CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicare Diabetes Prevention Program (MDPP) reimbursement

Governs Neighborhood Health Plan of Rhode Island coverage and reimbursement requirements for CDC/MDPP-approved Diabetes Prevention Program services for applicable members across Medicaid (excluding EFP), Commercial, and INTEGRITY lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare Diabetes Prevention Program (MDPP) reimbursement

Policy CodePolicy N/A

Change TypeCode list updated

Effective DateN/A

Next Review DateSep 18, 2024

Key ActionProviders must verify eligibility, coverage and authorization criteria and hold MDPP recognition to furnish services.

SourceLink

POLICY UPDATE CHANGES

Added new codes for 1/1/24 and removed codes.

3 session phasesMDPP session phases

5% weight lossWeight loss threshold

once per lifetimeService limit

G9886, G9887, G9880, G9888, G9890HCPCS codes listed

MDPP Coverage Criteria

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MDPP coverage criteria

Covered when ALL of the following member eligibility and program limits are met:

ALL of the following

ALL of the following
- ALL of the following
  - Body Mass Index (BMI) of at least 25 on the date of the first core session (>=23 if self-identified as Asian).
- ALL of the following
  - ONE of: Hemoglobin A1c between 5.7% and 6.4%.
  - OR: Fasting plasma glucose of 110–125 mg/dL.
  - OR: 2-hour plasma glucose (oral glucose tolerance test) of 140–199 mg/dL.
- ALL of the following
  - No previous diagnosis of diabetes to the date of the first core session (exception: prior gestational diabetes allowed).
- ALL of the following
  - Member does not have end-stage renal disease (ESRD).
ALL of the following
- ALL of the following
  - Member has achieved a minimum 5% weight (BMI) reduction from baseline as measured from the initial session weight.
  - Member maintains the 5% BMI reduction for the duration of ongoing maintenance sessions.
ALL of the following
- ALL of the following
  - MDPP services are limited to once per lifetime.
- Not covered for
  - Members with a diagnosis of diabetes at the start date of the first core session.
  - Members with End Stage Renal Disease (ESRD).
  - Members not covered by INTEGRITY.
  - Members who have previously received MDPP services.

ALL of the following

Sessions must be delivered by eligible MDPP coaches using a CDC-approved curriculum and recognized provider status is required.

HCPCS Codes and Clinical Thresholds

MDPP HCPCS codesHCPCS

G9886	Behavioral counseling for diabetes prevention, in-person, group, 60 minutes
G9887	Behavioral counseling for diabetes prevention, distance learning, 60 minutes
G9880	Beneficiary achieved ≥5% weight loss (one-time payment when first achieved months 1-12)
G9888	Maintenance 5% weight loss months 7-12
G9890	Bridge payment for first MDPP session furnished by an MDPP who previously received MDPP from a different supplier

Weight/BMI thresholds

BMI thresholdBMI ≥25 on date of first core session (≥23 if self-identified as Asian)

Hemoglobin A1c rangeHemoglobin A1c 5.7%–6.4%

Blood glucose test thresholdsFasting plasma glucose 110–125 mg/dL or 2‑hour OGTT 140–199 mg/dL (must meet one of the blood test requirements within 12 months before first core session)

Diabetes exclusionNo previous diagnosis of diabetes at date of first core session (except gestational diabetes)

Minimum weight-loss requirementMember must achieve and maintain ≥5% weight loss from baseline to qualify for ongoing maintenance sessions and for certain incentive payments

Verification, Recognition, and Reimbursement Requirements

Documentation Required

Maintain required MDPP/CDC recognition and qualified coaches

Providers must hold an approved MDPP recognition before furnishing services. The policy requires one of: MDPP Interim Preliminary Recognition, CDC Preliminary Recognition, MDPP Preliminary Recognition, or CDC Full Recognition, and sessions must be delivered by an eligible MDPP coach using a CDC-approved curriculum.

Obtain and maintain one of the listed MDPP/CDC recognitions prior to offering MDPP services.
Ensure all sessions are delivered by an eligible MDPP coach using a CDC‑approved curriculum.

Key Definitions and MDPP Session Phases

MDPP session phases

Core SessionsPrimary phase during months 0–6 focused on frequent behavioral counseling to initiate weight loss and lifestyle change

Core Maintenance SessionsSecondary phase during months 7–12 focused on supporting continued weight loss and transition toward maintenance

Ongoing Maintenance SessionsLong‑term phase during months 13–24 for members who have achieved and maintain required weight reduction, supporting sustained behavior change

Provider recognition types

MDPP Interim Preliminary RecognitionAn eligible recognition status that permits a provider to furnish MDPP services prior to full CDC recognition

CDC Preliminary RecognitionA CDC-issued preliminary recognition status allowing a provider to deliver MDPP services while completing recognition requirements

MDPP Preliminary RecognitionA preliminary MDPP recognition designation permitting service delivery under program standards

CDC Full RecognitionFull CDC recognition status required for ongoing furnishing of MDPP services under the program