CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicare Diabetes Prevention Program (MDPP) reimbursement

Defines Neighborhood Health Plan of Rhode Island's coverage and reimbursement requirements for CDC‑approved Diabetes Prevention Program (MDPP) services for applicable members (INTEGRITY plan).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare Diabetes Prevention Program (MDPP) reimbursement

Policy CodePolicy N/A

Change TypeCodes updated (added/removed)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify member eligibility, coverage and authorization criteria prior to rendering MDPP services.

SourceLink

POLICY UPDATE CHANGES

Added new codes for 1/1/24 and removed codes no longer covered as of 1/1/24.

3MDPP session phases over 24 months (Core, Core Maintenance, Ongoing Maintenance)

5%Minimum weight reduction for ongoing maintenance & incentives

onceMaximum lifetime limit for MDPP services

INTEGRITYPlan product

G9886,G9887,G9880,G9888,G9890Referenced HCPCS/CMS codes

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MDPP Coverage Criteria and Rules

MDPP coverage criteria and rules

Coverage is available for INTEGRITY plan members who meet MDPP eligibility and program requirements; services are reimbursed Fee‑For‑Service per provider contract.

ALL of the following

Member must be covered by the INTEGRITY plan

ALL of the following

Body Mass Index (BMI) >= 25 on date of first core session (>= 23 if self‑identified as Asian)
One qualifying blood test within 12 months prior to first core session
- Hemoglobin A1c 5.7% to 6.4%
- Fasting plasma glucose 110-125 mg/dL
- 2‑hour plasma glucose 140-199 mg/dL (oral glucose tolerance test)
No prior diagnosis of diabetes before the date of the first core session (gestational diabetes excepted)
Not diagnosed with End Stage Renal Disease (ESRD)

ALL of the following

Sessions must be furnished by providers with one of the following recognitions: MDPP Interim Preliminary Recognition, MDPP Preliminary Recognition, CDC Preliminary Recognition, or CDC Full Recognition
All sessions must be delivered by an eligible MDPP coach using a CDC‑approved curriculum focused on weight loss and lifestyle wellness

ALL of the following

MDPP consists of three phases over 24 months: Core Sessions (months 0-6), Core Maintenance Sessions (months 7-12), and Ongoing Maintenance Sessions (months 13-24)
Core sessions (months 0-6) are covered based on member attendance
Ongoing Maintenance sessions are covered only if the member achieves and maintains a minimum 5% weight (BMI) reduction from initial session weight and meets attendance goals

ALL of the following

MDPP services are limited to once per lifetime
Members for whom MDPP is not covered
- Members with a diabetes diagnosis prior to the start date of the first core session
- Members with End Stage Renal Disease (ESRD)
- Members not covered by the INTEGRITY plan
- Members who have previously received MDPP services

ALL of the following

Neighborhood reimburses MDPP claims Fee‑For‑Service as specified by provider contract

ALL of the following

Baseline weight is measured at the first core session and used to assess the 5% weight loss threshold for incentives and ongoing maintenance coverage

ALL of the following

Providers must verify eligibility, coverage, and authorization criteria prior to rendering services; claims are subject to contractual timely filing guidelines

Billing Codes, Thresholds, and Measurements

MDPP/CMS HCPCS codesHCPCSCovered

G9886	Behavioral counseling for diabetes prevention, in-person, group, 60 minutes
G9887	Behavioral counseling for diabetes prevention, distance learning, 60 minutes
G9880	The MDPP beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight in months 1-12 of the MDPP services period under the MDPP Expanded Model (EM). This is a one-time payment available when a beneficiary first achieves at least 5% weight loss from baseline as measured by an in-person weight measurement at a core session or core maintenance session.
G9888	Maintenance 5% WL from baseline weight in months 7-12
G9890	Bridge Payment: A one-time payment for the first Medicare Diabetes Prevention Program (MDPP) core session, core maintenance session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP beneficiary during months 1-24 of the MDPP Expanded Model (EM) who has previously received MDPP services from a different MDPP supplier under the MDPP Expanded Model. A supplier may only receive one bridge payment per MDPP beneficiary

Weight/BMI thresholds and measurement windows

BMI eligibility at first core sessionBMI >= 25 (>= 23 if self-identified as Asian) measured on date of first core session

Qualifying blood test windowOne qualifying blood test (A1c, fasting plasma glucose, or 2-hour OGTT) within 12 months prior to first core session

Qualifying A1c rangeHemoglobin A1c 5.7%–6.4%

Qualifying fasting plasma glucose rangeFasting plasma glucose 110–125 mg/dL

Qualifying 2-hour plasma glucose range2-hour plasma glucose (OGTT) 140–199 mg/dL

Weight-loss targets for incentives and maintenancePerformance incentives for achieving and maintaining 5% BMI reduction during Core Sessions; required 5% minimum reduction (from baseline weight) to qualify for Ongoing Maintenance coverage; an additional 9% reduction referenced for Core + Ongoing incentive measurement

Provider Requirements, Billing Rules, and Verification

Prior Authorization

Provider recognition requirement — MDPP recognition required

Providers must have one of the following recognitions to furnish MDPP services: MDPP Interim Preliminary Recognition; MDPP Preliminary Recognition; CDC Preliminary Recognition; or CDC Full Recognition. All sessions must be delivered by an eligible MDPP coach and be based on a CDC‑approved curriculum focused on weight loss and lifestyle wellness to prevent or delay type II diabetes. Ensure recognition is current and documented prior to providing services.

MDPP Interim Preliminary Recognition
MDPP Preliminary Recognition
CDC Preliminary Recognition
CDC Full Recognition
All sessions delivered by an eligible MDPP coach
CDC‑approved curriculum required

Documentation Required

Key MDPP Definitions and Eligibility Thresholds

Core Sessions, Core Maintenance Sessions, Ongoing Maintenance Sessions

Core SessionsPrimary program phase delivered in months 0–6 focused on weight loss and lifestyle change; coverage for core sessions provided based on member attendance

Core Maintenance SessionsFollow-up phase delivered in months 7–12 to support continued behavior change after Core Sessions

Ongoing Maintenance SessionsLong-term support phase delivered in months 13–24; covered only if member achieves and maintains required minimum weight loss and attendance goals

Lab thresholds for prediabetes eligibility

Hemoglobin A1c eligibility rangeA1c 5.7% to 6.4%

Fasting plasma glucose eligibility range