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.
- CDC Recognition and Enrollment in Medicare
- Billing and Claims
- MDPP Set of Services and Beneficiary Eligibility
- Coach Requirements and Supplier Standards
- Medicare Advantage (MA)
- Additional Resources
- Help Desk Support
Recognizing and Enrolling in Medicare
- How long does it take to obtain MDPP preliminary or full CDC recognition?
It takes at least 12 months to obtain CDC Preliminary Recognition and up to 24 additional months to achieve Full Recognition. Preliminary recognition requires a submission of 12 months of data from a National DPP cohort. Full CDC recognition requires that organizations deliver the year-long diabetes prevention lifestyle change program with fidelity to all CDC Diabetes Prevention Recognition Program (DPRP) Standards. This recognition status could be achieved within 36 months if all requirements are met. All requirements to achieve CDC Full Recognition status are listed in the CDC DPRP standards and 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.
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.
Does each site under an “umbrella” / larger organization need recognition?
Please see the CDC Diabetes Prevention Recognition Program (DPRP) standards or contact our partners at CDC at dprpAsk@cdc.gov for questions related specifically to recognition. In order to enroll in Medicare as an MDPP supplier, the enrolling organization must meet recognition criteria. You may list multiple locations under the enrolling organization.
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.
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, you may provide multiple locations on the same application within a given state, but you must include all required information for each location. You may be able to 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 site is structured under the DPRP.
My enrollment application was denied because I was non-compliant with the MDPP standards. What are my options for next steps??
When an organization has its enrollment denied or revoked for non-compliance, the organization has the opportunity to submit a Corrective Action Plan (CAP) to correct the deficiencies that resulted in the denial of its application. The CAP must be submitted within 30 days from the date of the denial notice. CMS will review the CAP and, based on whether the organization provided sufficient evidence for CMS to determine that the supplier has complied fully with the Medicare requirements, within 60 days CMS will reverse or refuse to reverse the denial of enrollment. Suppliers will receive a letter providing CMS’ decision If the CAP is denied, the letter will outline any appeals rights the supplier may have to reconsider their denial of enrollment. If the CAP is approved, the denial or revocation will be reversed.
How long does the supplier have to fix noncompliance issues (i.e., ineligible coach) when notified by CMS?
A supplier has no more than 30 days from the date of its denial or revocation notice to fix any and all noncompliance issues that resulted in its denial or revocation. For a supplier’s enrollment denial or renovation to be reversed, within 30 days from the date of its denial or revocation notice from CMS the MDPP supplier must submit a corrective action plan (CAP) that includes sufficient evidence to show that it has corrected any and all deficiencies that resulted in its enrollment denial or revocation.
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, can enroll 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 a form which includes a roster of all coaches who will be furnishing MDPP services along with its enrollment form.
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.
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.
Is there a fee associated with enrollment as an MDPP supplier?
Yes, there is a standard application fee for the initial enrollment in Medicare and for revalidation (every 5 years for MDPP suppliers). The fee is $569 for calendar year 2018 and is updated annually. Details about the Medicare enrollment application fee can be found on the cms.gov website. Organizations have the opportunity to apply for a hardship exemption waiving this enrollment fee. More information on the hardship exemption can be found starting on page 3 of the document here.
Does the application fee for Medicare enrollment differ based on geography? If my organization has multiple locations, is the fee applied more than once??
The application fee for initial enrollment is $569 for 2018, and the amount does not differ based on geography. An MDPP supplier may be required to pay this fee more than once depending on whether the applicant has locations in one or more state. If an MDPP supplier chooses to add an administrative location to an existing enrollment, there are cases in which that new location could result in an additional application fee if the location resulted in a new PTAN. Please contact your MAC for more information on how the enrollment fee may apply to your specific organization.
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.
Billing and Claims
- 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.
Where are the MDPP HCPCS G-codes listed?
The final Healthcare Common Procedure Coding System (HCPCS) G-codes can be found on page 53289 of the CY 2018 final rule. Please also refer to the table below.
Long Descriptor May be Reported with Modifer VM (Virtual Make-Up Session) Final Payment Amount G9873 First core session attended. No $25 G9874 Four core sessions attended. Yes $50 G9875 Nine core sessions attended. Yes $90 G9876 Two core maintenance sessions attended, beneficiary did not achieve/maintain at least 5% weight loss from his/her baseline weight. Yes $15 G9877 Two core maintenance sessions attended, beneficiary did not achieve/maintain at least 5% weight loss from his/her baseline weight. Yes $15 G9878 Two core maintenance sessions attended, beneficiary achieved at least 5% weight loss from his/her baseline weight. Yes $60 G9879 Two core maintenance sessions attended, beneficiary achieved at least 5% weight loss from his/her baseline weight. Yes $60 G9880 Beneficiary achieved at least 5% weight loss from baseline weight in months 1-12. No $160 G9881 The MDPP beneficiary achieved at least 9% weight from baseline weight in months 1-24. No $25 G9882 Two ongoing maintenance sessions attended by an MDPP beneficiary in months 13-15, beneficiary maintained at least 5% weight loss from baseline weight. Yes $50 G9883 Two ongoing maintenance sessions attended by an MDPP beneficiary in months 16-18, beneficiary maintained at least 5% weight loss from baseline weight. Yes $50 G9884 Two ongoing maintenance sessions attended by an MDPP beneficiary in months 19-21, beneficiary maintained at least 5% weight loss from baseline weight. Yes $50 G9885 Two ongoing maintenance sessions attended by an MDPP beneficiary in months 22-24, beneficiary maintained at least 5% weight loss from baseline weight. Yes $50 G9890 Bridge Payment: A one-time payment for the first session furnished by an MDPP supplier to a beneficiary during months 1-24 of the MDPP Expanded Model (EM) who has previously received MDPP services from a different MDPP supplier under the MDPP Expanded Model. A supplier may only receive one bridge payment per MDPP beneficiary. Yes $25 G9891 MDPP session reported as a line-item on a claim for a payable MDPP Expanded Model (EM) HCPCS code for a session furnished by the billing supplier under the MDPP Expanded Model and counting toward achievement of the attendance performance goal for the payable MDPP Expanded Model HCPCS code.(This code is for reporting purposes only). Yes $0
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.
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.
What are the requirements for billing for Rural Health Clinics (RHCs)/Federally Qualified Health Centers (FQHCs)?
Any provider with an existing enrollment type (including critical access hospitals, FQHCs and RHCs) must re-enroll 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. FQHC/RHCs may submit a separate enrollment application to Medicare to become enrolled as an MDPP supplier if they meet the CDC recognition and CMS MDPP supplier standard requirements. Once enrolled as an MDPP supplier, the FQHC/RHC may bill Medicare for MDPP services, but only using the MDPP HCPCS G-codes that were finalized in the CY2018 Physician Fee Schedule final rule (see table in response to question 17). MDPP services would be billed using a separate NPI on a CMS-1500 paper claim form or its electronic equivalent. 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.
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.
What claims submission software should I use for furnishing MDPP services?
There are no requirements for the type of claims submission software MDPP suppliers use for billing. If your organization does not have claims submission software, you can download a claims submission software called PC-Ace Pro 32, which CMS offers through its Medicare Administrative Contractors (MACs).This software carries a $25 yearly fee. There are several other electronic claims submissions software packages available in the market for purchase.
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.
Can you re-use HCPCS G-codes on claims forms?
HCPCS G-codes may be paid only once in a beneficiary’s lifetime, with the exception of the bridge payment and session reporting code. 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. Additionally, a table of the HCPCS G-codes can be found on pages 53289 – 53290 in the CY 2018 final rule (the list of HCPCS G-codes can be found in response to question 17 on this document).
- 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.
Can a third party or integrator, 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 or integrator meet the requirements.
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.
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.
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.
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.
Is there a limit on bridge payments?
Yes. A bridge payment (the $25 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.
When does a virtual modifier need to be used?
A virtual modifier should be appended to the HCPCS G-code on each claim line item that represents a virtual make-up session. The table with the HCPCS G-codes notes which codes can use a virtual modifier (see table in response to question 17).
When do claims have to be submitted?
CMS encourages suppliers to submit claims in a timely fashion to ensure payment. Because the MDPP is a once per lifetime benefit for beneficiaries, the first claim received for a HCPCS G-code will be paid and subsequent claims for that same HCPCS-G code will be denied for the same beneficiary. The only exception to this policy is the bridge 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 in the event that multiple suppliers submit claims for the same beneficiary.
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.
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.
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?
Code G9891 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). For more information on claims, please contact your Medicare Administrative Contractor (MAC). You can find information about MACs on the MDPP Enrollment Fact Sheet.
Does the billing have to begin with core session 1?
Yes. 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."
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.
MDPP Set of Services and Beneficiary Eligibility
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.
For the ongoing maintenance sessions, do we have to offer separate sessions for each cohort or can we combine cohorts for these ongoing maintenance sessions?
Cohorts that are receiving ongoing maintenance sessions can be combined with cohorts receiving core maintenance sessions, but not with cohorts that are receiving core sessions. The reason for this distinction is that the curriculum topics that are covered in core sessions focus on learning material for the first time, while the curriculum topics covered in maintenance sessions focus on reinforcing this material. The curriculum topics that are covered during ongoing maintenance sessions can repeat topics that were covered during core maintenance sessions.
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.
How can an MDPP supplier measure a beneficiary’s weight?
A beneficiary’s weight must be taken in-person at an MDPP core session, core maintenance session, or ongoing maintenance session if the weight will be used for the purposes of documenting a performance goal. In other words, any self-attested weight measurements or weight measured through digital scales during virtual make-up sessions will not count for the purposes of beneficiary eligibility or payment. For example, if a beneficiary attends his/her first ongoing maintenance session as a virtual make-up session, and he/she maintains 5% weight loss during that session, he/she would have to attend at least one additional in-person session within the interval and maintain 5% weight loss measured at that session to stay eligible for subsequent interval, and for the supplier to receive payment for the interval.
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.
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.
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.
Can MDPP suppliers furnish services entirely virtually?
No, MDPP services cannot be furnished entirely virtually. MDPP suppliers can only furnish and receive payment for a limited number of virtual make-up sessions as part of the set of MDPP services.
Can suppliers furnish MDPP services as a combination of virtual and in-person sessions?
No, regularly scheduled virtual sessions are not permitted as part of the MDPP set of services to beneficiaries. Virtual make-up sessions are only allowed as make-up sessions when requested by the MDPP beneficiary. MDPP suppliers cannot offer a combination of scheduled virtual and in-person MDPP services to beneficiaries. For example, a supplier could not offer a scheduled virtual core session 7 to a group of beneficiaries.
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.
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.
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.
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. During months 0-12, a beneficiary can attend as many or as few sessions as he or she wishes. MDPP suppliers must furnish these services to eligible beneficiaries regardless of whether or not they have achieved 5% weight loss, and can receive attendance-based performance payments throughout the core services period. However, to be eligible for the first ongoing maintenance session interval in months 13-15, beneficiaries must achieve or maintain at least five percent weight loss and have attended at least one in-person core maintenance session during months 10-12 to have their weight measured in-person. To be eligible for each additional ongoing maintenance session interval, the beneficiary must have attended at least two sessions and maintained 5% weight loss during the previous ongoing maintenance session interval.
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.
Do the blood tests require a physician’s referral?
Certain blood tests may require physician referrals. The fasting plasma glucose test and the oral glucose tolerance test are covered by Medicare for diabetes screening, per 42 CFR 410.18, but these tests require a referral from the beneficiary’s primary care physician or qualifying provider.
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.
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.
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.
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.
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.
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.
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 make-up sessions (if offered) up to the limits specified in the CY 2018 Physician Fee Schedule final rule.
Coach Requirements and Supplier Standards
- 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.
What are the requirements for submitting ongoing maintenance session data?
MDPP suppliers must 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.
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.
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.
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.
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.
For more guidance on this information, please visit:
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.
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.
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.
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.
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.
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 at: https://go.cms.gov/mdpp
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.
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.
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.
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.
What should a Medicare Advantage plan do if its Evidence of Coverage (EOC) materials do not indicate that MDPP services will be available on April 1, 2018?
MA plans should update their online CY 2018 EOC to include the following language:
Medicare Diabetes Prevention Program (MDPP) Expanded Model
Beginning April 1, 2018, MDPP services will be 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.Once a plan's existing stock of printed EOCs is exhausted, the content in the print version should also be updated to reflect this change. CMS addressed this issue in a November 29, 2017, HPMS email titled, “Coverage of Part A and Part B Services: Medicare Diabetes Prevention Program Expanded Model.”
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.
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.
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.
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.
|General MDPP Information|
Provider Enrollment, Chain, and Ownership System (PECOS)
National Plan and Provider Enumeration System (NPPES)
Medicare Administrative Contractors (MACs)
|Delivering MDPP Services|
Help Desk Support
|Inquiry Type||Inquiry Example||Help Desk||Contact|
|Technical inquiries related to the process of providing fingerprints||
||Accurate Biometrics Help Desk||
For information on fingerprinting:
|Technical inquiries related to the process of filling out the PECOS or I&A applications||
||CMS External User Services (EUS) Help Desk||
For information on PECOS (Medicare Enrollment Application):
For the MDPP supplier application form:
|Technical inquiries related to the process of filling out the NPPES application||
||National Plan & Provider Enumeration System (NPPES) Help Desk||
For obtaining an I&A account:
For information/ the application for obtaining an NPI:
|Technical inquiries related to enrollment and billing||
||Medicare Administrative Contractor (MAC) Help Desks||
For information on locating your MAC:
|Inquiries related to the DPRP and National DPP||
||Centers for Disease Control and Prevention (CDC) Diabetes Prevention Recognition Program (DPRP) electronic mailbox||
For information on the National Diabetes Prevention Program:
For information on CDC recognition (requirements and applying):