21-243 Help Delay or Prevent the Onset of Type 2 Diabetes
Date: 04/16/21
This information applies to Physicians, and Participating Physician Groups (PPGs).
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Refer eligible members to the Medi-Cal Diabetes Prevention Program
Prediabetes is a health condition characterized by blood glucose levels that are higher than normal, but not high enough to be diagnosed as diabetes. Prediabetes increases the risk for type 2 diabetes, heart disease and stroke. If left untreated, up to one-third of people with prediabetes will progress to diabetes within five years. You can help by testing your patients for prediabetes and refer those at risk to the Medi-Cal Diabetes Prevention Program (DPP).
The DPP is a Medi-Cal covered benefit
The Medi-Cal DPP is available to eligible Medi-Cal members as a covered benefit.
The Department of Health Care Services (DHCS) established the DPP as a Medi-Cal benefit within the fee-for-service and managed care delivery systems. The program is consistent with the guidelines provided by the Centers for Disease Control and Prevention and incorporates many components of the Centers for Medicare & Medicaid Services DPP in Medicare. For more information, refer to the DHCS website.
How the DPP helps members at risk
The DPP is an evidence-based, lifestyle change program that promotes and focuses on emphasizing weight loss through exercise, healthy eating and behavior modification. The program is designed to assist Medi-Cal beneficiaries diagnosed with prediabetes in preventing or delaying the onset of type 2 diabetes.
Session type | Frequency | Description |
|---|---|---|
Core sessions | 16 weekly | At least 16 sessions over the first 6 months (for months 1 through 6) |
Core maintenance sessions | 6 monthly | At least 1 session per month over the next 6 months (for months 6 through 12) |
Members who achieve and maintain a minimum weight loss of five percent by the end of the year will be eligible to receive ongoing maintenance sessions to help them continue healthy lifestyle behaviors.
Yes Health, Inc. will administer the DPP benefit. Yes Health is an all-mobile healthy lifestyle program. Eligible members will interact with a health coach, receive a wireless scale, and receive weekly online lessons.
DPP eligibility
Medi-Cal members who meet the following DPP eligibility requirements may be referred by providers:
- Be enrolled in Medi-Cal.
- Be at least age 18 or older.
- Have a body mass index (BMI) of at least 25 if not identified as Asian; have a BMI of at least 23 if identified as Asian.
- Have had one of the following within 12 months prior to the provider’s recommendation:
- A hemoglobin A1c test with a value between 5.7% and 6.7%
- A fasting plasma glucose of 110–125 mg/dL.
- A two-hour plasma glucose of 140–199 mg/dL.
- No previous diagnosis of type 1 or type 2 diabetes, excluding gestational diabetes.
- Do not have end-stage renal disease (ESRD).
How to refer a member for DPP participation
Providers can refer members who meet DPP eligibility requirements to the program by completing the Diabetes Prevention Program Provider Referral Form (PDF) and fax it to 800-628-2704. A fax cover sheet must accompany all fax transmissions of protected health information. The cover sheet must be labeled “PROTECTED HEALTH INFORMATION.”
Providers can also refer members to call Member Services at 800-675-6110 (TTY/TDD: 711) 24 hours a day, 7 days a week to learn more about the program. Members may contact Yes Health directly, and take the eligibility assessment for the DPP program.
Additional information
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 800-675-6110.