Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-71 - National Diabetes Prevention Program Service › Appendix - Appendix

Current through 2024-29, July 17, 2024
As set forth in Section
						71.03-2(A),
						member eligibility for services under this section is based, in part, on the
						member meeting the participant eligibility requirements in the DPRP Standards.
						As of the legal effective date of this rule, the following are the DPRP's
						participant eligibility requirements:
A. All of a program's participants must be 18 years of
						age or older. The program is intended for adults at high risk of developing
						type 2 diabetes.
B. All of a program's participants must have a body mass
						index (BMI) of [GREATOR THAN OR EQUAL TO] 25 kg/m2
						([GREATOR THAN OR EQUAL TO] 23 kg/m2, if Asian
						American).
C. All of a program's participants must be considered
						eligible based on either:
1. A blood test result within one year of participant
						enrollment. Blood test results may be self-reported for CDC recognition
						purposes. Participants enrolled in the Medicare Diabetes Prevention Program
						(MDPP) cannot self-report blood test results; lab results must be provided.
						Blood test results must meet one of the following specifications:
a. Fasting glucose of 100 to 125 mg/dl (Centers for
						Medicare and Medicaid Services (CMS) eligibility requirement for MDPP
						participants is 110 to 125 mg/dl);
b. Plasma glucose of 140 to 199 mg/dl measured 2 hours
						after a 75 gm glucose load;
c. HbA1c of 5.7 to 6.4; or
d. Clinically diagnosed gestational diabetes mellitus
						(GDM) during a previous pregnancy (allowed for CDC recognition and may be
						self-reported; not allowed for MDPP participants); or
2. A positive screening for prediabetes based on the
						Prediabetes Risk Test online at:
https://www.cdc.gov/prediabetes/takethetest/
.
						Note: The risk test is not an option for eligibility for MDPP
						participants.
D. Participants cannot have a previous diagnosis of type
						1 or type 2 diabetes prior to enrollment.
E. Participants cannot be pregnant at time of
						enrollment.
F. A health care professional may refer potential
						participants to the program, but a referral is not required for participation
						in a CDC-recognized program.*
Recognized organizations can retain participants if
						either of the following situations occur:
A. Participants develop type 2 diabetes while in the
						program. These participants should be referred to their primary care providers
						for referrals to American Diabetes Association (ADA)-recognized or Association
						of Diabetes Care and Education Specialists (ADCES)- accredited diabetes
						self-management education and support (DSMES) services and other resources such
						as Medical Nutrition Therapy (MNT) as appropriate. See Submitting Evaluation
						Data to the DPRP section for details on how to code these participants to
						ensure they are not considered eligible in the evaluation.
B. Participants become pregnant while in the program. The
						National DPP LCP emphasizes weight loss and is not appropriate for women who
						are currently pregnant. Participants who become pregnant may continue at the
						discretion of their health care providers and the CDC-recognized organization.
						See Submitting Evaluation Data to the DPRP section for details on how to code
						these participants to ensure they are not considered eligible in the
						evaluation.
*Pursuant to Section
						71.03-2(B),
						MaineCare requires a referral from a physician or other qualified provider
						acting within his or her scope of practice for a member to participate in the
						National DPP LCP.