§ 414.84 - Payment for MDPP services.

§ 414.84 Payment for MDPP services.

Cross Reference

Link to an amendment published at 88 FR 79530, Nov. 16, 2023.

(a) Definitions. In addition to the definitions specified at § 410.79(b) and § 424.205(a) of this chapter, the following definitions apply to this section.

Attendance payment means a payment that is made to an MDPP supplier for furnishing services to an MDPP beneficiary when the MDPP beneficiary attends an MDPP core or core maintenance session. CMS will allow up to 22 sessions (alone or in combination with other codes, not to exceed 22 sessions in a 12- month timeframe).

Bridge payment means a one-time payment to an MDPP supplier for furnishing its first MDPP session to an MDPP beneficiary who has previously received one or more MDPP services from a different MDPP supplier.

Performance goal means an attendance or a weight loss goal that an MDPP beneficiary must achieve during the MDPP services period for an MDPP supplier to be paid a performance payment.

Performance payment means a payment made to an MDPP supplier for furnishing certain MDPP services to an MDPP beneficiary when the MDPP beneficiary achieves the applicable performance goal.

(b) Performance payment. CMS makes one or more types of performance payments to an MDPP supplier as specified in this paragraph (b). Each type of performance payment is made only if the beneficiary achieves the applicable performance goal and . Certain performance goals are allowed only once per MDPP beneficiary and include the performance goals in paragraphs (b)(1)(i) and (b)(2)(i) of this section. A performance payment is made only on an assignment-related basis in accordance with § 424.55 of this chapter, and MDPP suppliers must accept the Medicare allowed charge as payment in full and may not bill or collect from the beneficiary any amount. CMS will make a performance payment only to an MDPP supplier that complies with all applicable enrollment and program requirements and only for MDPP services that are furnished by an eligible coach, on or after his or her coach eligibility start date and, if applicable, before his or her coach eligibility end date. As a condition of payment, the MDPP supplier must report the NPI of the coach who furnished the session on the claim for the MDPP session. The seven two types of performance payments are as follows:

(1) Performance Goal 1: Attends the first core session that initiates the MDPP services periodAchieves the required minimum 5-percent weight loss. CMS makes a performance payment to an MDPP supplier if for an MDPP beneficiary attends the first core session, which initiates the MDPP services period, and that first core session was who achieves the required minimum weight loss as measured in-person during a core session or core maintenance session furnished by that supplier. An MDPP supplier that has been paid this performance payment for an MDPP beneficiary is not eligible to be paid a bridge payment described in paragraph (c) of this section for that MDPP beneficiary. The amount of this performance payment is determined as follows:

(i) For a first core session or core maintenance session, as applicable, furnished January 1, 2022, 2024 through December 31, 2022 2024 the amount is $35$145.

(ii) For a first core session or core maintenance session, as applicable, furnished during a calendar year subsequent to CY 20222018. The performance payment amount specified in this paragraph for the prior year, adjusted as specified in paragraph (d) of this section.

(

2) Performance Goal 2: Attends four core sessions. CMS makes a performance payment to an MDPP supplier if an MDPP beneficiary achieves attendance at the fourth core session upon attendance at a core session furnished by that supplier. The amount of this performance payment is determined as follows:

(i) For the fourth core session furnished January 1, 2022, through December 31, 2022 the amount is $105.

(ii) For a fourth core session furnished during a calendar year subsequent to CY 2022. The performance payment amount specified in this paragraph for the prior year, adjusted as specified in paragraph (d) of this section.

(3) Performance Goal 3: Attends nine core sessions. CMS makes a performance payment to an MDPP supplier if an MDPP beneficiary achieves attendance at the ninth core session upon attendance at a core session furnished by that supplier. The amount of this performance payment is determined as follows:

(i) For the ninth core session furnished January 1, 2022, through December 31, 2022 the amount is $175.

(ii) For a ninth core session furnished during a calendar year subsequent to CY 2022. The performance payment amount specified in this paragraph for the prior year, adjusted as specified in paragraph (d) of this section.

(4) Performance Goal 4: Attends two core maintenance sessions during a core maintenance session interval

iii) If the beneficiary maintains the required minimum weight loss during a core maintenance session, as measured in-person or described in § 410.79(e)(3)(iii) the amount is $8.

(2) Performance Goal 2: Achieves 9-percent weight loss. CMS makes a performance payment to an MDPP supplier

if

for an MDPP beneficiary

attends two core maintenance sessions in a core maintenance session interval and achieves attendance at the second core maintenance session upon attendance at a core

who achieves at least a 9-percent weight loss as measured in-person during a core session, core maintenance session, or ongoing maintenance session furnished by that supplier.

CMS makes this performance payment to an MDPP supplier only once per MDPP beneficiary per core maintenance session interval.

The amount of this performance payment is determined as follows:

(i)

If the beneficiary also achieves or maintains the required minimum weight loss as measured in-person during

For a core

maintenance

session

furnished during the applicable

or core maintenance session

interval: (A) For a second core maintenance session

, as applicable, furnished January 1,

2022,

2024 through December 31,

2022 the amount is $93. (B

2024. $25.

(ii) For a

second

core

maintenance

session

furnished during a calendar year subsequent to CY 2022. The performance payment amount specified in this paragraph for the prior year, adjusted as specified in paragraph (d) of this section. (ii) If the beneficiary does not achieve

or

maintain the required minimum weight loss as measured in-person during a

core maintenance session

furnished during the applicable core maintenance session interval:

(A) For a second core maintenance session January 1, 2022, through December 31, 2022 the amount is $70.

(B) For a second core maintenance session

, as applicable, furnished during a calendar year subsequent to CY

2022

2018. The performance payment amount specified in this paragraph

for the prior year

, adjusted as specified in paragraph (d) of this section.

(

5) Performance Goal 5: Attends two ongoing maintenance sessions and maintains the required minimum weight loss during an ongoing maintenance session interval. For an MDPP beneficiary who attends his or her first core session on or before December 31, 2021, CMS makes a performance

c) Attendance payment: Attends a core session or core maintenance session. CMS makes a payment to an MDPP supplier if an MDPP beneficiary attends

two ongoing maintenance sessions during an ongoing maintenance session interval, achieves attendance at that second ongoing maintenance session upon attendance at an ongoing maintenance session furnished by that supplier, and achieves or maintains the required minimum weight loss as measured in-person during an ongoing maintenance session furnished during the applicable ongoing maintenance session interval. CMS makes this performance payment to an MDPP supplier only once per MDPP beneficiary per ongoing maintenance session interval. The amount of this performance payment is determined as follows:

(i) For a second ongoing maintenance session furnished in interval 1 (months 13–15 of the MDPP services period), January 1, 2022, through December 31, 2022, the amount is $52.

(ii) For a second ongoing maintenance session furnished in interval 2 (months 16–18 of the MDPP services period), January 1, 2022, through December 31, 2022, the amount is $52.

(iii) For a second ongoing maintenance session furnished in interval 3 (months 19–21 of the MDPP services period), January 1, 2022, through December 31, 2022, the amount is $53.

(iv) For a second ongoing maintenance session furnished in interval 4 (months 22–24 of the MDPP services period), January 1, 2022, through December 31, 2022 the amount is $53.

(v) For a second ongoing maintenance session furnished during a subsequent year. The performance payment amount specified in this paragraph, adjusted as specified in paragraph (d) of this section.

(6) Performance Goal 6: Achieves the required minimum weight loss. CMS makes a performance payment to an MDPP supplier for an MDPP beneficiary who achieves the required minimum weight loss as measured in-person during a core session or core maintenance session furnished by that supplier. The amount of this performance payment is determined as follows:

(i) For a core session or core maintenance session, as applicable, furnished January 1, 2022, through December 31, 2022, the amount is $169.

(ii) For a core session or core maintenance session, as applicable, furnished during a calendar year subsequent to CY 2018. The performance payment amount specified in this paragraph for the prior year, adjusted as specified in paragraph (d) of this section.

(7) Performance Goal 7: Achieves 9-percent weight loss. CMS makes a performance payment to an MDPP supplier for an MDPP beneficiary who achieves at least a 9-percent weight loss as measured in-person during a core session, core maintenance session, or ongoing maintenance session furnished by that supplier. The amount of this performance

a core session or core maintenance session. An attendance payment is made only on an assignment-related basis in accordance with § 424.55 of this chapter, and MDPP suppliers must accept the Medicare allowed charge as payment in full and may not bill or collect from the beneficiary any amount. CMS will make an attendance payment only to an MDPP supplier that complies with all applicable enrollment and program requirements and only for MDPP services that are furnished by an eligible coach, on or after his or her coach eligibility start date and, if applicable, before his or her coach eligibility end date. As a condition of payment, the MDPP supplier must report the NPI of the coach who furnished the session on the claim for the MDPP session.

(1) The first core session attended, which initiates the MDPP services period, and that first core session was furnished by that supplier.

(2) For the Extended flexibilities period described in § 410.79(e)(2)(iii), the distance learning HCPCS G-code applies for any Set of MDPP services that are delivered by distance learning, as described in § 410.79(b).

(3) Medicare pays for up to 22 sessions in a 12-month period. The amount of this payment is determined as follows:

(i) For a core session or core maintenance session

, as applicable,

furnished January 1,

2022,

2024 through December 31,

2022, the amount is $35.

(ii) For a core session or core maintenance session, as applicable, furnished during a calendar year subsequent to CY 2018. The performance payment amount specified in this paragraph, adjusted as specified in paragraph (d) of this section.

(c)

2024. $25.

(ii) [Reserved]

(d) Bridge payment. CMS makes a bridge payment to an MDPP supplier only for a core session or core maintenance session furnished to an MDPP beneficiary who has previously received MDPP services from a different MDPP supplier. An MDPP supplier that has previously been paid either a bridge payment or a performance payment for an MDPP beneficiary is not eligible to be paid a bridge payment for that beneficiary. A bridge payment is made only on an assignment-related basis in accordance with § 424.55 of this subchapter, and MDPP suppliers must accept the Medicare allowed charge as payment in full and may not bill or collect from the beneficiary any amount. CMS will make a bridge payment only to an MDPP supplier that complies with all applicable enrollment and program requirements, and only for MDPP services furnished by an eligible coach, on or after his or her coach eligibility start date and, if applicable, before his or her coach eligibility end date. As a condition of payment, the MDPP supplier must report the NPI of the coach who furnished the session on the claim for the MDPP session. The amount of the bridge payment is determined as follows:

(1) For core session or core maintenance session, as applicable, furnished January 1,

2022,

2024 through December 31,

2022,

2024 the amount is

$35

$25.

(2) For core session and core maintenance session, as applicable, furnished during a calendar year subsequent to CY 2022. The bridge payment amount specified in this paragraph, adjusted as specified in paragraph (d) of this section.

(

d

e) Updating performance payments, attendance payments, and the bridge payment. The performance payments, attendance payments, and bridge payment will be adjusted each calendar year by the percent change in the Consumer Price Index for All Urban Consumers (CPI–U) (U.S. city average) for the 12-month period ending June 30th of the year preceding the update year. The percent change update will be calculated based on the level of precision of the index as published by the Bureau of Labor Statistics and applied based on one decimal place of precision. The annual MDPP services payment update will be published by CMS transmittal.

[82 FR 53360, Nov. 15, 2017, as amended at 86 FR 65668, Nov. 19, 2021; 86 FR 73159, Dec. 27, 2021; 88 FR 79530, Nov. 16, 2023]