New diabetes prevention program for Medicare Advantage members

April 2, 2018

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)