MTM Module 2: Identifying Patients For MTM Services

Question 1

Patients enrolled in Medicare Part D must meet what in order to have MTM services reimbursed by Medicare?

Answer 1

Specific selection criteria

Question 2

How patients are targeted for MTM depends much on what?

Answer 2

Arrangements for reimbursement

Question 3

When a pharmacist provides MTM under Medicare Part D, the services must what?

Answer 3

Follow particular protocols

May be constrained by limited reimbursement

Question 4

Some pharmacy organizations also provide MTM services for whom?

Answer 4

Employers looking to reduce:

• healthcare costs
• absentee rates among their workforce

Question 5

For every $1 spent on MTM, how much can the employer save on healthcare costs?

Answer 5

Between $6 and $12

Question 6

Which care structure has an emphasis on MTM?

Answer 6

The Patient-Centered Medical Home (PCMH)

Question 7

The criteria for MTM is usually much what in the PCMH and workplace settings than that defined by Medicare Part D?

Answer 7

Broader

Question 8

What is the age of Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 8

Over 65 generally Medicare eligible

Question 9

What is the age of non-Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 9

Any age

Question 10

What is the referral path of Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 10

Referred through Medicare Part D sponsor to:

• Pharmacy benefit managers (PBMs)
• Contracted MTM provider (Outcomes MTM)
• Contracted community provider

Long-term Care residents are included

CMS generally views long-term care residents as community dwellers

• not inpatients
• are eligible for MTM in addition to the CMS-mandated monthly consultant pharmacist review

Question 11

What is the referral path of non-Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 11

Direct marketing

Employer contracts

PBMs for non-Med D insured

Contracts with pharmacies

Patient self-referral

Physician referrals

Pharmacy referrals
-from non-MTM providing pharmacies

Hospitals
Care transition organizations
Accountable care organization (ACO) affiliates
Patient centered medical homes (PCMH)

Question 12

What is the referral criteria of Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 12

Enrollees meeting specified targeting criteria per CMS requirements:

• annual drug costs greater than $4,044 (2019)
• minimum number of drugs (2-8)
• target disease states
• multiple chronic disease states

Expanded criteria

Enrollees meeting other plan-specific criteria
-agreed upon at the sponsor’s application to CMS and annual review

Question 13

What is the referral criteria of non-Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 13

Single chronic disease management

Multiple chronic disease management

Medication adherence issues

Self-referral for any reason in self-refer model

Question 14

What is the reimbursement of Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 14

Use of CPT codes:

• 99605
• 99606
• 99607

Question 15

What is the reimbursement of non-Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 15

Negotiated rates per contract with:

• employee groups
• other groups

Fee for service

Question 16

What is the MTM Service of Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 16

Must provide written summary in: Comprehensive Medication Review (CMR) format:

1: Cover Letter
2: Personal Medication List (PML)
3: Medication Action Plan (MAP)

Discuss concerns with drug therapy
Summary of purpose and instructions for medications
Review medications
-RX
-OTC
-supplements
Engage beneficiaries in management of drug therapy

Core elements of MTM model

May include other value-added services
-reimbursement may be a constraint

Question 17

What is the MTM Service of non-Medicare Part D patients for Patient Criteria and MTM Structure?

Answer 17

CMS MTM CMR recommended

Core elements of MTM model

Additional services:

• adherence support
• outside consultation with other healthcare providers
• continuity of care / care transition services
• provider protocols

Question 18

What are Medicare Part D sponsors (or payers)?

Answer 18

Private insurance companies that contract with Medicare to provide drug benefits to Part D enrollees

Question 19

How are MTM services offered by sponsors?

Answer 19

Sponsors may offer their own MTM services
-often provided via phone

May contract with pharmacies or specialized MTM organizations to provide phone or in-person MTM services
-sponsors will refer candidates to the pharmacy setting for MTM, based on the Medicare Part D criteria outlined

Question 20

What are the 3 criteria that patients must meet for automatic enrollment (eligibility) in MTM based on Medicare Part D requirements?

Answer 20

A