Medicaid Coverage for Diabetes Expanded

The Illinois Department of Public Health (IDPH) and Illinois Department of Healthcare and Family Services (HFS) today announced the Diabetes Prevention Program and the Diabetes Self-Management Education and Support Program, nationally-recognized diabetes prevention and management programs, will be newly eligible for Medicaid coverage in Illinois, upon final federal approval.

Diabetes is the seventh leading cause of death in Illinois.  An estimated over 1 million adults in Illinois have Type 2 diabetes, and a significant share of those individuals may not know it. It is estimated that many more Illinoisans have prediabetes, a condition where blood-sugar levels are high, but not high enough to warrant a Type 2 diabetes diagnosis.  The federal Centers for Disease Control and Prevention (CDC) estimates that 34% of the adult population in the U.S. currently has prediabetes, yet 80% of people are unaware of that diagnosis.

“Diabetes is both chronic and costly,” said Illinois Department of Healthcare and Family Services Director Theresa Eagleson. “Targeting prevention and stopping the progression for those most at risk of developing diabetes is at the heart of these programs. We know that rates of diabetes are higher within communities of color, and this initiative reflects HFS’ focus on making equity central to what we do. Providing this coverage allows us to meet our customers where they are on their healthcare journey and is key to putting many eligible Illinoisans on a path to a healthier future.”

The Diabetes Prevention Program (DPP) involves a yearlong, evidence-based lifestyle change aimed at reducing the risk of adults with prediabetes progressing to Type 2 diabetes. Developed by the CDC, the program’s Diabetes Prevention Lifestyle Change curriculum focuses on increased physical activity, healthy eating, and stress management.

CDC-recognized DPP organizations can enroll as Illinois Medicaid providers to deliver the program to eligible participants by administering services during regular sessions over the course of the year, including dietary and nutritional counseling, fitness assessments and educational sessions on how to prevent Type 2 diabetes.

A CDC-conducted evaluation of the DPP has found a 58% reduction in the risk of developing Type 2 diabetes.

To be eligible to enroll in the DPP program, individuals must be aged 18 to 64, be enrolled in the Illinois Medicaid program, have a Body Mass Index (BMI) that exceeds a certain level and either have elevated blood-glucose levels or a history of gestational diabetes mellitus. Enrollees who were previously diagnosed with Type 1 or Type 2 diabetes or who are currently pregnant are not eligible to participate in the program.

“Diabetes is a serious, chronic condition that can lead to heart disease, stroke, blindness, kidney failure, leg amputation, and even early death,” said Illinois Department of Public Health Director Dr. Ngozi Ezike. “The rate of new cases of diabetes among children and adolescents continues to grow and diabetes-related complications are increasing among those ages 18-64 years.  But with improved eating, more physical activity, and behavioral supports, we can slow or stop the growth.  And now with Medicaid coverage for diabetes prevention and management programs in Illinois, our goal is to get more people the help and support they need to live healthier lives.”

Health care providers and Illinois Medicaid Managed Care Organizations (MCO) are able to refer participants to the program, but a referral is not required to participate. Eligible enrollees can directly enroll with a fee-for-service or an MCO’s in-network, CDC-recognized DPP provider by supplying blood test results from within the past year indicating a diagnosis of prediabetes or gestational diabetes mellitus.

The second program, Diabetes Self-Management Education and Support (DSMES) provides services to prevent the progression of diabetes, thereby prolonging the life of the participants and promoting a healthier lifestyle.

DSMES must be recommended by a medical provider or a practitioner licensed to work with individuals to halt the progression of diabetes. Services may include counseling on long-term dietary changes and nutrition, increased physical activities, skills for diabetes self-care and behavioral strategies for weight control. Services can be offered via telehealth, in-home or in a health clinic or outpatient facility.

In order to be eligible for DSMES, individuals must be aged 18 to 64 and have a documented diagnosis based on certain criteria of Type 1, Type 2, or gestational diabetes. Participants must also receive a written referral from a qualified provider, which could be a physician, physician assistant, nurse practitioner or advanced practice nurse.

Participants are eligible to receive up to 18 hours of services during a 12-month period.

HFS and IDPH are collaborating with the Illinois Public Health Institute, with support from federal partners the CDC and the National Association of Chronic Disease Directors, on a Medicaid State Plan Amendment to add coverage for these two programs.

Combined, the DPP and DSMES programs are estimated to cost under $1 million the first year they are offered in Illinois. The state’s share of the cost is estimated at roughly $300,000 for the first year, and the remainder will be covered by federal funding.

For services provided under the fee-for-service delivery setting, HFS has requested an effective date of Aug. 1, and services may start to be administered upon approval by federal Centers for Medicare & Medicaid Services.

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