MTM Module 2: Identifying Patients For MTM Services Flashcards
Patients enrolled in Medicare Part D must meet what in order to have MTM services reimbursed by Medicare?
Specific selection criteria
How patients are targeted for MTM depends much on what?
Arrangements for reimbursement
When a pharmacist provides MTM under Medicare Part D, the services must what?
Follow particular protocols
May be constrained by limited reimbursement
Some pharmacy organizations also provide MTM services for whom?
Employers looking to reduce:
- healthcare costs
- absentee rates among their workforce
For every $1 spent on MTM, how much can the employer save on healthcare costs?
Between $6 and $12
Which care structure has an emphasis on MTM?
The Patient-Centered Medical Home (PCMH)
The criteria for MTM is usually much what in the PCMH and workplace settings than that defined by Medicare Part D?
Broader
What is the age of Medicare Part D patients for Patient Criteria and MTM Structure?
Over 65 generally Medicare eligible
What is the age of non-Medicare Part D patients for Patient Criteria and MTM Structure?
Any age
What is the referral path of Medicare Part D patients for Patient Criteria and MTM Structure?
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
What is the referral path of non-Medicare Part D patients for Patient Criteria and MTM Structure?
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)
What is the referral criteria of Medicare Part D patients for Patient Criteria and MTM Structure?
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
What is the referral criteria of non-Medicare Part D patients for Patient Criteria and MTM Structure?
Single chronic disease management
Multiple chronic disease management
Medication adherence issues
Self-referral for any reason in self-refer model
What is the reimbursement of Medicare Part D patients for Patient Criteria and MTM Structure?
Use of CPT codes:
- 99605
- 99606
- 99607
What is the reimbursement of non-Medicare Part D patients for Patient Criteria and MTM Structure?
Negotiated rates per contract with:
- employee groups
- other groups
Fee for service
What is the MTM Service of Medicare Part D patients for Patient Criteria and MTM Structure?
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
What is the MTM Service of non-Medicare Part D patients for Patient Criteria and MTM Structure?
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
What are Medicare Part D sponsors (or payers)?
Private insurance companies that contract with Medicare to provide drug benefits to Part D enrollees
How are MTM services offered by sponsors?
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
What are the 3 criteria that patients must meet for automatic enrollment (eligibility) in MTM based on Medicare Part D requirements?
A
