It’s That Time Again: MTM Program Submission
The 2024 Medication Therapy Management Program (MTMP) submission date is June 7 and the MTMP attestations are due June 21. The 2024 annual MTM program cost threshold is $5,330 ($444.16 per month).
The health plan website should have a separate page or section describing their MTM program using a font that is easily read and information that is easily understood.
The website information should include:
What the MTMP is, the purpose of the program, eligibility requirements and benefits of participating
How members can obtain the MTMP documents including the medication list
That the service is free to members
A summary of the program services
How the member will be notified of their eligibility and enrolled into the program
Descriptions of the Comprehensive Medication Review (CMR) and TMRs, how the reviews are done and documents delivered, and how much of the member’s time will be required
That it is advised but not mandatory - how to contact the plan for more information on the MTMP and that MTMP services are not considered a benefit
MTMP and Case Management
Since the inception of the program, MTMP was intended to partner with case management to ensure that medication utilization was medically necessary and cost effective. In addition to the provision of a medication list, potential medication problems were to be communicated to the member’s prescriber for resolution. It is not clear that any feedback loop or formal follow-up to assess the uptake of recommendations for change has ever been formally developed in MTM programs. Until we have the integration of MTM into case management, it is difficult to assess whether an MTM program is successful or not. The awarding of stars for the completion of the CMR is not a report card for the entire program.
CMS proposed significant changes for the MTM program in the Final Rule published 12.27.2022 which have not currently been approved.
“After an extensive analysis to identify potential disparities in MTM program eligibility and access, CMS is proposing changes to the MTM targeting criteria at § 423.153(d)(2) to promote consistent, equitable, and expanded access to MTM services. The combination of proposed changes includes: (1) requiring plan sponsors to target all core chronic diseases identified by CMS, codifying the current 9 core chronic diseases  in regulation, and adding HIV/AIDS for a total of 10 core chronic diseases; (2) lowering the maximum number of covered Part D drugs a sponsor may require from 8 to 5 drugs and requiring sponsors to include all Part D maintenance drugs in their targeting criteria; and (3) revising the methodology for calculating the cost threshold ($4,935 in 2023) to be commensurate with the average annual cost of 5 generic drugs ($1,004 in 2020). The proposed changes would reduce eligibility gaps so that more Part D enrollees with complex drug regimens at increased risk of medication therapy problems would be eligible for MTM services. They would also better align MTM eligibility criteria with statutory goals to reduce medication errors and optimize therapeutic outcomes for beneficiaries with multiple chronic conditions and taking multiple Part D drugs, while maintaining a reasonable cost criterion. In this rule, we are also proposing to codify longstanding CMS guidance that a beneficiary is unable to accept an offer to participate in the comprehensive medication review (CMR) only when the beneficiary is cognitively impaired and cannot make decisions regarding their medical needs. We are also proposing other technical changes to clarify that the CMR must include an interactive consultation that is conducted in real-time, regardless of whether it is done in person or via telehealth.”
CMS has been concerned that beneficiary enrollment in MTMPs has declined; health plans have instituted the most restrictive criteria for eligibility and Part D members with complex medication regimens who would benefit most from MTMP services do not meet the cost threshold and are therefore not eligible for the MTMP. If the MTMP program changes outlined by CMS are adopted, it has been estimated that the number of Part D enrollees eligible for MTM services would increase from 4.5 million to 11 million. Even if the draft proposals are not implemented for 2024, it is clear that CMS has plans for change in the MTMP to allow more member participation. It may be prudent for health plans to revise MTMP criteria to be less restrictive and to enroll members with complex medication regimens.