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CMS Sets Eligibility Rules for Medicare Diabetes Prevention Program


The program has been shown to reduce by 58% the likelihood of progressing to type 2 diabetes. Reimbursement details are still being worked out, but CMS clarified that Medicare patients will not be subject to cost-sharing.

On Wednesday, CMS finalized eligibility criteria for the Medicare Diabetes Prevention Program (MDPP), which will begin in January 1, 2018, after federal officials spend the next year working on a payment formula and other program details.

In March, HHS Secretary Sylvia Mathews Burwell announced that Medicare would start paying for beneficiaries to take part in the National Diabetes Prevention Program, which has been shown to reduce the likelihood a person with prediabetes progresses to type 2 disease by 58%, according to studies by the National Institutes of Health. A demonstration project with the YMCA found that Medicare saved $2650 per beneficiary over 15 months.

The program outlined Wednesday is a 12-month intervention that consists of 16 weekly, hour-long sessions during the first 6 months. Beneficiaries then attend 6 monthly maintenance sessions over the next 6 months. The July proposal called for providers—to be known as suppliers—to have reimbursement tied to whether patients attended enough sessions and lost at least 5% of their body weight.

CMS issued a proposed rule for the program in July as part of the 2017 Physician’s Fee Schedule, which was finalized Wednesday. However, some elements of the MDPP are still being worked out, including the reimbursement formula and some requirements for digital providers. However, CMS did clarify that Medicare cost sharing will not be required for patients.

In comments submitted in September, the American Association of Diabetes Educators (AADE), which has worked with the CDC to offer the program at 44 grant-funded sites, recommended changes to the reimbursement schedule that would give first-year programs more payment upfront. This, the group said, would give new programs a better chance at financial survival. The comment was based on AADE's experience with billing Medicare for diabetes self-management education.

Also, CMS said that, for now, it only plans to reimbursement programs that have received full recognition from the CDC, although materials on its website said this would be revisited. This would mean some community-based programs might not be eligible for Medicare reimbursement when it begins January 1, 2018.

Eligibility criteria for both participants and suppliers were outlined in CMS fast sheet. Medicare beneficiaries can take part in the program if:

  • They have a body mass index of 25 kg/m2, or 23 kg/m2 for participants who self-identify as Asian.
  • They have 1 of the following: a glycated hemoglobin (A1C) of 5.7% to 6.4% within the past 12 months, a fasting plasma glucose of 110-125 mg/dL, or a 2-hour plasma glucose of 140-199 mg/dL.
  • They have not been diagnosed with type 1 or type 2 diabetes, and they do not have end-stage renal disease.
  • They must enroll in Medicare Part B.

CMS also confirmed that each counselor or coach who delivers the program on a group’s behalf must have an individual National Provider Identifier.

In a blog post, CMS Acting Administrator Andy Slavitt and Acting Principal Deputy Administrator and Chief Medical Officer Patrick Conway, MD, MSc, reported new data that show Medicare will spend $42 billion more on fee-for-service beneficiaries with diabetes in 2016 than if they did not have diabetes.

“This increased spending reflects only Medicare’s share of costs; diabetic beneficiaries likely experience higher out-of-pocket spending as well,” they wrote.

Neal Kaufman, MD, MPH, co-founder and chief medical officer for one digital provider, Canary Health, said the announcement “further validates the role that evidence-based based preventive programs like the DPP can play in reducing the costs of care.

“By making it easier for payers to offer these services, and by supporting the digital delivery of these services, CMS is ensuring that millions more Americans will have access to programs that will either prevent or slow the progression of chronic diseases like diabetes," he said.

Support for Medicare reimbursement for DPP has been building for some time, but one major interest group filed comments against it, according to USA Today. The Pharmaceutical Research and Manufacturers of American said in comments that CMS was setting a flawed precedent in approving the program.

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