The Centers for Medicare & Medicaid Services (CMS) have expanded a benefit
for Medicare Advantage members ? the Medicare Diabetes Prevention Program
(MDPP). This benefit is offered to help prevent the onset of type 2 diabetes
for Medicare Advantage members who are showing signs of prediabetes. MDPP is a
structured health behavior change intervention that provides practical training
in long-term dietary change, increased physical activity, and problem-solving
strategies to help members overcome challenges to sustaining weight loss and a
healthy lifestyle.
Medicare Advantage members are eligible for MDPP if they meet the following
criteria:
- Are enrolled in Medicare Part B
- Have a body mass index of at least 25, or at least 23 if self-identified as
Asian
- Meet one of the following three blood test requirements within 12
months prior to the first core session:
- – A hemoglobin A1C test with a value between 5.7 and 6.4%
- – A fasting plasma glucose of 110 ? 125 mg/dL
- – A two-hour plasma glucose of 140 ? 199 mg/dL (oral glucose
tolerance test)
- Have no previous diagnosis of type 1 or type 2 diabetes (other than
gestational diabetes)
- Do not have end-stage renal disease
There is no coinsurance, copayment, or deductible when Medicare Advantage
HMO and PPO members receive the MDPP benefit from an in-network provider. For
PPO members who receive the benefit from an out-of-network provider, there is a
30 percent coinsurance. Please note that if the member receives a separate,
additional non-preventive evaluation and/or service, a copayment or coinsurance
will apply, depending on the provider type or place of service.
Finding an MDPP supplier
To be qualified as an MDPP supplier, providers and organizations must meet
specific criteria, including attaining Centers for Disease Control and
Prevention recognition and Medicare approval. Medicare Advantage members should
contact the Member Help Team for information on how to find an in-network MDPP
supplier. Later this year, the Independence Find a Doctor tool will be updated
to include in-network MDPP suppliers.
If you have any questions regarding the program, please contact Customer
Service as follows:
- For Keystone 65 HMO/POS members: 215-241-2365
(Philadelphia area) or 1-800-645-3965 (outside
Philadelphia)
- For Personal Choice 65SM PPO members:
215-561-4877 (Philadelphia area) or 1-888-718-3333 (outside
Philadelphia)