What Is the Medicare Diabetes Prevention Program?

The MDPP is designed to help Medicare beneficiaries who have symptoms of prediabetes develop healthy habits to prevent type 2 diabetes. The Centers for Medicare and Medicaid Services (CMS) oversees the program on a federal level.

Since 2018, the MDPP has been offered to people who qualify for Medicare. It was developed in response to the growing number of Americans with diabetes.

The numbers are even higher among Americans ages 65 and over. In fact, as of 2018, 26.8 percent of Americans over age 65 had diabetes. That number is expected to double or even triple by 2050.

Diabetes is a chronic condition — and an expensive one. In 2016 alone, Medicare spent $42 billion on diabetes care.

To help beneficiaries and to save money, a pilot program called the Diabetes Prevention Program (DPP) was developed. It allowed Medicare to spend money on diabetes prevention, with the hope this would mean less money spent later on treating diabetes.

The DPP focused on CDC guidance for lowering the risk of diabetes in people with prediabetes. Methods included teaching people enrolled in the DPP how to:

• change their diet
• increase their physical activity
• make overall healthier lifestyle choices

The original program ran for 2 years in 17 locations and was an overall success. It helped participants lose weight, reduce their chance of developing diabetes, and have fewer hospital admissions. Plus, it saved Medicare money on treatments.

In 2017, the program was expanded into the current MDPP.

Medicare Part B coverage

Medicare Part B is medical insurance. Together with Medicare Part A (hospital insurance), it makes up what’s known as original Medicare. Part B covers services like doctor’s visits, outpatient services, and preventive care.

Preventive care is completely covered for people enrolled in Medicare. This means you won’t need to pay 20 percent of these costs, like you would for most Part B services.

Preventive care includes a variety of programs and services to help you stay healthy, including:

• wellness visits
• smoking cessation
• vaccines
• cancer screenings
• mental health screenings

Like all preventive services, the MDPP won’t cost you anything as long as you meet the eligibility requirements (discussed below) and use an approved provider.

You’re only eligible for the MDPP once during your lifetime; Medicare won’t pay for it a second time.

Medicare Advantage coverage

Medicare Advantage, also known as Medicare Part C, is an option that allows you to buy a plan from a private insurance company that contracts with Medicare. All Medicare Advantage plans are required to offer the same coverage as original Medicare.

Many Advantage plans add additional coverage, such as:

• dental care
• vision care
• hearing aids and screenings
• prescription drugs
• fitness plans

Medicare Advantage plans also offer free preventive services. But some plans have a network, and you’ll need to stay in network for full coverage. If the MDPP location you’re interested in isn’t in network, you might need to pay some or all of the costs out of pocket.

If it’s the only MDPP location in your area, your plan might still cover it fully. If you have a local in-network option, though, the out-of-network location won’t be covered. You can call your plan provider directly for coverage details.

Just like with Part B, you can get covered for the MDPP only once.

The services you get from the MDPP will be the same no matter what part of Medicare you’re using.

This 2-year program is divided into three phases. During each phase, you’ll have set goals and you’ll get support to help you meet them.

Phase 1: Core sessions

Phase 1 lasts for the first 6 months that you’re enrolled in the MDPP. During this stage, you’ll have 16 group sessions. Each will happen once a week for about an hour.

Your sessions will be led by an MDPP coach. You’ll learn tips for healthy eating, fitness, and weight loss. The coach will also measure your weight at each session to track your progress.

Phase 2: Core maintenance sessions

During months 7 through 12, you’ll be in phase 2. You’ll attend at least six sessions during this phase, though your program may offer more. You’ll get ongoing help with developing healthy habits, and your weight will continue to be tracked.

To move past phase 2, you’ll need to show that you’re making progress in the program. Generally, this means attending at least one session in months 10 through 12 and showing weight loss of at least 5 percent.

If you’re not making progress, Medicare won’t pay for you to move on to the next phase.

Phase 3: Ongoing maintenance sessions

Phase 3 is the final stage of the program and lasts for 1 year. This year is split into four periods of 3 months each, called intervals.

You’ll need to attend at least two sessions in each period and continue to meet weight loss goals to continue in the program. You’ll have sessions at least once a month, and your coach will continue to help you as you adjust to your new diet and lifestyle.

What if I miss a session?

Medicare allows providers to offer makeup sessions but doesn’t require it. This means that it’s up to your provider.

Your MDPP provider should let you know when you sign up what your options are if you miss a session. Some providers may allow you to join another group on a different night, while others might offer one-on-one or even virtual sessions.

To start the MDPP, you need to be enrolled in Medicare Part B or Part C. You’ll then have to meet some additional criteria. To enroll, you can’t have been:

• diagnosed with diabetes, unless it was gestational diabetes
• diagnosed with end stage renal disease (ESRD)
• enrolled in the MDPP before

If you meet these requirements, you’ll need to show you have signs of prediabetes. These include a body mass index (BMI) of more than 25 (or more than 23 for participants who identify as Asian). Your BMI will be calculated from your weight at your first sessions.

You’ll also need lab work that shows you have prediabetes. You can use one of three results to qualify:

• hemoglobin A1c test with results of 5.7 percent to 6.4 percent
• fasting plasma glucose test with results of 110 to 125 mg/dL
• oral glucose tolerance test with results of 140 to 199 mg/dL

Your results will need to be from the last 12 months and you must have your doctor’s verification.

One of your first steps for enrollment should be talking with your doctor about your prediabetes signs. Your doctor can verify your current BMI and order the lab work you’ll need before joining a program.

You can then search for programs in your area using this map.

Make sure any program you use is Medicare approved. If you have a Medicare Advantage (Part C) plan, you’ll want to make sure the program is in network.

You shouldn’t receive a bill for these services. If you do, you can contact Medicare right away by calling 800-Medicare (800-633-4227).

The MDPP is meant to prevent diabetes. If you already have diabetes or develop it later, you can get coverage for a range of care needs. Under Part B, coverage includes:

• Diabetes screenings. You get coverage for two screenings every year.
• Diabetes self-management. Self-management teaches you how to inject insulin, monitor your blood sugar, and more.
• Diabetic supplies. Part B covers supplies like test strips, glucose monitors, and insulin pumps.
• Foot exams and care. Diabetes can affect the health of your feet. For this reason, you will be covered for a foot exam every 6 months. Medicare will also pay for care and supplies, such as special shoes or prostheses.
• Eye exams. Medicare will pay for you to get a glaucoma screening once a month, since people with diabetes are at an increased risk.

If you have Medicare Part D (prescription drug coverage), you can also get coverage for:

• antidiabetic medications
• insulin
• needles, syringes, and other supplies

Any Medicare Advantage plan will cover all the same services as Part B, and many include some of the items covered by Part D as well.

If you have prediabetes, the MDPP can help you prevent type 2 diabetes. Remember that:

• Participating in the MDPP is free if you qualify.
• You can only be in the MDPP once.
• You need to have indicators of prediabetes to qualify.
• The MDPP can help you make healthy lifestyle changes.
• The MDPP lasts for 2 years.