Key Takeaways
Medication therapy management (MTM) is a free Medicare Part D program to help people with multiple chronic conditions manage their medications.
MTM is an underutilized benefit, so counselors should help people with Medicare who qualify learn how to take advantage of this program.
Medication Therapy Management (MTM) is a free program offered by Part D plans to certain members to help improve their medication use so they can better manage their chronic conditions (e.g., diabetes, hypertension, asthma) and improve their overall health.
MTM is designed to be patient-centric. It includes an annual comprehensive medication review (CMR), including a face-to-face or telehealth consultation and written summary provided by a pharmacist or other qualified health provider (e.g., physician), and quarterly follow-ups for ongoing monitoring and assistance. In the event the beneficiary is unable to participate in the CMR, the beneficiary’s caregiver or authorized agent may participate on their behalf.
How can MTM programs help?
MTM services can improve medication use and adherence and promote health quality outcomes. For example, MTM can help prevent adverse drug interactions for members taking multiple medications. MTM also offers shared cost savings. Through improved medication use, members may spend less annually on their medications, which in turn saves costs to the overall Part D program. MTM programs also provide opportunities for vulnerable members to ask qualified health care professionals (e.g., pharmacists) questions or share concerns about their medications.
Who is eligible?
Plans have some flexibility to determine which members to target for MTM services. There are three general eligibility requirements:
- Current federal guidelines require Part D plans to target plan members who have multiple chronic conditions (at least two or more of the “core” chronic conditions; see list below), AND
- Are taking multiple Part D drugs (two to eight drugs), AND
- Are likely to spend more than $4,376 in 2021 in annual out-of-pocket costs for covered Part D drugs.
Additionally, plans are encouraged to offer MTM services to beneficiaries that meet plan internal criteria for opioid over-utilization, especially in the treatment of patients with chronic non-cancer pain.
The “core” chronic conditions include (and plans must target at least five of nine core chronic conditions):
- Alzheimer’s Disease
- Bone Disease/Arthritis (e.g., osteoporosis, osteoarthritis, rheumatoid arthritis)
- Chronic Heart Failure
- Diabetes
- Dyslipidemia (abnormal amount of lipids, such as cholesterol or fat, in the blood)
- End-Stage Renal Disease (ESRD)
- Hypertension
- Mental health disorder (e.g., depression, schizophrenia, bipolar disorder, chronic or disabling disorder)
- Respiratory disease (e.g., asthma, chronic obstructive pulmonary disease, or COPD) or chronic lung disorder
Within these eligibility guidelines, Part D plans can select their MTM criteria, such as deciding which chronic conditions they want to focus their MTM on, and how many Part D drugs are required for eligibility (e.g., eight drugs). Your clients will need to check with their Part D plan to find out the specific MTM criteria.
How does someone enroll in medication therapy management?
The Centers for Medicare & Medicaid Services (CMS) requires that all plans automatically enroll plan members who meet their MTM criteria. Auto-enrolled members can decide whether to participate in the MTM program, opt out, or refuse or decline MTM services without having to actually dis-enroll from the MTM program. Members’ participation or non-participation in MTM services does not affect their enrollment in their Part D plan.
How can counselors help clients?
You can help your clients by encouraging them to contact their Part D plan to find out about available MTM services. Many may already be enrolled in their plan’s MTM, but they may not be taking advantage of the services. Plans have flexibility to decide how MTM providers (e.g., pharmacists) will notify members about MTM services, so your clients should check with their plan to find out how they get the initial comprehensive review and/or ongoing follow-up reviews.
With your help, clients can learn more about MTM programs from their plan, through the annual Medicare & You handbook, and online at the Medicare Plan Finder under “Your Plan Details”.
