Care Model Eligibility – CMS Medicare Diabetes Prevention Program (MDPP) Expanded Model

Patients who are at risk for developing Type 2 diabetes.

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Patient Segment Eligibility Description Data Source
Patients with HbA1c value between 5.7% and 6.4% Patients must also meet the following criteria:

  • Enrolled in Medicare Part B or Part C
  • BMI of at least 25 (23 if self-identified as Asian) on the date of the first core session
  • No previous diagnosis or diabetes prior to the date of the first core session (with exception of gestational diabetes)
  • Do not have end-stage renal disease (ESRD)
  • Has not previously received MDPP services
 EHR:

  • Determine HbA1c test value
  • Determine BMI on date of first core session
  • Ensure no previous diagnosis of diabetes
  • Ensure no record of ESRD
Patients with a fasting plasma glucose of 110-125 mg/dL Patients must also meet the following criteria:

  • Enrolled in Medicare Part B or Part C
  • BMI of at least 25 (23 if self-identified as Asian) on the date of the first core session
  • No previous diagnosis or diabetes prior to the date of the first core session (with exception of gestational diabetes)
  • Do not have end-stage renal disease (ESRD)
  • Has not previously received MDPP services
 EHR:

  • Determine fasting plasma glucose level
  • Determine BMI on date of first core session
  • Ensure no previous diagnosis of diabetes
  • Ensure no record of ESRD
Patients with a 2-hour plasma glucose of 140-199 mg/dL Patients must also meet the following criteria:

  • Enrolled in Medicare Part B or Part C
  • BMI of at least 25 (23 if self-identified as Asian) on the date of the first core session
  • No previous diagnosis or diabetes prior to the date of the first core session (with exception of gestational diabetes)
  • Do not have end-stage renal disease (ESRD)
  • Has not previously received MDPP services
 EHR:

  • Determine 2-hour plasma glucose level
  • Determine BMI on date of first core session
  • Ensure no previous diagnosis of diabetes
  • Ensure no record of ESRD

Care Model Implementation – CMS Medicare Diabetes Prevention Program (MDPP) Expanded Model

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Time Frame Action
Trigger event Beneficiary diagnosed with an indication of prediabetes with no previous diagnosis of type 1 or type 2 diabetes
Months 1 – 6 Beneficiary attends a minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention approved curriculum furnished in a group – based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control.

Inform the patient that only one practitioner can furnish and be paid for the service during a calendar month.
Months 7 – 12 Beneficiary attends a minimum of 2 “core maintenance” sessions every three months to help ensure that the beneficiary maintains healthy behaviors.
Months 13 – 24 Beneficiary attends a minimum of 2 “ongoing maintenance” sessions every three months to help ensure that the beneficiary maintains healthy behaviors.

Care Model Compliance – CMS Medicare Diabetes Prevention Program (MDPP) Expanded Model

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Intervention Intervention Description Data Source
Furnish MDPP core, core maintenance, and ongoing maintenance sessions Enroll and  track beneficiary participation and performance in  MDPP sessions.

See detailed information on previous slide for Care Model: Diabetes Prevention – Implementation.

 Claims:

HCPCS codes to identify  MDPP services based on beneficiary participation and performance