Diabetes Prevention Program

PURPOSE: 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 publication of the entire text of the material that 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 di abetes 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 deter mined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual, which is incorpo rated 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 on January 6, 2025. 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 pro gram 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 predia betes 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 a level of recognition 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) dia betes with the exception of gestational diabetes; and (E) Have, within the last twelve (12) months— 1. Hemoglobin A1C test with a value of five and seventenths 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; or 3. 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. (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 CDCapproved 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. 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 one (1) of the following: (I) A minimum weight loss of five percent (5%) of baseline body weight at the end of the first twelve (12) months; (II) A modest reduction in hemoglobin A1C of at least two-tenths of a percent (0.2%). C. If a participant does not meet the weight-loss threshold, the prescribing provider shall perform the necessary lab work to rule out the presence of other conditions (e.g., endocrine disorders) that may complicate efforts to reduce weight and, if present, should request to continue, if appropriate, diabetes prevention program services for the identified condition(s). D. For participants that are eligible for the ongoing maintenance sessions, a referral for the additional twelve (12) months of ongoing maintenance sessions from the prescribing provider is needed in the treatment record. (B) Additional diabetes prevention services, including core sessions and ongoing maintenance sessions beyond the initial allocation must be requested and 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. (5) Records Retention and Documentation Requirements. (A) Providers who provide Diabetes Prevention Program ser vices shall follow section 13 CSR 70-3.030. (B) The DPP provider must retain the prescribing provider’s referral. (C) The DPP provider must complete and retain an evaluation at the end of twelve (12) months to determine the appropriate ness for continuation to the ongoing maintenance services. (D) Once the services are complete, the prescribing provider shall maintain a treatment record outlining how the partici pant will maintain weight loss. AUTHORITY: sections 208.201 and 660.017, RSMo 2016.* Original rule filed Feb. 7, 2020, effective Aug. 30, 2020. Amended: Filed May 12, 2025, effective Nov. 30, 2025. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.