resulted in the application being approved, the effective date of billing privileges would be the date the corrective action plan was submitted.

4. Can suppliers offer MDPP in addition to medical nutrition therapy (MNT) and diabetes self-management training (DSMT) services and charge Medicare concurrently?

   Yes, under certain circumstances, organizations may offer MDPP services in addition to MNT and DSMT services and bill Medicare concurrently. MDPP suppliers can only bill for MDPP services under their MDPP enrollment. In order to bill for MNT or DSMT services, the MDPP supplier must have a separate enrollment other than as an MDPP supplier that would enable them to furnish MNT or DSMT services. In this scenario, an organization could bill Medicare for both MDPP services and MNT or DSMT services.  Additionally, the receipt of MDPP services does not preclude a beneficiary from accessing other treatments for diabetes during the time period that the beneficiary is covered for MDPP services. CMS strongly encourages suppliers to emphasize to beneficiaries who develop diabetes to consult with their health care provider on the most appropriate treatment plan for their diabetes, which may or may not include MDPP services.

5. What are the billing requirements for existing Medicare providers, such as Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs), who are new to MDPP?

   Any provider with an existing Medicare enrollment type (including critical access hospitals, FQHCs and RHCs) must re-enroll in Medicare as an MDPP supplier and bill using the CMS-1500 paper claim form or its electronic equivalent in order to bill Medicare for MDPP services. To enroll as an MDPP supplier, FQHC/RHCs may submit a separate enrollment application to Medicare if they meet the CDC recognition and CMS MDPP supplier standards. Once enrolled as an MDPP supplier, the FQHC/RHC may bill Medicare for MDPP services using the separate MDPP supplier NPI on a CMS-1500 paper claim form or its electronic equivalent. MDPP services must be billed using only the MDPP HCPCS Payment G-codes CY 2024 (PDF) that were finalized in the Calendar Year (CY) 2024 Physician Fee Schedule final rule. RHCs and FQHCs must ensure that there is no co-mingling of MDPP services with RHC or FQHC services, and any costs related to furnishing MDPP services must be reported as non-reimbursable costs on the RHC or FQHC cost report.

6. Do we bill out of our administrative location for all of our MDPP class locations?

   An administrative location means any physical location associated with the suppliers’ primary business operations, therefore MDPP suppliers may bill out of their administrative location. An MDPP supplier may have more than one administrative location, in which case, billing could occur from more than one location.

7. What claims submission software should I use for furnishing MDPP services?

   There are no requirements for the type of claims submission software MDPP suppliers should use for billing. Existing providers with a billing system can continue to use that system for submitting claims to Medicare. If your organization does not have claims submission software, you can download a free claims submission software called PC-Ace Pro32, which CMS offers through its Medicare Administrative Contractors (MACs).

8. If an organization already has a billing system, can it continue to use that system for billing MDPP services?

   Yes. Existing providers with a billing system can continue to use that system for submitting claims to Medicare and are not required to purchase or establish additional infrastructure specifically for the MDPP expanded model.

9. Can you re-use Healthcare Common Procedure Coding System (HCPCS) G-codes on claims forms?

   As of CY 2024, the number of MDPP G-Codes has been reduced from 11 to 6.  Suppliers must submit one of two new G-Codes (G9886 for in-person / G9887 for distance learning) when submitting claims for payment for MDPP core and core maintenance sessions to their MACs.  CMS will allow up to 22 sessions (alone or in combination with other codes, not to exceed 22 sessions in a 12-month timeframe).

   For more information on claim forms, please contact your Medicare Administrative Contractor (MAC). You can find information about MACs on the MDPP Enrollment Fact Sheet (PDF). Please visit a MDPP HCPCS Payment G-codes CY 2024 (PDF) for more information.

10. Can a bridge payment be made with a performance payment for the same session?

    Yes. If a beneficiary achieves a performance goal on the first session attended with the subsequent supplier, the supplier may bill both a bridge payment and the appropriate performance payment. However, the subsequent supplier must obtain the beneficiary’s MDPP records from the previous supplier before billing the performance payment to ensure accuracy.

11. Can a third-party administrator or billing agent, if properly set up under Medicare, bill for MDPP services if the program is implemented by an MDPP supplier?

    An organization is permitted to partner with third party administrators to facilitate MDPP supplier requirements. However, claims preparation and submission are the responsibility of the MDPP supplier or the billing agent who furnishes the MDPP supplier’s billing and collection services. If requirements are met, Medicare will pay the MDPP supplier or its billing agent (if applicable). Additionally, the MDPP supplier is held accountable for compliance with all appropriate regulations and requirements, regardless of its use of a third-party entity. For this situation, CMS suggests seeking counsel to determine if the third-party administrator or billing agent meets the requirements.

12. By enrolling in Medicare as an MDPP supplier and receiving performance payments, what payment amounts must the MDPP supplier make to its coaches or employees?

    If the MDPP supplier is enrolling in Medicare and furnishing MDPP services, the supplier will receive payments under the finalized payment structure. MDPP regulations do not govern how an MDPP supplier distributes funds within its organization after claims are paid by Medicare.

13. Must MDPP suppliers accept mandatory assignment?

    Yes. CMS currently mandates assignment for claims from multiple types of suppliers and practitioners, including MDPP suppliers. This means that MDPP suppliers must accept the Medicare allowed amount as payment in full for their services, regardless of the supplier’s participation status in the Medicare program. The beneficiary (or the person authorized to request payment on the beneficiary’s behalf) is not required to assign the claim to the supplier in order for an assignment to be effective, and when these claims are inadvertently submitted as unassigned, Medicare Administrative Contractors (MACs) process them as assigned.

14. Can MDPP suppliers bill eligible beneficiaries for these services (e.g., billing the difference between the program cost and MDPP payment)?

    No. Eligible beneficiaries receive these services as preventive services, which require no copays. Additionally, the performance payments are made only on an assignment-related basis, therefore MDPP suppliers must accept the Medicare allowed charge as payment in full and may not bill or collect any amount from an eligible beneficiary.

15. What NPIs should be used on a claim form when billing MDPP services?

    The supplier’s NPI goes in the “billing provider” space, and the coach’s NPI goes in the “rendering provider” space on each line item associated with an MDPP session furnished and the date of service.

16. Is there a limit on bridge payments?

    Yes. A bridge payment, or the payment for when a beneficiary switches to a new supplier, may only be made once per beneficiary per supplier. However, beneficiaries have the freedom to switch suppliers at any time, so there is no limit on the number of suppliers who may receive a bridge payment for an individual beneficiary.

17. When does a virtual modifier need to be used?

    For claims with a date of service between April 1, 2018, and December 31, 2023, a virtual modifier, “VM,” should be appended to the HCPCS G-code on each claim line item that represents an MDPP core or core maintenance session that was delivered virtually.

    For MDPP dates of service on or after January 1, 2024, an additional HCPCS G-code for distance learning (G9887) was added to the MDPP G-codes to be used instead of the virtual modifier (VM) when submitting MDPP claims, including claims for make-up sessions. This allows CMS to better track trends related to the distance learning delivery of the MDPP Set of services. Please review a MDPP HCPCS Payment G-codes CY 2024 (PDF) for changes implemented as part of the CY 2024 PFS for more information.

18. When do claims have to be submitted?

    CMS encourages suppliers to submit claims in a timely fashion to ensure payment. Although standard CMS billing procedures allow suppliers up to one year to submit a claim from the date of service that the session was furnished, not submitting claims in a timely fashion will increase a supplier’s risk of not receiving payment.

19. Is there a minimum or maximum number of the amount of participants we need to have in each class?

    No. However, if a supplier intends to institute a self-determined capacity limit, the supplier must have previously made this limit publicly available; for example, denoting the limit in any brochures, web sites, or other materials that outline their MDPP services.  Suppliers may not deny access to MDPP services to eligible beneficiaries based on any reason other than the supplier’s own self-determined and published capacity limits to furnish MDPP services to additional people and, on a discretionary basis, if a beneficiary significantly disrupts the session for other participants or becomes abusive.

20. Can individual coaches submit claims, or is it only organizations that can submit claims to Medicare?

    Only organizations that are enrolled in Medicare as MDPP suppliers may bill Medicare for MDPP services. Individuals (coaches) that furnish MDPP services do not bill Medicare directly.

21. Does the G9891 Code need to be indicated as a separate line item for all sessions attended, and is it to be billed after each class or when we submit the other codes for the attendance performance markers?

    For claims with a date of service on or before December 31, 2023, code G9891 (non-payable session code) only needs to be reported as a separate line item for sessions that do not correspond with a performance payment. All sessions reported using the G9891 code should be reported on the same claim as the performance payment to which those sessions contributed and do not need to be billed separately after each session.

    For example, in a case in which a beneficiary has accessed all MDPP services from the same supplier, when that supplier submits a claim for the fourth core session (using code G9874), the supplier would also list code G9891 on two additional line items (once for core session 2 and once for core session 3, because these sessions are not associated with performance payments).

    Please note that the G9891 Code should not be utilized for claims with a date of service on or after January 1, 2024, given changes to the MDPP payment schedule in the finalized CY 2024 Physician Fee Schedule (PFS) (PDF). For MDPP claims with dates of service on or after January 1, 2024, suppliers may receive up to 22 fee-for-service payments for beneficiary attendance during the core services period while retaining the performance-based payments for diabetes risk reduction (weight loss).

    For more information on claims, please contact your Medicare Administrative Contractor (MAC).

22. Does the billing have to begin with core session 1?

    For claims with a date of service on or before December 31, 2023, billing for MDPP services must begin with core session 1, unless the beneficiary is switching after first receiving the services from another supplier, in which case the new supplier would begin billing with the "bridge payment."

    For claims with a date of service on or after January 1, 2024, suppliers will use one of two new G-Codes (G9886 for in-person / G9887 for distance learning) when submitting claims for payment for MDPP core and core maintenance sessions to their MACs.  CMS will allow up to 22 sessions (alone or in combination with other codes, not to exceed 22 sessions in a 12- month timeframe).

23. If I am enrolling with multiple locations do I still have the same Medicare Administrative Contractor (MAC)? (If we have multiple locations, do we use the same MAC?)?

    Your MAC depends on your site location. Different site locations may have different MACs depending on the jurisdiction. For more information on where to locate your MAC, please visit this website and search for the Part A/B MAC that serves your geographical area.

24. How have the limits and criteria for make-up sessions changed?

    For MDPP suppliers who provide the MDPP set of services virtually, CMS has waived the limits on the number of virtual make-up sessions in 42 C.F.R. § 410.79(d)(2) and (d)(3)(i). CMS waived the limits of make-up sessions in instances where MDPP suppliers were able to use a make-up session curriculum that addressed the same CDC-approved DPP curriculum topic as the regularly scheduled session.

    Please Note: Suppliers cannot submit multiple claims for G9886/G9887 with the same date of service (DOS). CMS does not require make-up sessions to be a full week apart from the regularly scheduled sessions; however, if multiple MDPP sessions have the same date of service (DOS), MACs are not able to differentiate between the make-up sessions versus the regularly scheduled sessions. These claims will not be adjudicated by the MAC and will be returned to the supplier as non-processible.

25. What Place of Service (POS) code should suppliers use to bill for virtual sessions?

    For virtual session claims with a date of service (DOS) on or after January 1, 2024, suppliers should use the distance learning HCPCS code G9887 and the POS code “Other” (99).

    For MDPP sessions provided in a community setting, suppliers should use POS code “Other” (99).

    For MDPP billing, suppliers can list the currently enrolled location (not the coach’s home address) as the POS.

26. How should a supplier bill for patients who are restarting services after having paused or cancelled their MDPP set of services due to the COVID-19 public health emergency (PHE)?

    CMS waived the once-per-lifetime requirement for MDPP patients who were receiving the set of services as of March 1, 2020 and whose sessions were paused or cancelled due to the PHE. This waiver allowed patients to receive the MDPP set of services more than once per lifetime.

    If a patient chooses to restart MDPP, they should restart the expanded model at the first core session. Suppliers will submit claims for the MDPP services provided as if for a new patient.

27. Some patients do not have insurance coverage for the CDC’s National Diabetes Prevention Program (DPP), while other patients have insurance that covers the DPP.  Can MDPP suppliers furnish Medicare covered items and services for free to some patients but not others?

    Medicare does not make payment for Part A or B covered items or services that neither the beneficiary nor any other person or organization (by reason of such individual’s membership in a prepayment plan or otherwise) has a legal obligation to pay for or provide (See 1862(a)(2) of the Social Security Act and 42 CFR 411.4).  We refer to this payment exclusion as the “no legal obligation to pay” payment exclusion.  This exclusion applies where items and services are furnished for free without regard to the patient’s ability to pay and without expectation of payment from any source, such as free x-rays or immunizations provided by health organizations.

    However, Medicare reimbursement is not precluded merely because a supplier waives the charge in the case of a particular patient or group or class of patients, as the waiver of charges for some patients does not impair the right to charge others, including Medicare patients.  The determinative factor in applying this exclusion is the reason the particular individual is not charged.  (See Pub. 100-02 Medicare Benefit Policy Manual, Chapter 16, Section 40 (PDF).)  The following examples illustrate the applicability of this payment exclusion to various situations for the purposes of the MDPP.

    1. Example 1: Supplier furnishes Medicare Part A or B covered items or services to all patients for free regardless of insurance or ability to pay (does not bill the patient or (if any) their insurer(s)). The no legal obligation to pay payment exclusion is not implicated because no claim will be submitted to Medicare.
    2. Example 2:  Supplier furnishes Medicare Part A or B covered items or services to non-Medicare patients for free (does not bill the patient or (if any) their insurer(s)) but submits claims for Medicare beneficiaries. Medicare’s no legal obligation to pay payment exclusion applies, which means Medicare payment cannot be made and the Medicare beneficiary cannot be charged for the covered items or services.
    3. Example 3:  Supplier has a policy to furnish items and services, including those covered by Medicare Part A or B, to indigent patients for free regardless of insurance (does not bill the patient or (if any) their insurer(s)) and all non-indigent patients are billed. If the items or services are free to all indigent patients (both Medicare beneficiaries and non-Medicare patients) because of their inability to pay, Medicare’s no legal obligation to pay payment exclusion does not preclude payment and Medicare payment may be made for those items and services billed to non-indigent Medicare beneficiaries.

    Note that furnishing items or services for free to Medicare patients regardless of whether the patients are indigent may implicate certain fraud and abuse laws such as the Federal anti-kickback statute and the civil monetary penalty provision prohibiting inducements to beneficiaries (the “Beneficiary Inducements CMP”). Information about the fraud and abuse laws, including the Federal anti-kickback statute and the Beneficiary Inducements CMP, can be found on the HHS Office of Inspector General website: https://oig.hhs.gov/compliance/.

    Finally, when a supplier furnishes Medicare Part A or B covered items or services (which includes MDPP services), it is subject to Medicare’s mandatory claim submission rules. Therefore, a supplier who treats a Medicare beneficiary for a covered item or service must either enroll in Medicare and submit a claim on that beneficiary’s behalf for those services or furnish the Medicare-covered services for free.

MDPP Set of Services and Beneficiary Eligibility

1. Do services have to be furnished in traditional health care settings such as physician offices or hospitals?

   No. MDPP services do not need to be furnished in a traditional health care setting, but must follow the requirements for MDPP locations. For more information on the location requirements, please view the Enrollment Checklist (PDF) and the CY 2018 Physician Fee Schedule Final Rule.

2. Do MDPP suppliers have to offer the ongoing maintenance sessions or is this an optional extension of the diabetes prevention program 12-month core?

   An MDPP supplier must offer ongoing maintenance sessions to beneficiaries as long as the beneficiary is eligible for these sessions. If the beneficiary loses eligibility before or during the ongoing maintenance sessions, the MDPP supplier is no longer required to offer ongoing maintenance sessions to that beneficiary.

3. How can an MDPP supplier measure a beneficiary’s weight?

   During the PHE and PHE flexibilities extension, a beneficiary’s weight may be taken in-person by the MDPP supplier, via digital technology (such as scales that transmit weights securely via wireless or cellular transmission), or self-reported by the MDPP beneficiary from an at-home digital scale if the weight will be used for the purposes of documenting a performance goal. Self-reported weights must be obtained during live, synchronous online video technology, such as video chatting or video conferencing, wherein the MDPP coach observes the beneficiary weighing themselves and views the weight indicated on the at-home digital scale. Alternatively, the beneficiary may self-report their weight by submitting to the MDPP supplier a date-stamped photo or video recording clearly documenting the beneficiary's weight as it appears on a digital scale, with the beneficiary visible in their home.

4. Are people with End Stage Renal Disease (ESRD) eligible to participate in MDPP?

   No. Because someone with ESRD typically requires more complex care than can be provided by MDPP coaches, those with ERSD are not eligible to participate in MDPP. While beneficiaries who have Medicare due to their ESRD are not eligible for MDPP, a beneficiary who previously had ESRD may be eligible to participate in MDPP. 

• If the beneficiary has Medicare due to age (65 or older) or certain disabilities, and if they meet the following conditions, then they would be eligible to participate in MDPP: 
• It has been 12 months after the month the beneficiary stops dialysis treatments, or
• It has been 36 months after the month the beneficiary had a kidney transplant.|
  
  Please note that a beneficiary must maintain Medicare Part B coverage and not be diagnosed with ESRD throughout the entire duration of the MDPP services period to remain eligible to receive coverage for MDPP services. 
  
  More information is available here.   

5. Why must MDPP services be approximately one hour in length?

   MDPP services must be ‘‘approximately one-hour in length” to align with DPRP standards and meet auditable requirements, which is a critical component of CMS’s program integrity efforts.  The DPRP standards specify that “each session must be of a sufficient duration to convey the session content – or approximately one hour in length.” We believe that “approximately one-hour in length” aligns with the CDC’s intended session duration and allows enough flexibility to account for the fact that session lengths may vary based on factors such as number of attendees, beneficiaries’ assessed needs, and the approach to the curriculum. However, the guideline is also auditable to help ensure program integrity.

6. Does an administrative location have to be operational (e.g., coaches present, sessions in delivery) during normal business hours?

   Yes, but there is flexibility regarding how to implement this requirement. Thus, each MDPP supplier can determine and disclose the operating hours when it plans to have staff physically present at an administrative location. An MDPP supplier can also disclose its operating hours for services provided outside of its administrative location. An MDPP supplier can also disclose when its operations will be handled over the phone or in a location other than its administrative location. There is flexibility in that employees, staff or volunteers can fulfill this requirement to be operational, and we take no position as to whether these individuals serve as MDPP coaches or in another function for the supplier. The intent for this supplier requirement is to ensure MDPP suppliers maintain operational hours and fulfill these hours.

7. Which MDPP sessions can be furnished as virtual make-up sessions?

   Any session can be delivered as a virtual make-up session except for the first core session, since baseline weight must be measured at the core session. Please note that official weight measurements cannot be taken during virtual make-up sessions. Any weights taken during virtual make-up sessions will not count towards payment or continued beneficiary eligibility.

8. Can MDPP suppliers furnish services entirely virtually?

   Yes. During the PHE and PHE flexibilities extension, MDPP suppliers may provide all MDPP sessions virtually, as long as the virtual services are furnished in a manner that is consistent with the CDC Diabetes Prevention Recognition Program (DPRP) standards for distance learning sessions, follow the CDC-approved National DPP curriculum requirements, the supplier has an in-person DPRP organizational code, the supplier has the capability to furnish MDPP services in-person, and all other requirements specified at § 410.79(e)(3)(iv) are satisfied.

9. Can suppliers furnish MDPP services as a combination of virtual and in-person sessions?

   Yes. The PHE and the PHE flexibilities extension allow MDPP suppliers to furnish MDPP services as a combination of virtual and in-person sessions, as long as the virtual services are furnished in a manner that is consistent with the CDC Diabetes Prevention Recognition Program (DPRP) standards for distance learning sessions. The curriculum furnished during the virtual sessions should also address the same topics as the CDC-approved National Diabetes Prevention Program (National DPP) curriculum, and the supplier is required to have an in-person DPRP organizational code. Suppliers should note that online (asynchronous) delivery of MDPP services is not covered as part of MDPP virtual services during the MDPP extended flexibilities period (January 1, 2024 to December 31, 2027).

10. How does an MDPP supplier enroll an eligible Medicare beneficiary in MDPP?

    To enroll eligible beneficiaries in MDPP, suppliers should:

    1. Verify and document beneficiary eligibility. 
       1. Please see MDPP Verify Medicare Coverage Guide (PDF) for information on the beneficiary verification process for MDPP.
    2. Begin providing MDPP services
    3. Submit MDPP-related claims to the appropriate MAC.
       1. A beneficiary is considered enrolled in MDPP after the first claim has been submitted to the appropriate MAC by the MDPP supplier that provided services to the beneficiary.

       2. Please note that the MDPP services period begins with the initiating claim (G9873 if the date of service for the first core session was in 2018 to 2023; G9876 or G9877 if date of service for the first core session was in 2024 or later) and ends 12 months later.

          CMS encourages suppliers to submit claims in a timely fashion to ensure payment.

11. Are suppliers required to offer virtual make up sessions? In other words, are suppliers required to be equipped to offer virtual make-up sessions?

    No, suppliers are not required to offer virtual make-up sessions; they have the flexibility to do so, as long as the standards for virtual make-up sessions are met.

12. Can MDPP suppliers provide incentives (or free items) to beneficiaries?

    Beneficiary engagement incentives are optional, and MDPP suppliers can opt to provide them at their own expense. CMS will not fund or pay suppliers for beneficiary engagement incentives offered as part of the MDPP expanded model. Any free item or service provided to an MDPP beneficiary by an MDPP supplier must meet the requirements for beneficiary engagement incentives. These are listed below. If any MDPP supplier is interested in providing these items and wants to determine whether the particular item or service they are interested in providing qualifies as a beneficiary engagement incentive per MDPP regulations, then we suggest that the MDPP supplier consult with legal counsel.

    1. The item or service must be furnished directly to an MDPP beneficiary by an MDPP supplier or by an agent of the MDPP supplier, such as a coach, under the MDPP supplier’s direction and control.

    2. The item or service must be reasonably connected to the CDC approved DPP curriculum furnished to the MDPP beneficiary during a core session, core maintenance session, or ongoing maintenance session furnished by the MDPP supplier.

    3. The item or service must be a preventive care item or service or an item or service that advances a clinical goal for an MDPP beneficiary by engaging him or her in better managing his or her own health.

    4. The item or service must not be tied to the receipt of items or services outside of the MDPP services.

    5. The item or service must not be tied to the receipt of items or services from a particular provider, supplier, or coach.

    6. The availability of the item or service must not be advertised or promoted as an in-kind beneficiary engagement incentive available to an MDPP beneficiary receiving MDPP services from the MDPP supplier except that an MDPP beneficiary may be made aware of the availability of the item or service at the time the MDPP beneficiary could reasonably benefit from it during the engagement incentive period.

    7. The cost of the item or service must not be shifted to another Federal health care program.

    8. The cost of the item or service must not be shifted to an MDPP beneficiary.

13. Are beneficiaries able to switch suppliers while receiving the MDPP set of services?

    Yes, beneficiaries are able to switch MDPP suppliers as many times as they wish and at any time during the period in which they receive the MDPP set of services. However, once a beneficiary attends the first core session, the MDPP services period begins and the beneficiary’s once per lifetime limit goes into effect. For example, if a beneficiary attends the first core session and then does not attend again for 12 months following that first core session, the beneficiary would not be eligible for additional MDPP services.

14. Does MDPP have beneficiary attendance requirements?

    Once the MDPP services period is initiated through attendance at the first core session, there are no attendance requirements for beneficiaries to attend core sessions or core maintenance sessions in months 0-12. Starting in 2024, Medicare will only pay for up to 22 MDPP sessions, including up to 16 weekly sessions in months 1-6 and up to 6 monthly sessions in months 7-12. Medicare will only pay for sessions that beneficiary attends. MDPP suppliers must furnish these services to eligible beneficiaries regardless of if they have achieved 5% weight loss and can receive payments for attendance throughout the MDPP service period.

15. If a patient drops out of MDPP after a claim has been submitted, what is the time frame in which the patient can re-enroll in MDPP, and additional sessions can be billed to Medicare?

    Once a beneficiary attends the first core session, the MDPP services period begins counting towards that beneficiary’s once per lifetime limit on MDPP services. 

    Beneficiaries can attend up to 22 sessions within a 12- month period. If the beneficiary experiences an unexpected and/or life altering event within the core session services period, they have the option to pause their sessions and resume attending within the 12-month services period. Once the 12-month service period ends, a participating organization cannot bill for subsequent sessions. 

16. Does MDPP require a referral?

    No, CMS does not require referrals for MDPP services, but we encourage beneficiaries to always consult with their primary health care provider about whether MDPP services are clinically appropriate.

17. Do the blood tests covered by Medicare require a physician’s referral?

    Yes, the blood tests used for diabetes screening require a provider referral to be covered as part of the diabetes screening benefit. As part of the Medicare Preventive Services, Medicare covers the fasting plasma glucose test and the oral glucose tolerance test. Starting in 2024, Medicare will also cover the Hemoglobin A1C test (HbA1c) test as part of the diabetes screening benefit.

18. Which blood tests does Medicare cover?

    Medicare covers the fasting plasma glucose test and the oral glucose tolerance test when a beneficiary has a referral from his or her primary care physician or a qualifying provider. Medicare does not currently cover the hemoglobin A1c test for pre-diabetes screening.

19. Can a beneficiary use lab results not referred by a physician to prove their blood test eligibility? / Does a letter or form with blood test results suffice for eligibility?

    CMS does not designate specific types or forms of documentation that should or must be used as evidence that a beneficiary meets the MDPP eligibility requirements and cannot provide guidance on whether specific types of documentation would be sufficient under the MDPP regulations.

20. Which eligibility requirements can beneficiaries self-report?

    Beneficiaries can self-report the following eligibility requirements: Asian ethnicity, no history of type 1 or 2 diabetes (other than gestational), no previous receipt of MDPP services, and development of End-Stage Renal Disease for beneficiaries who age into Medicare.

21. Can beneficiaries who develop diabetes during the course of the MDPP set of services continue to receive the services?

    Yes. Beneficiaries who develop diabetes while receiving MDPP services are eligible to continue receiving the full set of MDPP services for which they are eligible. Additionally, the receipt of MDPP services does not preclude a beneficiary from accessing other treatments for diabetes during the time period that the beneficiary is covered for MDPP services. However, we believe it is most appropriate for MDPP suppliers to recommend that beneficiaries who develop diabetes see their primary health care provider who is best suited to develop a treatment plan for each individual beneficiary.

22. Is a beneficiary who previously participated in the National DPP eligible to participate in MDPP?

    Yes, a beneficiary who previously participated in the National DPP is still eligible for MDPP services as long as prior DPP sessions were not billed to Medicare and the beneficiary meets all other MDPP eligibility requirements.

23. Is there a database that suppliers can access to determine whether beneficiaries have previously received MDPP services?

    We are exploring an electronic mechanism using existing CMS systems that MDPP suppliers could access to verify beneficiaries’ prior receipt of MDPP services and intend to provide additional information on this mechanism in future guidance, as appropriate. In the meantime, MDPP suppliers can contact their Medicare Administrative Contractor (MAC) to see if MDPP services have previously been received by a beneficiary. To find an organization's MAC, please visit the cms.gov website on MACs.

24. What if a beneficiary moves to a location where there is no MDPP supplier after he or she has started receiving the set of MDPP services?

    If there is no MDPP supplier in the new location, the beneficiary can attend virtual sessions through distance learning (e.g., a live virtual classroom), if offered.  The beneficiary may also identify other MDPP suppliers that offer distance learning delivery of MDPP services.

25. Can a FFS Medicare patient enroll with any MDPP supplier offering distance learning MDPP sessions, even if the supplier is located in a different state?

    Yes. Eligible FFS Medicare patients can enroll with any MDPP supplier offering MDPP sessions via distance learning, regardless of where the patient and supplier are located.

26. Can MDPP suppliers offer distance learning MDPP sessions to FFS patients living in other states?

    Yes. Please note that suppliers must ensure that all patients are eligible for MDPP under FFS Medicare and follow all CDC DPRP Standards for distance learning delivery. All MDPP suppliers must maintain the capacity to offer MDPP services in person, even if they are currently delivering most or all MDPP sessions via distance learning.

27. How should MDPP suppliers submit claims for MDPP sessions delivered via distance learning to patients located in other states?

    MDPP suppliers should submit all claims for MDPP services to their MAC, regardless of where the patient is located. The claims submission process will be the same for MDPP sessions delivered via distance learning as for MDPP sessions delivered in-person but note that MDPP suppliers should use “Other” (99) as their Place of Service (POS) code for sessions delivered via distance learning and that the Virtual Modifier (VM) is not required on claims for G9887. For MDPP billing, claims may list the currently enrolled location (not the coach’s home address) as the POS.

Coach Requirements and Supplier Standards

1. Do MDPP coaches have to hold any specific credentials or have clinical experience?

   No, coaches are not required to have clinical experience. CMS does not stipulate requirements around coach training, but relies on the CDC's Diabetes Prevention Recognition Program (DPRP) standards. To find Lifestyle Coach Training Programs, please visit the staffing and training page of the CDC DPRP website.

2. What are the requirements for submitting ongoing maintenance session data?

   CMS retired ongoing maintenance services as of Calendar Year (CY) 2024, but any outstanding ongoing maintenance session data must still be submitted.

   For ongoing maintenance services delivered on or before December 31, 2023, MDPP suppliers must continue to submit performance data for any beneficiaries who attend ongoing maintenance sessions in a manner and form as specified by CMS. This performance data must align with the performance data elements as required by CDC for the DPRP standards. MDPP suppliers are required to submit session-level data, consistent with performance data MDPP suppliers are already providing to CDC, for ongoing maintenance sessions.

3. When do I have to begin submitting data and how often?

   The crosswalk should be supplied to CMS beginning 6 months after the organization begins furnishing MDPP services, and quarterly thereafter.  The crosswalk would be maintained in a spreadsheet (for example, an Excel file or a CSV file), in a form and manner specified by CMS. There is currently no template for compiling the crosswalk data. CMS plans to provide future guidance on compiling and submitting this crosswalk data.

4. How long must MDPP suppliers maintain records / blood tests?

   MDPP suppliers must maintain all books, contracts, records, documents, and other evidence for 10 years from the last day the beneficiary received  MDPP services from the supplier or from the date of completion of any audit, evaluation, inspection, or investigation, whichever is later.

5. Can I use my existing the EHR system or do I need to get a separate one for MDPP suppliers?

   You can use your existing EHR system as long as it complies with documentation and record keeping requirements. Organizations should evaluate whether their system may collect and obtain the required information securely and for the required duration.

6. What are HIPPA requirements for data sharing? (Covered entity)

   MDPP suppliers are required to maintain and handle any personally identifiable information (PII) and protected health information (PHI) in compliance with applicable law, including HIPAA, other applicable state and federal privacy laws. MDPP suppliers will also be expected to comply with the MDPP program standards and other applicable CMS policies and standards. For a discussion of our privacy policies including HIPAA, see pages 53323-4 of the CY 2018 PFS final rule. CMS recommends that MDPP suppliers consult with counsel to determine whether they qualify as a HIPAA-covered entity, and how to manage and transfer data appropriately based on applicability of HIPAA, other applicable state and federal privacy laws, and CMS standards.

7. Where can an MDPP Supplier find guidance on compliance policies and procedures?

   The Office of the Inspector General for the Department of Health and Human Services (OIG) has issued a guidance document, General Compliance Program Guidance (GCPG), which is a reference guide for the health care compliance community and other health care stakeholders. The GCPG provides information about relevant Federal laws, compliance program infrastructure, OIG resources, and other information useful to understanding health care compliance.  The GCPG is voluntary guidance that discusses general compliance risks and compliance programs. While the GCPG is not binding on any individual or entity, it discusses the seven elements of an effective compliance program that individuals and entities may wish to adopt.  As described in the GCPG, one of those elements is having compliance policies and procedures, which should encompass at least two areas: (1) the implementation and operation of the entity’s compliance program; and (2) processes to reduce risks caused by noncompliance with Federal and State laws. The GCPC can be found here.

Medicare Advantage (MA)

This section includes frequently asked questions about the new Medicare Diabetes Prevention Program Expanded Model’s Part B preventive service and its coverage in Medicare Advantage. If you still have questions after reviewing this section, you may contact the Division of Policy, Analysis, and Planning Mailbox at https://dpap.lmi.org/dpapmailbox/mailbox/ and be sure to include MDPP in the subject line.

1. If a Medicare Advantage plan currently offers prediabetes services as a supplemental benefit, must the plan also cover MDPP services?

   Yes. An MA plan must offer MDPP services even if the plan already offers similar prediabetes services as a supplemental benefit. MDPP services are covered as a Part B benefit; as such, MDPP services are separate and distinct from similar prediabetes services that some MA plans choose to cover as supplemental benefits. MA plans have the continued option to provide, as a supplemental benefit, similar prediabetes services that do not qualify as MDPP services; however, similar prediabetes services offered as a supplemental benefit cannot be used as a substitute for MDPP services.

2. Does the MDPP once-per-lifetime limit apply to Medicare Advantage enrollees?

   Yes. The once-per-lifetime limit applies equally to enrollees covered under Original Medicare as it does to enrollees covered under Medicare Advantage. To be eligible for coverage for MDPP services, an enrollee must not have previously received the set of MDPP services in his or her lifetime. However, MA plans may cover - as a supplemental benefit - prediabetes services beyond the scope of the Part B benefit.

3. May Medicare Advantage plans develop their own eligibility criteria that MA enrollees must meet to access MDPP services?

   No. MA plans may not modify the eligibility requirements established in regulation, which determine an enrollee’s eligibility to receive MDPP services. However, plans may provide MDPP services to MA enrollees who do not meet the eligibility requirements for MDPP services as a supplemental benefit.

4. Must Medicare Advantage plans utilize only Medicare-enrolled MDPP suppliers to furnish MDPP services to enrollees?

   Yes. MDPP services can only be furnished under Medicare by organizations who are enrolled in Medicare as MDPP suppliers.

5. Can a Medicare Advantage Organization (MAO) enroll in Medicare as an MDPP Supplier?

   Yes. MAOs have the option to enroll in Medicare as MDPP suppliers; however, there is no requirement to do so. To enroll as an MDPP supplier, an MAO is subject to the same Medicare enrollment requirements as entities that are not MAOs. More information about MDPP supplier enrollment is available on the MDPP web page.

6. Will a list of Medicare-enrolled MDPP suppliers be made available?

   A map of enrolled MDPP suppliers can be found on the interactive MDPP supplier Map. Alternatively, a list of all currently enrolled MDPP suppliers is available, including supplier location and contact information. 

7. Must Medicare Advantage Organizations utilize the fee-for-service (FFS) rates and payment structure for MDPP services to pay MDPP suppliers for MDPP services provided to MA enrollees?

   For in-network providers or suppliers, including MDPP suppliers, CMS is prohibited from requiring an MAO to contract with specific providers and from requiring specific price or payment structures under their contracts with network providers or suppliers. Therefore, MAOs may negotiate payment terms with in-network providers. However, pursuant to section 1852(a)(2) and (k)(1) and 42 C.F.R. 422.214, MAOs must pay out-of-network providers or suppliers (that is, providers or suppliers that do not contract with the MAO), and such providers or suppliers must accept as payment in full, the amount that would have been paid under Original Medicare for out-of-network services furnished to an MA plan enrollee. The Original Medicare payment schedule for MDPP services can be found at 42 CFR §424.55.

8. Must Medicare Advantage plans employ the use of CMS’s recently published G-codes for MDPP billing purposes?

   No. The MDPP G-codes specified in our rule are specific to billing in Original Medicare. Although some plans may choose to use these codes for billing purposes, we clarify that it is optional for them to do so.

9. What if there are currently no existing MDPP suppliers in a given geographic location served by a Medicare Advantage plan?

   An MA plan must provide its enrollees with a level of access to Medicare-covered services that is consistent with prevailing community patterns of care. This can mean that in some instances, an enrollee covered under either Original Medicare or Medicare Advantage might have to travel to a provider, supplier, or facility that is geographically - distant in order to receive a Medicare-covered service. In such cases, the MA plan would not be required to cover travel expenses (but may elect to cover such expenses as a supplemental benefit) as long as the MA plan is referring the enrollee to providers in a manner consistent with community patterns of care. However, the MA plan would still be required to cover MDPP services without beneficiary cost-sharing if MDPP services are not provided in-network because there is no in-network provider.

10. What should a Medicare Advantage plan do if its Evidence of Coverage (EOC) materials do not indicate that MDPP services are to beneficiaries?

    MA plans should update their online EOC to include the following language:

    Medicare Diabetes Prevention Program (MDPP) Expanded Model

    MDPP services are covered for eligible Medicare beneficiaries under all Medicare health plans.

    The MDPP expanded model is a structured health behavior change intervention to prevent development of type 2 diabetes in individuals with an indication of prediabetes. It provides training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle.

    The Medicare Advantage plan must review all required documents for accuracy and submit changes or corrections to CMS. When changes are approved by CMS, the MA plan should correct inaccurate EOC materials.  Once a plan's existing stock of printed EOCs is exhausted, the content in the print version must also be updated to reflect this change.

11. How will MA plans be required to report encounter data for risk adjustment purposes for services provided to MA enrollees as required under 42 CFR §422.310?

    MDPP services should not be treated differently from other services furnished by an MA plan for which the data requirements of 42 CFR §422.310 apply.

12. Aside from applicable reporting requirements related to encounter data, are MA plans required to report to CMS on MDPP services, suppliers, or MDPP beneficiaries?

    No. Where an MA plan is not an MDPP supplier itself, the MA plan is not required to report to CMS on MDPP services--that requirement falls on the MDPP supplier that furnishes MDPP services to the MA plan's enrollees. However, where an MA plan is also an MDPP supplier, the MA plan in its capacity as an MDPP supplier must abide by all MDPP supplier reporting requirements for any MDPP beneficiaries to whom it furnishes MDPP services.

13. If a Medicare Advantage member does not meet the MDPP eligibility requirements, are plans expected to consider this an organizational determination and process within the specific requirements related to Chapter 13 of the Medicare Managed Care Manual?

    Coverage requests related to MDPP services should not be treated differently from requests for other basic benefits furnished by an MA plan. If a request concerning coverage of a discrete item or service submitted to a plan fits within one of the actions defined as an organization determination under 42 CFR §422.566(b), then the MA plan should treat the request as an organization determination.

14. Will MA plan members have appeal rights to this program?

    If a request is an organization determination under 42 CFR §422.566(b), then the coverage decision would be subject to the Subpart M appeals process.

Crosswalk File Submission

1. What is the Crosswalk File?

   MDPP suppliers are required to maintain a crosswalk file, which lists MDPP crosswalk data, including beneficiary identifiers used for the Centers for Disease Control and Prevention (CDC) performance data submissions, and the corresponding Medicare identifiers for each beneficiary who receives MDPP services. This requirement is essential for the evaluation of the MDPP expanded model.

2. What is the MSPP crosswalk data?

   MDPP crosswalk data is the information included in the Crosswalk file and refers to a list of beneficiary identifiers used for an organization’s Centers for Disease Control and Prevention (CDC) National DPP data submission, and the corresponding Medicare identifiers for each beneficiary that receives MDPP services from the organization.

3. Who must submit a crosswalk file?

   Only MDPP suppliers must submit a crosswalk file. Once an MDPP supplier has furnished services for six months, the MDPP supplier must submit a crosswalk file at each of the quarterly due dates.

4. When are the quarterly due dates for the crosswalk file?

   Once an MDPP supplier furnishes MDPP services for six months, the MDPP supplier must begin to submit a crosswalk file at each of these quarterly due dates.

   The quarterly due dates are: January 15, April 15, July 15, and October 15.

   For example, an MDPP An MDPP supplier begins furnishing services on September 1, 2018. This means that the MDPP supplier will have furnished services for six months on March 1, 2019. The next quarterly due date after March 1 is April 15; therefore, the MDPP supplier’s first crosswalk file is due on April 15, 2019.

5. Will my organization receive notifications regarding crosswalk file submission due dates?

   All crosswalk related reminders will be sent to MDPP suppliers through the MDPP supplier-specific listserv. Your organization must sign up to be added to the supplier-specific listserv in order to receive the notifications. MDPP suppliers can sign up at any time by sending a request to the MDPP mailbox at MDPP@cms.hhs.gov.

6. Is there a particular format for the crosswalk file?

   Yes. The crosswalk must be submitted using the standard online data submission system. To gain access to the submission system, each MDPP supplier will need to register at: https://goo.gl/forms/mVEr0l7B9J12dhjg2. 

   After registration, login information and how to set a password will be sent to a supplier’s organization. Supplier’s will submit crosswalks at: https://mdpp.knack.com/crosswalk

   Suppliers will receive instructions on how to enter, review, and edit data. For any questions, please contact RTIsuppliercrosswalkhelp@rti.org.

7. What is the Crosswalk File?

   MDPP suppliers are required to maintain a crosswalk file, which lists MDPP crosswalk data, including beneficiary identifiers used for the Centers for Disease Control and Prevention (CDC) performance data submissions, and the corresponding Medicare identifiers for each beneficiary who receives MDPP services. This requirement is essential for the evaluation of the MDPP expanded model.

8. Where do suppliers upload the crosswalk file?

   To assist with data collection, our contractor, RTI International, has created a secure File Transfer Protocol (FTP) website where suppliers can upload their organization’s crosswalk file after the requisite data are entered into the template. Specific login IDs and passwords ensure that only a supplier’s organization and CMS can access MDPP data uploaded to the FTP site.

   To gain access to this website, suppliers will need to register at https://goo.gl/forms/mVEr0l7B9J12dhjg2. Suppliers can also use this website to download the MDPP crosswalk template.

   After registration is complete, login information will be sent to your organization within approximately one week along with instructions on how to upload your crosswalk file. At that time, suppliers will also be provided with information on how to download and enter your data into the crosswalk file template.

9. Are there any resources on the MDPP website about the crosswalk?

   Yes, in addition to these FAQs, the presentation from the Crosswalk Guidance Office Hours is available on the MDPP website. You can also access Guidance on compiling crosswalk data and submitting the crosswalk file in the Crosswalk Guidance found here: https://www.cms.gov/priorities/innovation/Files/x/mdpp-crosswalk-guidance.pdf (PDF).

10. Does an organization have to submit a crosswalk file if it is not enrolled as an MDPP supplier yet?

    No, only MDPP suppliers are required to submit the crosswalk file.

11. If an organization has pending CDC recognition, does it have to submit a crosswalk file?

    No. Only MDPP suppliers are required to submit a crosswalk file, which requires organizations to have either preliminary or full CDC recognition. Organizations with pending recognition cannot be MDPP suppliers, and therefore do not have to submit a crosswalk file.

12. If an organization lost preliminary or full CDC recognition, does it have to submit a crosswalk file?

    If an organization has lost its preliminary or full CDC recognition and now has either pending recognition or no recognition, then the organization is not eligible to be an MDPP supplier, and their Medicare enrollment as an MDPP supplier will have been revoked. Only MDPP suppliers must submit a crosswalk file. Therefore, the organization would not need to submit a crosswalk file.

13. If the MDPP supplier is working with a vendor to furnish services, does the supplier or the vendor send the information to CMS?

    CMS does not stipulate who submits the crosswalk file. However, maintenance and submission of the crosswalk file is an MDPP supplier requirement and failure to fully comply with the crosswalk submission requirement may result in revocation of the organization’s enrollment in Medicare as an MDPP supplier.

14. When a beneficiary receives their MBI, do previous entries have to be changed from the HICN to the MBI?

    If a beneficiary obtains an MBI during the MDPP services period, add the beneficiary’s MBI to the MBI column of the crosswalk file and remove the HICN in the HICN column. Crosswalk files should never include both HICNs and MBIs for a beneficiary.

15. Until all beneficiaries have an MBI, should both HICNs and MBIs be reported?

    Crosswalk files should never include both a HICN and MBI for a beneficiary.

    Use the following scenarios to determine the appropriate Medicare identifier to report:

    • If a beneficiary has a HICN:  Insert the HICN in the HICN column and leave the MBI column blank.
    • If a beneficiary has an MBI: Insert the MBI in the MBI column and leave the HICN column blank.
    • If a beneficiary obtains an MBI during the MDPP services period: Add the beneficiary’s MBI to the MBI column and remove the HICN from the HICN column.

16. Is there a resource where I can look up an MDPP beneficiary’s MBI?

    Yes. You can use your Medicare Administrative Contractor’s (MAC’s) secure portal Medicare Beneficiary Identifier (MBI) look-up tool, which returns beneficiaries’ MBIs even if the beneficiary has not received his new card yet. If you do not already have access, sign up for your MAC’s portal to use the tool.
     

17. How does the crosswalk submission work when a beneficiary switches between MDPP suppliers?

    In cases where the beneficiary switches between MDPP suppliers, the previous MDPP supplier should keep the beneficiary’s data in its crosswalk file. Do not remove the beneficiary’s entry in the crosswalk file from future submissions. The new MDPP supplier should add the beneficiary’s information to its next crosswalk.

18. If an MDPP supplier furnishes mixed cohorts that include Medicare beneficiaries receiving MDPP services and other individuals who are receiving National Diabetes Prevention Program (DPP) services does the supplier need to include the other individuals in its crosswalk?

    No. Only Medicare beneficiaries eligible for coverage of MDPP services who have received at least one session from the MDPP supplier should be included in the crosswalk file.

19. Should a crosswalk file be submitted per organizational code or per administrative location?

    One crosswalk file should be submitted per MDPP supplier enrollment. A given enrollment may encompass multiple CDC organizational codes, administrative locations, or community settings, depending on the way the organization has chosen to structure its MDPP enrollment.

20. If a beneficiary drops out of the program, should they be included in the next submission?

    Yes. The crosswalk file is cumulative and beneficiaries should never be removed from the file once they have been properly added. This includes beneficiaries who have completed their set of services and those who have since transferred to a different supplier or who dropped out of the program after receiving at least one session of MDPP services from your organization.

21. If you are an MDPP supplier, but currently have no Medicare beneficiaries receiving MDPP services, do you still have to submit a crosswalk file?

    If an MDPP supplier has never served an eligible Medicare beneficiary, then the crosswalk file does not yet need to be submitted. Only MDPP suppliers who have furnished MDPP services for at least six months are eligible to submit a crosswalk. However, if an MDPP supplier has already submitted a crosswalk file, the MDPP supplier should continue to submit a crosswalk file at each due date even if no additional Medicare beneficiaries will be added to their crosswalk file at that time.

22. How do MDPP suppliers sign up to the MDPP listserv?

    The MDPP expanded model has two listservs: a general one that is focused on providing information to a wide range of stakeholders and individuals who are interested in MDPP-related updates, and a second one that provides information, reminders, and updates pertinent to organizations enrolled in Medicare as MDPP suppliers. To sign up to receive updates about MDPP, please subscribe to the Medicare Diabetes Prevention Program listserv. If you are an MDPP supplier and wish to sign up for the MDPP supplier listserv, please email MDPP@cms.hhs.gov with your request. The MDPP supplier listserv is the mechanism by which MDPP suppliers will receive important information and reminders, such as upcoming due dates.

23. How long does it take to become a supplier once the application is submitted?

    Applications take approximately 80-90 calendar days for Medicare Administrative Contractors (MACs) to review, but may extend beyond this period. Processing times are longer if a paper application is submitted (up to 210 days), and may also be longer if there are issues with the application (i.e., development requests).

MDPP PHE Flexibilities

1. When will the MDPP Public Health Emergency (PHE) flexibilities extension end? 

   The Calendar Year (CY) 2024 Physician Fee Schedule 42 CFR 410.79(e) was amended to extend certain flexibilities that were established as a result of the COVID-19 PHE. These include alternatives to the requirement for in-person weight measurement and the elimination of the maximum number of virtual services. These flexibilities are extended through December 31, 2027.

2. Have any of the MDPP regulatory flexibilities that were implemented as part of the PHE been extended?

   The following regulatory flexibilities were extended through December 31, 2027:

• MDPP suppliers may pause or delay the delivery of the MDPP set of services and resume services on a delayed schedule.
• MDPP beneficiaries receiving the MDPP set of services as of March 1, 2020, and whose sessions were paused or cancelled due to the PHE may receive the set of MDPP services more than once per lifetime. 
• The 5% weight loss and most in-person attendance requirements were waived during the PHE for MDPP beneficiaries who were receiving the MDPP set of services as of March 1, 2020. 
• The limit on virtual sessions was waived for MDPP suppliers who can provide the MDPP set of services virtually, as long as the virtual sessions are furnished in a manner that is consistent with the CDC Diabetes Prevention Recognition Program (DPRP) standards for virtual sessions, and all other requirements specified at § 410.79(e)(3)(iv) are satisfied.

3. How can suppliers provide MDPP services virtually?

   Virtual delivery of MDPP services is limited to the CDC DPRP definition of “distance learning.”Although online delivery is defined in the Calendar Year (CY) 2024 Physician Fee Schedule, it is not covered as part of the PHE for COVID-19 extended flexibilities. During the Extended flexibilities period, CMS will not cover online delivery for MDPP, even for makeup sessions.

   According to CDC, Distance learning involves “a yearlong National DPP lifestyle change program delivered 100 percent by trained Lifestyle Coaches via remote classroom or telehealth. The Lifestyle Coach provides live (synchronous) delivery of session content in one location and participants call-in or videoconference from another location.”

   Although “telehealth” is included in CDC’s definition of distance learning, CMS stated in the CY 2017 PFS final rule (82 FR 52976) that MDPP services delivered via a telecommunications system or other remote technologies do not qualify as telehealth services.

   Suppliers can find more information on the CDC DPRP. Suppliers may contact the National Diabetes Prevention Program Customer Service Center with additional questions about CDC’s DPRP delivery modes.

4. Are MDDP suppliers required to deliver MDPP set of services using only one modality (e.g., virtual or in-person)?

   No. As long as services are furnished in a manner consistent with the CDC DPRP standards MDPP suppliers may provide MDPP sessions through multiple modalities, including: virtually, through distance learning, or a combination of in-person or distance learning, as appropriate for their participant populations.

   Participants may opt to receive a combination of both distance learning and in-person sessions if they wish or participate using only one modality (virtual or in-person).

5. Should suppliers use the Virtual Modifier code “VM” to bill for sessions provided virtually during the PHE

   For claims with a date of service (DOS) on or before December 31, 2023, a Virtual Modifier, “VM,” should be appended to the HCPCS G-code on each claim line item that represents a virtual make-up session.

   For claims with a DOS on or after January 1, 2024, suppliers should use the HCPCS G-Code G9887 on all claims associated with a service that was provided through distance learning delivery. 

6. What Place of Service (POS) code should suppliers use to bill for sessions with a VM modifier consistent with 42 CFR §410.79(e)?

   The POS codes show where the MDPP service is provided, e.g., “Office” (11), “Outpatient Facility Code” (19 or 22), or “Other” (99).

   For claims with a date of service (DOS) on or before December 31, 2023, suppliers should use “Other” (99) as their POS when a service is provided through distance learning and a Virtual Modifier is used. For claims with a date of service (DOS) on or after January 1, 2024, if the session is a distance learning session, use the distance learning HCPCS code G9887. For MDPP billing, claims may list the currently enrolled location (not the coach’s home address) as the POS.

7. Can suppliers accept self-reported weight measurements from beneficiaries?

   Yes. Self-reported weights must be obtained during live, synchronous telehealth sessions, such as online video chats or video conferencing. During the sessions, the MDPP coach should observe the beneficiary weighing themselves, and view the weight indicated on the at-home digital scale. Alternatively, the beneficiary may self-report their weight by submitting to the MDPP supplier a date-stamped photo or video recording clearly documenting the beneficiary's weight as it appears on a digital scale, with the beneficiary visible in their home.

8. Do the CMS telehealth expansion waivers and regulations apply to MDPP services?

   No. Virtual MDPP services aren’t considered Medicare telehealth services and Medicare telehealth rules don’t apply to virtual MDPP services. 

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