I 
112TH CONGRESS 
2D SESSION 
H. R. 6548 
To amend title XVIII of the Social Security Act to provide coverage under 
the Medicare program for diabetes prevention services. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 21, 2012 
Mr. SHULER (for himself and Mrs. DAVIS of California) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committee on Ways and Means, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
coverage under the Medicare program for diabetes pre-
vention services. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Diabetes Prevention 
Act of 2012’’. 
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SEC. 2. MEDICARE COVERAGE FOR DIABETES PREVENTION 
SERVICES. 
Title XVIII of the Social Security Act is amended by 
adding at the end the following new section: 
‘‘SEC. 1899B. DIABETES PREVENTION PROGRAM. 
‘‘(a) PAYMENTS FOR DIABETES PREVENTION SERV-
ICES.— 
‘‘(1) IN GENERAL.—Beginning not later than 
January 1, 2013, the Secretary shall make payments 
to qualified third-party intermediaries for diabetes 
prevention services furnished to prediabetic Medicare 
beneficiaries by eligible entities in local communities 
that are networked and managed by such third-party 
intermediaries, for the purpose of preventing such 
beneficiaries from developing diabetes. 
‘‘(2) SOURCE.—The payments under paragraph 
(1) shall be made from the Federal Supplementary 
Medical Insurance Trust Fund. 
‘‘(3) SPECIAL CONSIDERATION FOR THE DUAL 
ELIGIBLE INDIVIDUALS.—In implementing this sec-
tion, the Secretary of Health and Human Services 
shall give special consideration to the needs of dual 
eligible individuals (as such term is defined in sec-
tion 1915(h)(2)(B)). 
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‘‘(b) 
DIABETES
PREVENTION
SERVICES
AND 
PREDIABETIC MEDICARE BENEFICIARY DEFINED.—For 
purposes of this section: 
‘‘(1) DIABETES
PREVENTION
SERVICES.—The 
term ‘diabetes prevention services’ means services 
that— 
‘‘(A) are furnished to prediabetic Medicare 
beneficiaries by an eligible entity; and 
‘‘(B) are components of a diabetes preven-
tion program that meets the requirements, 
goals, and objectives of the National Diabetes 
Program of the Centers for Disease Control 
and Prevention (including use of the curriculum 
of such program). 
‘‘(2) PREDIABETIC MEDICARE BENEFICIARY.— 
The term ‘prediabetic Medicare beneficiary’ means 
an individual who is entitled to benefits under part 
A, or enrolled for benefits under part B and who 
meets criteria that the Secretary may establish, in 
consultation with the Director of the Centers for 
Disease Control and Prevention. Such criteria shall 
be similar to the criteria for participation in the Na-
tional Diabetes Program of the Centers for Disease 
Control and Prevention. 
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‘‘(c) ELIGIBLE ENTITIES.—For purposes of this sec-
tion: 
‘‘(1) IN GENERAL.—The term ‘eligible entity’ 
means an entity (such as a provider of services, phy-
sician, or other health care practitioner, a trained 
lifestyle coach, community-based organization, or a 
health insurance or services company) that the Sec-
retary determines— 
‘‘(A) can appropriately furnish diabetes 
prevention services through a diabetes preven-
tion program that satisfies the requirements of 
subsection (b)(1)(B); 
‘‘(B)(i) has entered into a contract with a 
qualified third-party intermediary that meets 
the requirements of subsection (e); or 
‘‘(ii) is a third-party intermediary and 
meets 
the 
requirements 
of 
subsection 
(d)(1)(A)(ii); and 
‘‘(C) is recognized by the Centers for Dis-
ease Control and Prevention under the Diabetes 
Prevention Recognition Program and such rec-
ognition has not expired. 
‘‘(2) TRAINED LIFESTYLE COACH.—The term 
‘trained lifestyle coach’ means an individual who has 
received adequate training, as determined by the 
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Secretary, in the curriculum of the National Diabe-
tes Program of the Centers for Disease Control and 
Prevention to provide diabetes prevention services. 
‘‘(d) QUALIFIED THIRD-PARTY INTERMEDIARY.— 
‘‘(1) IN GENERAL.—For purposes of this sec-
tion, the term ‘qualified third-party intermediary’ 
means a third-party intermediary that has entered 
into a contract with the Secretary to conduct the fol-
lowing activities: 
‘‘(A) MANAGED
NETWORK
OF
ELIGIBLE 
ENTITIES.—The third-party intermediary— 
‘‘(i) has entered into a contract that 
meets the requirements of subsection (e) 
with one or more eligible entities; or 
‘‘(ii) is an eligible entity. 
‘‘(B) TRACKING, PROCESSING, AND
EN-
GAGEMENT.—The 
third-party 
intermediary 
shall— 
‘‘(i) if such intermediary has not en-
tered into a contract described in subpara-
graph (A)(i), furnish diabetes prevention 
services; 
‘‘(ii) track, using adequate informa-
tion technology systems, the outcomes (in-
cluding class attendance and weight loss) 
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of the diabetes prevention services fur-
nished to prediabetic Medicare bene-
ficiaries by such intermediary or by any el-
igible entity with a contract with the inter-
mediary under subparagraph (A)(i); 
‘‘(iii) implement business processes to 
manage workflow (such as eligibility, re-
porting, claims billing, class scheduling, 
and enrollment) related to the provision of 
diabetes prevention services to prediabetic 
Medicare beneficiaries by the intermediary 
or eligible entities with contracts with the 
intermediary under subparagraph (A)(i); 
‘‘(iv) perform various forms of en-
gagement 
with, 
and 
outreach 
to, 
prediabetic Medicare beneficiaries, includ-
ing individuals receiving diabetes preven-
tion services from eligible entities with con-
tracts with the intermediary under sub-
paragraph (A)(i); 
‘‘(v) comply with all program integrity 
requirements established by the Secretary; 
and 
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‘‘(vi) perform such other functions as 
required by the Secretary through the con-
tract under this paragraph. 
‘‘(C) CLAIMS
BILLING.—The third-party 
intermediary will promptly and accurately sub-
mit billing information to the Secretary for dia-
betes 
prevention 
services 
furnished 
to 
a 
prediabetic Medicare beneficiary by an eligible 
entity with which the third-party intermediary 
has a contract under subparagraph (A)(i). 
‘‘(D) OUTREACH TO HEALTH CARE PRO-
VIDERS.—The third-party intermediary provides 
outreach and education for health care pro-
viders (as such term is defined in section 
1855(d)(5)) about the availability of diabetes 
prevention services and the benefits of patient 
participation in such services. 
‘‘(E) REPORTING
ON
SERVICES
PRO-
VIDED.—The third-party intermediary shall re-
port to the Secretary the following information: 
‘‘(i) Information on the participation 
of prediabetic Medicare beneficiaries in the 
diabetes prevention services furnished— 
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‘‘(I) by each eligible entity with 
which such intermediary has a con-
tract under subparagraph (A)(i); and 
‘‘(II) the third-party beneficiary, 
if the third-party intermediary is an 
eligible entity. 
‘‘(ii) Information on the impact of 
such participation on such beneficiaries 
(including weight loss). 
‘‘(iii) Any information required by the 
Secretary for purposes of ensuring that the 
third-party intermediary is conducting the 
oversight required under subsection (e)(5). 
‘‘(F) ORGANIZATIONAL STRUCTURE.—The 
third-party intermediary meets such require-
ments for organizational structure as the Sec-
retary may specify, to ensure that such third- 
party intermediary can meet the requirements 
of this Act. 
‘‘(2) 
TYPES
OF
THIRD-PARTY
INTER-
MEDIARIES.—The term ‘third-party intermediary’ 
may include— 
‘‘(A) an accountable care organization 
under section 1899; 
‘‘(B) a technology company; 
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‘‘(C) a provider of services (as such term 
is defined in section 1861(u)); 
‘‘(D) a health insurance or services com-
pany (including population health or disease 
management companies); 
‘‘(E) a community-based organization or a 
network of community-based organizations; 
‘‘(F) a faith-based organization; or 
‘‘(G) any other organization that the Sec-
retary determines is capable of managing a net-
work of eligible entities and meeting the re-
quirements for a qualified third-party inter-
mediary under paragraph (1). 
‘‘(3) OVERSIGHT.—The Secretary shall monitor 
the third-party intermediaries to prevent fraud and 
abuse in the provision of diabetes prevention services 
to prediabetic Medicare beneficiaries. 
‘‘(e) CONTRACTS BETWEEN ELIGIBLE ENTITIES AND 
THIRD-PARTY INTERMEDIARIES.—A contract between an 
eligible entity and a third-party intermediary meets the 
requirements of this subsection if the contract provides for 
the following: 
‘‘(1) PAYMENT
FOR
SERVICES.—The third- 
party intermediary shall provide payment to the eli-
gible entity for diabetes prevention services fur-
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nished to prediabetic Medicare beneficiaries by such 
entity. 
‘‘(2) ELIGIBILITY
AND
ENROLLMENT.—The 
third-party intermediary shall conduct the following 
activities (unless the contract specifically assigns any 
of these activities to the eligible entity): 
‘‘(A) Determine whether individuals are 
prediabetic Medicare beneficiaries who are eligi-
ble to receive diabetes prevention services pur-
suant to this section. 
‘‘(B) Scheduling and enrollment for diabe-
tes prevention services furnished by the eligible 
entity. 
‘‘(C) Develop and manage a process to as-
sist health care providers (as such term is de-
fined in section 1855(d)(5)) in referring 
prediabetic Medicare beneficiaries to eligible en-
tities for diabetes prevention services. 
‘‘(3) OUTREACH AND CUSTOMER SERVICE FOR 
BENEFICIARIES.—The 
third-party 
intermediary 
shall— 
‘‘(A) use a variety of methods to identify 
individuals who are likely to be prediabetic 
Medicare beneficiaries and inform such bene-
ficiaries of diabetes prevention services offered 
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by the eligible entity (and other eligible entities 
with which such third-party intermediary has a 
contract under this subsection); and 
‘‘(B) provide customer service and support 
for prediabetic Medicare beneficiaries who are 
seeking or receiving diabetes prevention services 
furnished by the eligible entity. 
‘‘(4) PERFORMANCE.—The third-party inter-
mediary shall monitor the performance of the eligible 
entity with respect to diabetes prevention services 
furnished to prediabetic Medicare beneficiaries by 
such entity and ensure that such performance is 
consistent with the requirements of this section. 
‘‘(5) 
OVERSIGHT.—The 
third-party 
inter-
mediary shall monitor the eligible entity to prevent 
fraud and abuse in the provision of diabetes preven-
tion services to prediabetic Medicare beneficiaries. 
‘‘(6) AUDITS.— 
‘‘(A) IN GENERAL.—The third-party inter-
mediary may conduct audits of the eligible enti-
ty to ensure— 
‘‘(i) that such entity— 
‘‘(I) is providing diabetes preven-
tion services that meet the require-
ments, goals, and objectives of the 
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National Diabetes Program of the 
Centers for Disease Control and Pre-
vention; and 
‘‘(II) is complying with the re-
quirements of subsection (g) (related 
to privacy); 
‘‘(ii) that individuals receiving diabe-
tes prevention services for which payment 
is made pursuant to a contract under this 
section to the eligible entity are prediabetic 
Medicare beneficiaries; and 
‘‘(iii) that the claims for payment sub-
mitted by the eligible entity to the third- 
party intermediary are accurate and com-
ply with the requirements of the contract 
under this subsection. 
‘‘(B) ACCESS.—The eligible entity shall 
provide the third-party intermediary with access 
to information necessary to complete the audits 
under subparagraph (A). 
‘‘(f) PAYMENTS FOR DIABETES PREVENTION PRO-
GRAM SERVICES.— 
‘‘(1) IN GENERAL.—Under the contract under 
subsection (d)(1) the Secretary shall agree to make 
payments to the third-party intermediary for diabe-
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tes prevention services furnished to prediabetic 
Medicare beneficiaries by eligible entities with con-
tracts with such third-party intermediary (or in the 
case of a third-party intermediary that is an eligible 
entity, diabetes prevention services furnished to such 
beneficiaries by such third-party intermediary). 
‘‘(2) AMOUNT OF PAYMENT FOR 2013.—With 
respect to diabetes prevention program services fur-
nished to a prediabetic Medicare beneficiary, the 
amount of payment made under paragraph (1) for 
2013 is the sum of any of the following amounts 
that are applicable to such beneficiary: 
‘‘(A) $100 for the enrollment of such indi-
vidual in a diabetes prevention program that 
meets the requirements, goals, and objectives of 
the National Diabetes Program of the Centers 
for Disease Control and Prevention (including 
use of the curriculum of such program) and is 
provided by an eligible entity with which the 
third-party intermediary has a contract under 
subsection (e) or by the third-party inter-
mediary directly, if the third-party intermediary 
is an eligible entity. 
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‘‘(B) $150 for any such individual who at-
tends at least 4 class sessions, as specified in 
such curriculum. 
‘‘(C) $200 for any such individual who at-
tends at least 9 class sessions (including the 4 
class sessions described in subparagraph (B)), 
as specified in such curriculum. 
‘‘(D) $120 for any such individual who— 
‘‘(i) attends all of the sessions de-
scribed in subparagraphs (B) and (C); and 
‘‘(ii) loses at least 5 percent of the in-
dividual’s total body weight during the 
time period that begins on the date of the 
first such session attended by such indi-
vidual, and ends 60 days after the comple-
tion of the last such session attended by 
such individual. 
‘‘(E) An additional $40 for any individual 
who meets the requirements of subparagraph 
(D)(i) and who loses at least 9 percent of total 
body weight during the time period described in 
subparagraph (D)(ii). 
‘‘(3) PAYMENT AMOUNTS FOR 2014 AND SUBSE-
QUENT
YEARS.—For 2014 and subsequent years, 
with respect to diabetes prevention program services 
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furnished to a prediabetic Medicare beneficiary, the 
amount of payment under this subsection shall be 
the amount payable under this subsection in the pre-
vious year, increased by an appropriate amount, as 
determined by the Secretary, to account for infla-
tion. The amount of such increase shall not be less 
than the percentage change in the Consumer Price 
Index for all urban consumers (U.S. city average) 
for such year. 
‘‘(g) PRIVACY
AND SECURITY REQUIREMENTS.— 
Each eligible entity and third-party intermediary shall, to 
the extent such entity or intermediary handles individually 
identifiable health information related to furnishing diabe-
tes prevention services under this section, be treated as 
a covered entity for purposes of the application of the pro-
visions of (and regulations promulgated under) part C of 
title XI, section 264(c) of the Health Insurance Portability 
and Accountability Act of 1996 (42 U.S.C. 1320d–2 note), 
and subtitle D of title XIII of the American Recovery and 
Reinvestment Act of 2009. 
‘‘(h) NO COST SHARING.—No premium, deductible, 
coinsurance, or other cost-sharing requirement shall apply 
to any diabetes prevention service furnished to a 
prediabetic Medicare beneficiary under this section. 
‘‘(i) EVALUATION AND REPORT TO CONGRESS.— 
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‘‘(1) EVALUATION.—The Secretary shall con-
duct an evaluation on the coverage of diabetes pre-
vention services under this title. Such evaluation 
shall include the analysis of— 
‘‘(A) the impact of the provision of such 
coverage on Medicare beneficiaries, including 
the impact on various populations, such as indi-
viduals who are dual eligible individuals (as 
such term is defined in section 1915(h)(2)(B)), 
and the impact of the provision of such cov-
erage on health disparities; 
‘‘(B) the rate at which physicians refer 
prediabetic Medicare beneficiaries to eligible en-
tities and third-party intermediaries providing 
such diabetes prevention services; 
‘‘(C) the rate at which Medicare bene-
ficiaries access such services and the awareness 
of Medicare beneficiaries of coverage for such 
services under this title; 
‘‘(D) the health outcomes resulting from 
the participation of prediabetic Medicare bene-
ficiaries in diabetes prevention services under 
this title; 
‘‘(E) recommendations for important pro-
gram integrity protections related to the pay-
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ment for diabetes prevention services under this 
title; and 
‘‘(F) other topics determined appropriate 
by the Secretary. 
‘‘(2) REPORT.—Not later than January 1, 
2018, the Secretary shall submit to Congress a re-
port that contains— 
‘‘(A) the results of the evaluation con-
ducted under paragraph (1); and 
‘‘(B) recommendations for any legislative 
or administration actions that the Secretary de-
termines appropriate.’’. 
Æ 
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