Medicare Diabetes Prevention Program (MDPP) Enrollment

View MDPP enrollment details on this page.

The clinical intervention consists of 16 intensive "core" sessions of a curriculum 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.

After the 16 core sessions, less intensive monthly follow-up sessions help ensure that the participants maintain healthy behaviors. The primary goal of the intervention is lowering the progression to type 2 diabetes, measured using a proxy of at least 5 percent average weight loss among participants.

Organizations furnish MDPP services to beneficiaries with an indication of pre­diabetes for one year.

The individuals who meet certain performance goals, may continue eligibility to receive MDPP services through monthly ongoing maintenance sessions for up to an additional year.

Enrollment Eligibility

One of the following must be met for the Center for Disease Control and Prevention (CDC).

  • CDC recognition:
    • MDPP Preliminary recognition which includes both Interim Preliminary Recognition as designated by CMS as well as preliminary DPRP recognition as designated by CDC and effective date of this preliminary recognition must be within one year from application date
    • CDC DPRP Full Recognition
  • Valid EIN and NPI at organizational level
  • Submit a list of MDPP coaches who will lead sessions (including full name, date of birth, SSN, valid NPI and coach eligibility end date (if applicable)
  • Comply with MDPP supplier standards
  • Accept in-person MDPP suppliers. MDPP cannot be virtual only
    • Of MDPP sessions allowed, no more than four virtual MDPP sessions may be furnished to still qualify as an in-person MDPP supplier
  • MDPP supplier applicants do not require any licensure, accreditation, or certificates to be eligible to enroll as an MDPP supplier
  • MDPP are mandatory par
    • To participate in Medicare program means that provider/organization agrees to accept assignment for all services furnished to Medicare beneficiaries. Becoming a participant means you agree to accept amount approved by Medicare as total payment for covered services
  • A new PTAN will only be assigned when an MDPP supplier administrative location has a different unique CDC organizational code or when administrative location that has same organization code is adding another location in a different state

Supplier Standards

Located in instructions on CMS-20134

  • Must have and maintain preliminary recognition or full recognition from CDC DPRP
  • Cannot have billing privileges terminated or be excluded by a State Medicaid agency
  • Must have coaches who meet eligibility standards set by CMS
  • Must maintain at least one administrative location (location where coaches are dispatched or based, and where MDPP services may or may not be furnished) on an appropriate site. Must include the following:
    • Signage posted on exterior of building or suite, in a building directory, or on materials located inside of building which include LBN/DBA as well as hours of operation
    • Must be open for business during stated operational hours
    • Employees, staff, or volunteers present during operation hours
    • Site cannot be a private residence
  • All locations must be reported on CMS-20134 and may be subject to site visits
  • Must update its enrollment application within 30 days for:
    • Any changes of ownership
    • Changes to the coach roster
    • Final adverse action history
  • Report all other changes within 90 days
  • Must maintain a primary business telephone that is operating at administrative locations or directly where services are furnished

NOTE: Must be listed with business name in public view

  • Cannot deny an MDPP beneficiary access to MDPP services during MDPP benefit period
  • Offer MDPP a beneficiary entirety of MDPP benefit to which he/she is eligible
  • Cannot influence an MDPP beneficiary's decision to being accessing MDPP services or change to a different MDPP supplier specifically
  • Detailed information must be disclosed regarding MDPP benefit to each beneficiary before initial core session is furnished
  • Must answer MDPP beneficiary questions about MDPP services and respond to MDPP related complaints
    • All complaints must be logged with Name, Beneficiary ID, summary of complaint and any actions that were taken, along with person whom provided those actions name and/or NPI. This information must be kept at each administrative location and made available to CMS or MAC's request
  • A file must be maintained which indicates beneficiary information to corresponding CDC performance data and must be submitted to CMS or MAC
  • Submit performance data for MDPP beneficiaries to CMS

Application Completion

If completing application via PECOS, ensure application questionnaire is answered correctly. CMS 20134, CMS-588 (Electronic Funds Transfer (EFT)) application will populate.

  • If completing application via paper, the following must be submitted:
  • A voided check or signed bank letter is necessary documentation for EFT portion of application
  • Must include legal business name (LBN) of MDPP, routing and account number and practice address
  • Submit application fee
    • Fee is required for application. Can be paid on PECOS website
    • Select pay application fee on right-hand side under Helpful Links

If a supplier is adding an administrative location in another state that is within the MACs jurisdiction, a separate initial form is not required if the following three conditions are met:

  1. Location is not part of a separate organization
  2. Location does not have a separate EIN and LBN
  3. Location has same CDC organizational code

Identifying Information

  • Name on application must match on CDC registry
  • Code on CDC registry must match on application

Final Adverse Legal Actions/Convictions

  • MDPP suppliers enrolling are required to complete section 3 as it relates to MDPP supplier

MDPP Location Information

  • Must have at least one administrative location and must report all administrative locations on application
  • Administrative locations are subjected to site visits
  • All community setting which the MDPP services are being supplied at must be reported but are not subject to site visits
    • Community setting is a location where MDPP supplier furnishes MDPP services outside of their administrative locations in meeting locations open to public. May include church basements or multipurpose rooms in recreation centers, etc.
  • Organization with ownership interest and/or managing control
    • Any organization that exercises operational or managerial control over supplier, or conducts day-to-day operations of supplier, is a managing organization and must be reported
    • ALL organizations that have any of the following must be listed organization with ownership interest and/or managing control section/topic:
      • Five percent (5%) or greater direct or indirect ownership interest in the supplier
      • Interest must be equal to or more than 5% of property and assets
      • A partnership interest regardless of percentage of ownership, or whether partner is a general partner or limited partner
      • Managing control of supplier. Any organization that exercises operational or managerial control over supplier, or conducts day-to-day operations of supplier, is a managing organization and must be reported. The organization need not have an ownership interest in supplier in order to qualify as a managing organization. For instance, it could be a management services organization under contract with supplier to furnish management services for business
      • Owning and managing organizations generally fall into one of the following categories: corporations (including non-profit), partnerships and limited partnerships, limited liability companies, charitable and religious organizations, governmental/tribal organizations
    • Supply any Final Adverse Legal Actions sustained by Organization with ownership interest and/or managing control
      • If completing via PECOS, select yes or no to final adverse legal action topic
      • If completing via paper, ensure section 5B is completed for each organization added in this section
      • Submit final outcome documents or current status of final adverse legal action
    • Attach an organizational flowchart identifying all organizations in this section/topic
    • Example of flow: MDPP Organization LBN > Name of Organization with Ownership > Owners within Organization with Ownership
  • Individuals with ownership interest and/or managing control
    • All individuals with ownership or managing control in enrolling organization must be listed in this section/topic
    • Individuals must be listed in this section/topic if they are one of the following:
      • A 5% or greater ownership in supplier
      • Authorized Official (AO)
      • Authorized Officials must be:
        • 5% direct owner of provider or supplier
        • Have ownership interest or control of provider or supplier as:
          • President
          • General partner
          • Chairman of the board
          • Chief financial officer
          • Chief executive officer
      • Delegated Official (DO)
        • Delegated Officials must be:
        • Having ownership of control interest
        • W-2 managing employee. They can be the following:
          • General Manager
          • Business Manager
          • Administrator
          • Operational or Managerial control over operations
      • Managing Employee
      • Director
      • CEO/CFO
      • Sole Owner
    • Interest must be equal to or more than 5% of property and assets
    • Directors/Officers (Members of the Board)
    • A partnership interest regardless of percentage of ownership, or whether partner is a general partner or limited partner
    • Managing control of supplier
    • At least one managing employee must be indicated on application. Managing employee can be a W2 or Contracted Managing Employee
    • Supply any Final Adverse Legal Actions sustained by individual with ownership interest and/or managing control
      • If completing via PECOS, select yes or no to final adverse legal action topic
      • If completing via paper, ensure section 6B is completed for each person added in this section
      • Submit final outcome documents or current status of final adverse legal action

Coach Roster

  • Coaches are individuals who furnish MDPP services on behalf of an MDPP supplier as an employee, contractor, or volunteer
  • If any coaches are being added or changed updated information must be reported on a change application via PECOS or CMS-20134
  • MDPP coaches are not required to enroll into Medicare only MDPP Supplier. They are also required to obtain an NPI.
  • Coaches must not have:
    • Billing privileges revoked by Medicare and/or Medicaid
    • Exclusions from any other Federal health care program
    • Debarred, suspended or otherwise excluded from participating in any other Federal procurement or non-procurement program
    • State or Federal felony convictions in previous 10 years:
      • Crimes against persons
      • Financial crimes
      • Any felony that placed the Medicare or its beneficiaries at immediate risk
      • Any felonies for which individual was convicted, had a guilty plea or adjudicated pretrial diversion that would result in mandatory exclusion under section 1128(a) of Act
  • New coaches being added will be reviewed to see if they are currently on OIG or SAM list
  • Coaches eligibility Start and End Date
    • Start dates
      • May be post-dated into the future 30 days
      • Because changes must be reported within 30 days, coaches effective date can only go back 30 days from date contractor receives application
    • If Noridian determines coach to be ineligible, coach's eligibility start and end date will be documented as same date; therefore, coach was never eligible
    • End dates
      • May be added to coaches but must be within 30 days in future or 30 days in past from date application is received
      • Coach may also be end dated if MDPP supplier is revoked or does not revalidate its enrollment
    • MDPP supplier may only be paid for services furnished by eligible coaches within their eligibility start and end dates
  • If an MDPP supplier has an ineligible coach on its roster, enrollment may be denied or revoked and MDPP supplier will have opportunity to submit a CAP removing coach from its roster within 30 days of receiving notice
  • If MDPP supplier is knowingly using an ineligible coach, MDPP supplier will be revoked

Supporting Documents

  • IRS document when:
    • Initial enrollment
    • A change of legal business name
    • Any instance contractor identifies a discrepancy between an application and/or CMS-588 EFT submission and MDPP enrollment record
  • CDC recognition status
    • Supporting documents for MDPP preliminary recognition verification includes:
      • A letter written on any letterhead from either CDC or CMS and that the letter indicates that the organization has met preliminary recognition with an effective date within a year of application
      • Organization code on application matches both organization code on letter as well as either CDC's online registry or any list provided by CMS for those with interim preliminary recognition
      • CDCs online registry or any list provided by CMS indicates that the entity associated with the organizational code has met MDPP preliminary recognition
      • Name associated with organizational code on list is consistent with name that is listed on supporting documentation
    • Supporting documents of full CDC recognition verifications included:
      • Submitted certificate reflects that the organization has met full recognition with an effective date within a year of application
      • Organization code on section 2 of form CMS-20134 matches both organization code on CDC's online registry and on certificate
      • CDC's online registry indicates that entity associated with that organizational code has met full recognition
      • Name associated with organizational code on CDC's online registry is consistent with what is listed on certificate

Resources

 

Last Updated Wed, 26 May 2021 14:42:53 +0000