CMS finalizes policies to extend DPP to eligible Medicare beneficiaries with prediabetes

Issue: December 2016

The CMS has finalized policies to expand the duration and scope of the Medicare Diabetes Prevention Program for Medicare beneficiaries with prediabetes beginning in January 2018, according to a CMS press release.

The Medicare Diabetes Prevention Program (DPP) expanded model, finalized under the 2017 Physician Fee Schedule final rule, marks the first time a prevention model from the CMS Innovation Center will be adopted under the CMS authority to expand successful payment and service delivery models to reach all eligible beneficiaries.

The Medicare DPP core benefit is a 12-month intervention that consists of at least 16 weekly core, hour-long sessions for 6 months, followed by at least six monthly core maintenance sessions from months 6 to 12, regardless of weight loss. Beneficiaries also have access to 3-month intervals of ongoing maintenance sessions after the core 12-month intervention if they achieve and maintain the required minimum 5% weight loss in the preceding 3 months. Medicare cost-sharing will not apply to Medicare DPP services.

“Through the Medicare [DPP] expanded model, eligible beneficiaries will be able to access a community-based intervention that prevents diabetes and keeps people healthy,” Patrick Conway, MD, MSc, acting principal deputy administrator and CMS chief medical officer, said in a statement. “Preventing the onset of diabetes through proven measures not only keeps people living healthier lives, but also helps to preserve Medicare. This is an exciting milestone for prevention and population health.”

Beneficiaries must meet the following criteria:

enrolled in Medicare Part B;
BMI of at least 25 kg/m² if not self-identified Asian, or at least 23 kg/m² if self-identified Asian;
HbA1c between 5.7% and 6.4%; fasting plasma glucose between 110 mg/dL and 125 mg/dL, or a 2-hour plasma glucose between 140 mg/dL and 199 mg/dL;
no previous diagnosis of type 1 or type 2 diabetes, except for gestational diabetes; and
no end-stage renal disease.

In March, CMS announced that the DPP model test met statutory criteria for expansion under the authority of CMS to expand successful payment and service delivery models.

The DPP expanded model will allow suppliers that have CDC recognition to prepare to enroll in Medicare and submit claims for services.

Joanna Craver DiBenedetto, BS, MNM, director of prevention with the American Association of Diabetes Educators, called the changes “a breath of fresh air.”

“When we first started this program, we knew that 80% of our DSME programs and 80% of our members were reporting to already work with people with prediabetes in some form ... and only 0.4% reported getting reimbursed for these services,” Craver DiBenedetto told Endocrine Today. “We, as an organization, found this to be a huge gap that we could help address ... making sure these programs could add the DPP as another service to provide in their community — that their community needed.”

“This is an evidence-based program, and the evidence shows that someone who goes to this program and completes it is 58% less likely to develop type 2 diabetes,” Craver DiBenedetto said. “For people over 60 [years old], they are 71% less likely to develop type 2 diabetes.”

AADE is currently preparing services to assist programs through the process of CDC Recognition and DPP implementation as well as CMS applications to become an MDPP Supplier in 2017, Craver DiBenedetto said.

In the release, CMS noted it plans to finalize a process “as soon as possible” for these organizations to enroll in Medicare so they can furnish services and begin billing by the time the expanded model becomes effective. – by Regina Schaffer