Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

August 2018

New Preventive Service for Medicare Members at Risk for Type 2 Diabetes

The Medicare Diabetes Prevention Program (MDPP) has been proven by a National Institutes of Health (NIH) trial to greatly reduce the progression of prediabetes to type 2 diabetes1. Effective immediately, your at-risk senior patients who have a Blue Cross and Blue Shield of Texas (BCBSTX) Medicare health plan and meet the eligibility criteria can participate in this program at no cost to them.

MDPP Eligibility Criteria:

  • Blood value:
    • Fasting plasma glucose of 110 to 125 mg/dL, or
    • A1C value between 5.7 to 6.4, or
    • Oral glucose tolerance test between 140 to 199 mg/dL
  • BMI greater than 25 (or if Asian, greater than 23)
  • No diagnosis of end-stage renal disease, type 1 or type 2 diabetes; previous gestational diabetes is not an exclusion to participation

BCBSTX has partnered with Solera Health Inc. (Solera) to facilitate MDPP services for our members. Solera will work closely with members to enroll them in programs in their area.

This program is meant to help participants change their lifestyle, establish healthy habits and lose five to nine percent of their body weight. This modest weight loss dramatically decreases the risk of developing type 2 diabetes.

This two-year program is focused on encouraging healthier food choices and increased activity. The first year includes weekly lessons in a small group setting for six months, followed by monthly lessons for six months. The second year provides ongoing support for participants who, during the first year, meet the five percent weight-loss goal and attend a minimum of two sessions every three months. Throughout the two years, participants have access to a one-on-one lifestyle health coach to help set goals and stay on track.

Your patients who may be eligible have already received letters from BCBSTX informing them of Solera’s services. If you or your patients need additional information, please refer to the FAQs below. Patients can verify their eligibility and enroll in the program by going to solera4me.com/bcbstx or by calling 866-671-8597 (TTY 771), Monday through Friday from 8 a.m. to 8 p.m. CT.

Solera Health Medicare Diabetes Prevention Program – Provider FAQ

Q: What is the MDPP (also known as the National Diabetes Prevention Program [NDPP])?
A: The MDPP is an evidence-based lifestyle program that prevents or delays the progression of prediabetes to type 2 diabetes by helping participants lose weight and adopt healthy habits.

Q: How effective is the MDPP in reducing the risk of type 2 diabetes?
A: The NIH demonstrated in a 2002 randomized controlled trial of over 3,000 adults that the NDPP reduced the risk of developing type 2 diabetes by 58 percent, a significant improvement over Metformin. Numerous translation studies have shown similar results in all age groups; however, the MDPP was most effective in those over age 65.¹

Q: What is the MDPP?
A: The MDPP is the NDPP available to those Medicare beneficiaries who meet the program eligibility requirements. The MDPP uses the same curriculum as the NDPP, but the eligibility requirements for Medicare coverage are more targeted in that they require qualifying blood values before enrollment. While the NDPP can be provided either in-person or virtually, the MDPP must be delivered in-person. The MDPP program is a once in a lifetime service delivered for a period of two years for members who meet sustained engagement and weight loss targets.

Q: What’s included in the program?
A:

  • Core Services: 16 weekly lessons over the first six months, followed by monthly sessions over the last six months
  • Ongoing Maintenance: Second year of maintenance sessions for those who meet the 5 percent weight-loss goal and attend a minimum of two sessions per three-month period
  • Lifestyle health coach helps set goals and keeps participants on track
  • Small, in-person groups for support and encouragement

Q: Who is eligible for the program?
A: MDPP is a covered preventive service for eligible Blue Cross Medicare AdvantageSM Medicare members.

Members must complete a blood screening test within 12 months prior to enrollment and meet the requirements below to qualify for the program. If your patient needs a blood screening test, please refer them to an in-network lab.

MDPP criteria for eligibility are:

  • Enrollment in Medicare Part B
  • Blood value:
    • Fasting plasma glucose of 110-125 mg/dL, or
    • A1C value between 5.7-6.4, or
    • Oral glucose tolerance test between 140
    • 199 mg/dL
  • BMI greater than 25 (or if Asian, greater than 23)
  • No diagnosis of end-stage renal disease, type 1 or type 2 diabetes (previous gestational diabetes is not an exclusion to participate)

Q: If eligible, how do members enroll?
A: Eligible members enroll in the MDPP through our program administrator, Solera Health, by visiting solera4me.com/bcbstx or by calling 866-671-8597 (TTY 771), Monday through Friday from 8 a.m. to 8 p.m. CT.

As a health care provider, you may refer eligible patients to this program. Patients can also self-refer by visiting solera4me.com/bcbstx or by calling Solera directly.

Q: Is there a cost to members for participating?
A: MDPP is a covered preventive service with no cost-sharing. There is no cost to members – no copay, no coinsurance and no deductible. The member may receive an Explanation of Benefits (EOB) from Blue Cross Medicare Advantage for this service. No action is necessary if a member receives an EOB, since there is no cost to the member.

Q: Whom should I contact if I have questions about the program?
A: For questions about the MDPP, please call Solera Health at 866-671-8597 (TTY 771), Monday through Friday from 8 a.m. to 8 p.m. CT.

1Centers for Disease Control and Prevention

Solera4me is provided by Solera Health, an independent company. Solera is wholly responsible for its own products and services. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Solera.

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.