I 

113TH CONGRESS 

1ST SESSION H. R. 962 

To amend title XVIII of the Social Security Act to reduce the incidence 

of diabetes among Medicare beneficiaries. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 5, 2013 

Mrs. DAVIS of California (for herself and Mr. VELA) introduced the following 

bill; which was referred to the Committee on Energy and Commerce, and 

in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to reduce 

the incidence of diabetes among Medicare beneficiaries. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Diabetes 

5 Prevention Act of 2013’’. 

6 SEC. 2. DIABETES PREVENTION UNDER THE MEDICARE 

7 PROGRAM. 

8 (a) COVERAGE OF DIABETES PREVENTION PROGRAM

9 SERVICES.— 


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1 (1) COVERAGE OF SERVICES.— 

2 (A) IN GENERAL.—Section 1861(s)(2) of 

3 the Social Security Act (42 U.S.C. 1395x(s)(2)) 

4 is amended— 

5 (i) in subparagraph (EE), by striking 

6 ‘‘and’’ after the semicolon at the end; 

7 (ii) in subparagraph (FF), by insert8 ing ‘‘and’’ after the semicolon at the end; 

9 and 

10 (iii) by adding at the end the fol11 lowing new subparagraph: 

12 ‘‘(GG) items and services furnished under a di13 abetes prevention program (as defined in subsection 

14 (iii)(1)) to an eligible diabetes prevention program 

15 individual (as defined in subsection (iii)(2));’’. 

16 (B) DEFINITIONS.—Section 1861 of the 

17 Social Security Act (42 U.S.C. 1395x) is 

18 amended by adding at the end the following 

19 new subsection: 

20 ‘‘Diabetes Prevention Program; Eligible Diabetes Preven21 tion Program Individual; Qualified Diabetes Preven22 tion Program Provider 

23 ‘‘(iii)(1)(A) The term ‘diabetes prevention program’ 

24 means a program that— 


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1 ‘‘(i) meets the criteria described in subpara2 graph (B); and 

3 ‘‘(ii) is furnished by a qualified diabetes preven4 tion program provider (as defined in paragraph 

5 (3)(A)). 

6 ‘‘(B) The Secretary shall establish the criteria for a 

7 diabetes prevention program. Such criteria shall be in ac8 cordance with the standards under the National Diabetes 

9 Prevention Program, as established by the Centers for 

10 Disease Control and Prevention, and shall require that the 

11 program complies with the Federal regulations (con12 cerning the privacy of individually identifiable health in13 formation) promulgated under section 264(c) of the 

14 Health Insurance Portability and Accountability Act of 

15 1996. In establishing such criteria, the Secretary may also 

16 consider other factors or clinical evidence as the Secretary 

17 determines appropriate. 

18 ‘‘(C) Items and services furnished under a diabetes 

19 prevention program may be furnished in a community set20 ting, as defined by the Secretary. 

21 ‘‘(D) The Secretary shall establish procedures under 

22 which a qualified diabetes prevention program provider 

23 may contract with a diabetes prevention program delivery 

24 partner to furnish the items and services under a diabetes 

25 prevention program. For purposes of this subsection, the 


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1 term ‘diabetes prevention program delivery partner’ means 

2 an entity, including non-profit organizations, public and 

3 private hospitals, State and local departments of public 

4 health, and Federally qualified health centers, that meets 

5 criteria established by the Secretary. Such criteria shall 

6 be in accordance with the standards under the National 

7 Diabetes Prevention Program, as established by the Cen8 ters for Disease Control and Prevention. In establishing 

9 such criteria, the Secretary may also consider other fac10 tors or clinical evidence as the Secretary determines ap11 propriate. 

12 ‘‘(2)(A) The term ‘eligible diabetes prevention pro13 gram individual’ means an individual at risk for diabetes 

14 (as defined in subsection (yy)(2)) who would benefit from 

15 items and services under a diabetes prevention program, 

16 as determined based on criteria established by the Sec17 retary. 

18 ‘‘(B) The criteria established under subparagraph 

19 (A) shall be in accordance with the standards under the 

20 National Diabetes Prevention Program, as established by 

21 the Centers for Disease Control and Prevention. In estab22 lishing such criteria, the Secretary may also consider other 

23 factors or clinical evidence as the Secretary determines ap24 propriate. 


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1 ‘‘(3)(A)(i) The term ‘qualified diabetes prevention 

2 program provider’ means any entity, including a Federally 

3 qualified health center, that the Secretary determines— 

4 ‘‘(I) is appropriate to furnish items and services 

5 under a diabetes prevention program; and 

6 ‘‘(II) meets criteria established by the Sec7 retary, in consultation with the Centers for Disease 

8 Control and Prevention. 

9 ‘‘(ii) A qualified diabetes prevention program pro10 vider may be, as determined appropriate by the Secretary, 

11 a supplier (as defined in subsection (d)), a provider of 

12 services (as defined in subsection (u)), a health insurance 

13 or services company, a community-based organization, or 

14 any other appropriate entity. 

15 ‘‘(B) A qualified diabetes prevention program pro16 vider shall— 

17 ‘‘(i) furnish the items and services under the di18 abetes prevention program through a delivery part19 ner (pursuant to paragraph (1)(D)) unless no such 

20 delivery partner is available; 

21 ‘‘(ii) manage and track the outcomes of a diabe22 tes prevention program (including attendance and 

23 weight loss of participating individuals) through de24 fined systems, including outcomes of programs fur25 nished under contract with a diabetes prevention 


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1 program delivery partner as defined in paragraph 

2 (1)(D); 

3 ‘‘(iii) implement business processes to manage 

4 program workflow, such as eligibility, reporting, 

5 claims billing, class scheduling, and enrollment; 

6 ‘‘(iv) manage and verify billing accuracy and 

7 beneficiary eligibility (as described in paragraph 

8 (2)); 

9 ‘‘(v) comply with applicable laws and regula10 tions and ensure such compliance by a diabetes pre11 vention program delivery partner; 

12 ‘‘(vi) perform various forms of engagement 

13 with, and outreach to, eligible diabetes prevention 

14 program individuals, including those participating in 

15 programs furnished under contract with a diabetes 

16 prevention program delivery partner; 

17 ‘‘(vii) comply with all program integrity require18 ments as established by the Secretary; and 

19 ‘‘(viii) perform such other functions as estab20 lished by the Secretary.’’. 

21 (2) AMOUNT OF PAYMENT.—Section 1833(a)(1) 

22 of the Social Security Act (42 U.S.C. 1395l(a)(1)) 

23 is amended— 

24 (A) by striking ‘‘and (Z)’’ and inserting 

25 ‘‘(Z)’’; and 


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1 (B) by inserting before the semicolon at 

2 the end the following: ‘‘, and (AA) with respect 

3 to items and services furnished under a diabetes 

4 prevention program (as defined in section 

5 1861(iii)(1)), the amount paid shall be 100 per6 cent of (i) except as provided in clause (ii), the 

7 lesser of the actual charge for the items and 

8 services or the amount determined under the 

9 fee schedule that applies to such items and 

10 services under this part, as determined by the 

11 Secretary, and (ii) in the case of such items and 

12 services that are covered OPD services (as de13 fined in subsection (t)(1)(B)), the amount de14 termined under subsection (t)’’. 

15 (3) WAIVER OF APPLICATION OF DEDUCT16 IBLE.—The first sentence of section 1833(b) of the 

17 Social Security Act (42 U.S.C. 1395l(b)) is amend18 ed— 

19 (A) by striking ‘‘and’’ before ‘‘(10)’’; and 

20 (B) by inserting before the period the fol21 lowing: ‘‘, and (11) such deductible shall not 

22 apply with respect to items and services under 

23 a diabetes prevention program (as defined in 

24 section 1861(iii)(1))’’. 


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1 (4) ASSIGNMENT OF CLAIMS.—Section 

2 1842(b)(18)(C) of the Social Security Act (42 

3 U.S.C. 1395u(b)(18)(C)) is amended by adding at 

4 the end the following new clause: 

5 ‘‘(vii) A qualified diabetes prevention program 

6 provider (as defined in section 1861(iii)(3)(A)).’’. 

7 (5) EXCLUSION OF ITEMS AND SERVICES

8 UNDER A DIABETES PREVENTION PROGRAM FROM

9 SKILLED NURSING FACILITY PROSPECTIVE PAYMENT

10 SYSTEM.—Section 1888(e)(2)(A)(ii) of the Social Se11 curity Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amend12 ed by inserting ‘‘items and services under a diabetes 

13 prevention program (as defined in section 

14 1861(iii)(1)),’’ after ‘‘qualified psychologist serv15 ices,’’. 

16 (6) INCLUSION IN FEDERALLY QUALIFIED

17 HEALTH CENTER SERVICES.—Section 1861(aa)(3) of 

18 the Social Security Act (42 U.S.C. 1395x(aa)(3)) is 

19 amended— 

20 (A) in subparagraph (A), by striking 

21 ‘‘and’’ at the end; 

22 (B) in subparagraph (B), by striking the 

23 comma at the end and inserting ‘‘; and’’; and 

24 (C) by adding after subparagraph (B) the 

25 following new subparagraph: 


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1 ‘‘(C) items and services under a diabetes pre2 vention program (as defined in section 

3 1861(iii)(1)),’’. 

4 (7) SPECIAL CONSIDERATION FOR THE DUAL

5 ELIGIBLE POPULATION.—In implementing the 

6 amendments made by this subsection, the Secretary 

7 of Health and Human Services shall give special 

8 consideration to the needs of individuals who are du9 ally eligible for benefits under the Medicare and 

10 Medicaid programs. 

11 (8) EVALUATION AND REPORT TO CONGRESS.— 

12 (A) EVALUATION.—The Secretary of 

13 Health and Human Services shall conduct an 

14 evaluation on the coverage of items and services 

15 under a diabetes prevention program under the 

16 Medicare program, as added by the amend17 ments made by this subsection. Such evaluation 

18 shall include an analysis of— 

19 (i) the impact of the provision of such 

20 coverage on Medicare beneficiaries, includ21 ing the impact on various populations, 

22 such as individuals who are dually eligible 

23 for benefits under the Medicare and Med24 icaid programs, and the impact of the proVerDate Mar 15 2010 03:23 Mar 07, 2013 Jkt 029200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H962.IH H962

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1 vision of such coverage on health dispari2 ties; 

3 (ii) the rate at which physicians refer 

4 eligible diabetes prevention program indi5 viduals to diabetes prevention programs 

6 under the Medicare program; 

7 (iii) Medicare beneficiary participation 

8 levels in diabetes prevention programs 

9 under the Medicare program and the 

10 awareness of Medicare beneficiaries of the 

11 benefit; 

12 (iv) the health outcomes resulting 

13 from completion of a diabetes prevention 

14 program under the Medicare program; 

15 (v) program integrity protections im16 portant to diabetes prevention programs 

17 under the Medicare program; and 

18 (vi) other areas determined appro19 priate by the Secretary. 

20 (B) REPORT.—Not later than January 1, 

21 2019, the Secretary of Health and Human 

22 Services shall submit to Congress a report on 

23 the evaluation conducted under subparagraph 

24 (A), together with recommendations for such 


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1 legislation and administrative actions as the 

2 Secretary determines appropriate. 

3 (9) EFFECTIVE DATE.—The amendments made 

4 by paragraphs (1) through (6) shall apply with re5 spect to services furnished on or after January 1, 

6 2015. 

7 (b) INCLUSION OF REFERRAL RATES TO DIABETES

8 PREVENTION PROGRAMS IN THE MEDICARE PHYSICIAN

9 QUALITY REPORTING SYSTEM.—Section 1848(k)(2)(C)(i) 

10 of the Social Security Act (42 U.S.C. 1395w– 

11 4(k)(2)(C)(i)) is amended by adding at the end the fol12 lowing new sentence: ‘‘For purposes of reporting data on 

13 quality measures for covered professional services fur14 nished during 2018 and each subsequent year, the quality 

15 measures specified under this paragraph shall include a 

16 measure with respect to referrals of eligible diabetes pre17 vention program individuals (as defined in paragraph (2) 

18 of section 1861(iii)) to diabetes prevention programs (as 

19 defined in paragraph (1) of such section).’’. 

20 (c) INCLUSION OF DIABETES RISK ASSESSMENT IN

21 MEDICARE PERSONALIZED PREVENTION PLAN.— 

22 (1) IN GENERAL.—Section 1861(hhh)(2)(C) of 

23 the Social Security Act (42 U.S.C. 

24 1395x(hhh)(2)(C)) is amended by inserting before 

25 the period at the end the following: ‘‘, and an assessVerDate Mar 15 2010 03:23 Mar 07, 2013 Jkt 029200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H962.IH H962

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1 ment of whether the individual is an individual at 

2 risk for diabetes (as defined in subsection (yy)(2))’’. 

3 (2) EFFECTIVE DATE.—The amendments made 

4 by this subsection shall apply to personalized preven5 tion plans created or updated on or after January 

6 1, 2015. 

7 SEC. 3. FINDINGS; SENSE OF THE HOUSE OF REPRESENTA8 TIVES REGARDING DIABETES PREVENTION 

9 UNDER THE MEDICAID PROGRAM. 

10 (a) FINDINGS.—Congress makes the following find11 ings: 

12 (1) The prevalence and cost of diabetes is a sig13 nificant concern for State Medicaid programs. By 

14 2021, the Medicaid program is expected to cover 

15 13,000,000 people with diabetes and about 

16 9,000,000 people who may have pre-diabetes. By 

17 2021, States will spend an estimated 

18 $83,000,000,000 on individuals with diabetes or pre19 diabetes. 

20 (2) The National Diabetes Prevention Program, 

21 as established by the Centers for Disease Control 

22 and Prevention, has been proven to reduce the onset 

23 of diabetes in at-risk adults by 58 percent, using a 

24 cost-effective, community-based intervention. 


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1 (b) SENSE OF THE HOUSE OF REPRESENTATIVES.— 

2 It is the sense of the House of Representatives that the 

3 National Diabetes Prevention Program presents an oppor4 tunity for States to reduce the incidence of diabetes among 

5 individuals enrolled in their Medicaid programs. 

Æ 


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