CurrentkernfamilyhealthcarePolicy N/A

Diabetes Prevention Program (DPP) coverage criteria

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Defines Kern Family Health Care's implementation of a Diabetes Prevention Program benefit for members, describing eligibility and program features for providers and network partners.

Policy Summary

Payerkernfamilyhealthcare

PolicyDiabetes Prevention Program (DPP) coverage criteria

Policy CodePolicy N/A

Change TypeNew benefit added (DPP)

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionRefer eligible members (age ≥18 with HbA1c 5.7–6.4 or high risk) to the one-year Diabetes Prevention Program per DHCS APL 18-018.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2019, Kern Health Systems will implement a Diabetes Prevention Program (DPP) as a benefit available to members.

Program eligibility includes members over age 18 with HbA1c 5.7–6.4 or those considered high risk for developing diabetes.

The program lasts one year with the option to continue for an additional qualifying year.

>=18member age eligibility

5.7-6.4HbA1c threshold

1 yr (+1)program duration

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CurrentkernfamilyhealthcarePolicy N/A

Diabetes Prevention Program (DPP) coverage criteria

Customize your policy alerts

Sign up for all kernfamilyhealthcare policy alerts

Know when kernfamilyhealthcare releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines Kern Family Health Care's implementation of a Diabetes Prevention Program benefit for members, describing eligibility and program features for providers and network partners.

Policy Summary

Payerkernfamilyhealthcare

PolicyDiabetes Prevention Program (DPP) coverage criteria

Policy CodePolicy N/A

Change TypeNew benefit added (DPP)

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionRefer eligible members (age ≥18 with HbA1c 5.7–6.4 or high risk) to the one-year Diabetes Prevention Program per DHCS APL 18-018.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2019, Kern Health Systems will implement a Diabetes Prevention Program (DPP) as a benefit available to members.

Program eligibility includes members over age 18 with HbA1c 5.7–6.4 or those considered high risk for developing diabetes.

The program lasts one year with the option to continue for an additional qualifying year.

>=18member age eligibility

5.7-6.4HbA1c threshold

1 yr (+1)program duration

Coverage Criteria for Diabetes Prevention Program (DPP)

inv-01: Initial Eligibility

Covered when ALL of the following are met

DPP eligibility: Member is over age 18 AND has HbA1c 5.7 to 6.4 OR is considered high risk for developing diabetes per DHCS guidance.age >=18; HbA1c 5.7-6.4

Program follows DHCS All Plan Letter 18-018

inv-02: Duration / Continuation

Program duration and continuation

Duration: Program is provided for one year and may continue for an additional year for members who qualify.1 year (+1 optional)

Qualification criteria for the second year are not specified in this document; refer to DHCS All Plan Letter 18-018.

This document does not list any explicit exclusions for the Diabetes Prevention Program (DPP).

No additional coverage limitations or "not medically necessary" items are specified in this policy.

Coding, Laboratory and Demographic Criteria

inv-06: HbA1c — laboratory eligibility threshold

HbA1c threshold5.7 to 6.4%

Purpose of thresholdIdentifies members with prediabetes eligible for DPP participation

Source referenceDocument states members with an HgA1c level of 5.7 to 6.4 are eligible

inv-07: Age — member age eligibility

Minimum age>= 18 years

Population coveredAll members aged 18 and older may be considered for DPP if other eligibility criteria are met

Effective date

Provider Actions and Administrative Notes

Prior Authorization

Prior authorization not required / Not stated

The policy does not specify any prior authorization requirement for enrolling members in the Diabetes Prevention Program (DPP). No forms, authorization processes, or PA codes are listed in this document.

Step Therapy

No step therapy described

The document does not describe any step therapy or sequencing requirements before a member may participate in the DPP benefit.

Documentation Required

Documentation and program reference (DHCS APL 18-018)

Background

The Diabetes Prevention Program (DPP) is an evidence-based, year-long lifestyle education benefit implemented by Kern Health Systems effective January 1, 2019 in accordance with DHCS direction. The program is intended for adults at increased risk for type 2 diabetes and focuses on weight management and behavior change through structured activities such as peer coaching, self-monitoring and problem solving, routine weigh-ins, feedback and encouragement, and provision of informational materials to support goals. Participation criteria include being aged >= 18 years with an HbA1c of 5.7–6.4 or being otherwise considered high risk for developing diabetes per DHCS guidance. The program is provided for one year and may continue for an additional qualifying year.

Definitions

inv-13: DPP — definition of Diabetes Prevention Program (year-long lifestyle education program)

Program nameDiabetes Prevention Program (DPP)

DurationOne year (with option to continue for an additional qualifying year)

Core componentsYear-long lifestyle education using approved lifestyle changes, peer coach, self-monitoring, problem solving, informational materials, and routine weigh-ins

Regulatory referenceProgram implemented per DHCS All Plan Letter 18-018

inv-14: High risk — definition of 'high risk' for developing diabetes as referenced

Definition of high riskMembers with HbA1c 5.7 to 6.4 or those considered high risk for developing diabetes per DHCS guidance