Mo. Code Regs. tit. 13 § 70-25.130
Current through Register Vol. 49, No. 23, December 2, 2024
Section 13 CSR 70-25.130 - Diabetes Prevention ProgramPURPOSE: 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; or3. 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.Adopted by Missouri Register July 15, 2020/Volume 45, Number 14, effective 8/31/2020