Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: The purpose of this rule is to establish the
Department of Social Services' MO HealthNet Division guidelines regarding
coverage and reimbursement for Diabetes Prevention Program services. The goal
of this policy is to improve health outcomes for the adult population at risk
for developing diabetes by managing obesity and associated
co-morbidities.
PUBLISHER'S NOTE: The secretary of state has
determined that the publication of the entire text of the material which is
incorporated by reference as a portion of this rule would be unduly cumbersome
or expensive. This material as incorporated by reference in this rule shall be
maintained by the agency at its headquarters and shall be made available to the
public for inspection and copying at no more than the actual cost of
reproduction. This note applies only to the reference material. The entire text
of the rule is printed here.
(1) Administration. The Diabetes Prevention
Program (DPP) shall be administered by the MO HealthNet Division. The diabetes
prevention program services covered and not covered, the limitations under
which services are covered, and the maximum allowable fees for all covered
services shall be determined by the MO HealthNet Division and shall be included
in the MO HealthNet Physician Provider Manual, which is incorporated by
reference and made part of this rule as published by the Department of Social
Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109,
at its website http://manuals.momed.com/manuals/,
December 27, 2019. This rule does not incorporate any subsequent amendments or
additions. Diabetes Prevention Program services covered by the MO HealthNet
program shall include only those which are clearly shown to be medically
necessary.
(A) In the administration of the
rule, "Diabetes Prevention Program" or "DPP" means a structured, lifestyle
change program specifically developed and recognized by the Centers for Disease
Control and Prevention (CDC) to prevent type 2 diabetes. The program is
intended for people who have prediabetes or are at risk for type 2 diabetes,
but who do not already have diabetes, to promote lifestyle changes that
decrease the progression to type 2 diabetes. The program services include group
support and lifestyle changes such as eating healthier foods, reducing stress,
and increasing physical activity.
(2) Provider Participation. To be eligible
for participation as a provider in the MO HealthNet Diabetes Prevention
Program-
(A) DPP service providers must be
enrolled as MO HealthNet providers; and
(B) DPP service providers must have pending,
preliminary, or full recognition status from the CDC's Diabetes Prevention
Recognition Program. The CDC regulates the standards needed for
recognition.
(3)
Participant Criteria. Any person who is an eligible Missouri Medicaid
participant who meets the following criteria shall be eligible to receive these
services:
(A) Be twenty-one (21) years old or
older;
(B) Not currently
pregnant;
(C) Have, as of the date
of attendance at the first core session, a BMI equal to or greater than
twenty-five (25) or twenty-three (23) if of Asian descent;
(D) Have no previous diagnosis of type one
(1) or two (2) diabetes with the exception of gestational diabetes;
(E) Have, within the last twelve (12) months-
1. Hemoglobin A1C test with a value of five
and seven-tenths percent (5.7%) to six and four-tenths percent
(6.4%);
2. A fasting plasma glucose
of one hundred (100) mg/dl to one hundred twenty-five (125) mg/dl; or
3. Two (2) hour plasma glucose of one hundred
forty (140) to one hundred ninety-nine (199) mg/dl after the seventy-five (75)
oral glucose tolerance test; and
(F) Not concurrently receiving authorization
for other MO HealthNet reimbursed weight reduction services.
(4) Diabetes Prevention Program
Services.
(A) DPP Services are structured
interventions that include lifestyle, behavior-counseling focusing on weight
reduction and lifestyle changes. A prescriber provider's referral, utilizing
the eligibility criteria set forth by the CDC, is required for the participant
to be eligible for this program. The prescribing provider will need to
prescribe the service in the participant's plan of care during a regular office
visit. A prescribing provider is defined as a licensed practitioner authorized
to prescribe within their scope of practice either directly or by protocol
consistent with their scope of practice under state law.
1. DPP core services period that includes a
twelve (12) month period of intervention with a minimum of twenty-two (22)
sessions and a maximum of twenty-six (26) sessions.
A. During months one (1) through six (6) of
the DPP core services period, DPP service providers will be required to provide
a minimum of sixteen (16) weekly sessions utilizing CDC-approved DPP core
module curriculum.
(I) This curriculum
provides counseling that focuses on, but is not limited to, information about
Type Two (2) Diabetes and how to prevent it; self-monitoring weight and food
intake; healthy eating; introduction to physical activity; dealing with
lifestyle changes; developing lasting lifestyle changes; and stress
management.
B. During
months seven (7) through twelve (12) of the DPP core services period, DPP
service providers will be required to provide a minimum of six (6) monthly
sessions utilizing CDC-approved DPP core maintenance module curriculum.
(I) This curriculum provides counseling that
focuses on maintaining long-term dietary changes, increased physical activity,
and behavior change strategies for continued weight loss.
C. DPP core services period also includes,
but is not limited to, weight monitoring and tracking, physical activity
tracking, and caloric intake tracking as required.
D. The prescribing provider will need to seek
prior authorization for the first twelve (12) months of the diabetes prevention
program from MO HealthNet prior to starting the program.
2. DPP ongoing maintenance period includes
access to one (1) year of ongoing maintenance sessions to eligible
participants.
A. The ongoing maintenance
sessions are done in three- (3-) month intervals for a maximum of four (4)
sessions during months thirteen (13) through twenty-four (24).
B. In order to qualify for the ongoing
maintenance sessions after the initial twelve (12) month program, the
participant must achieve and maintain a minimum weight loss of five percent
(5%) at the end of the first twelve (12) months.
C. For participants that are eligible for the
ongoing maintenance sessions, the prescribing provider must seek an additional
prior authorization from MO HealthNet for the additional twelve (12) months of
ongoing maintenance sessions.
(B) Additional diabetes prevention services,
including core sessions and ongoing maintenance sessions beyond the initial
allocation must be requested and will need to go through the prior
authorization process and must be deemed medically necessary.
(C) A participant that is unable to meet
and/or maintain the criteria for the additional twelve (12) months of ongoing
maintenance sessions has the option, after twelve (12) months, to re-enroll in
the diabetes prevention program starting with the first twelve (12) months if
the participant meets the established criteria and has an approved prior
authorization.
(5)
Records Retention and Documentation Requirements.
(A) Providers who provide Diabetes Prevention
Program services shall follow section
13 CSR
70-3.030.
(B) The DPP provider must retain the
prescribing provider's referral with approved prior authorization from MO
HealthNet.
(C) The DPP provider
must complete and retain an evaluation at the end of twelve (12) months to
determine the appropriateness for continuation to the ongoing maintenance
services.
(D) Once the services are
complete, the prescribing provider shall maintain a treatment record outlining
how the participant will maintain weight loss.
