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CMS Announces Participants Selected for Part D Enhanced MTM Model

On October 3, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation announced the participants in the Part D Enhanced Medication Therapy Management (Enhanced MTM) model. Six Medicare Part D plan (PDP) sponsors operating a total of 22 Plan Benefit Packages and covering approximately 1.6 million beneficiaries will participate in the first year of the model in five Part D regions.

Beginning Jan. 1, 2017, and lasting five years, CMS believes that the Enhanced MTM model offers “an opportunity and financial incentives for basic stand-alone Part D Prescription Drug Plans (PDPs) in selected regions to offer innovative MTM programs in lieu of the standard CMS MTM model.” Selected PDP sponsors include Blue Cross and Blue Shield of Florida Inc.; Blue Cross and Blue Shield Northern Plains Alliance; CVS Health; Humana Insurance Company; UnitedHealthcare; and WellCare Prescription Insurance Co. Through this model, CMS expects the PDP sponsors to identify and implement “innovative strategies to optimize medication use, improve care coordination and strengthen system linkages.”

The Medicare Part D rules for MTM programs target individuals who have multiple chronic diseases; are taking multiple, covered Part D drugs; and are identified as likely to incur annual costs for covered Part D drugs that exceed certain thresholds. According to CMS, evidence suggests MTM services offered by PDPs have fallen short of their potential, most likely due to misaligned financial incentives and regulatory constraints.

PDP sponsors will be allowed to customize the intensity and types of MTM interventions in their PDPs based on beneficiary risk level and provide innovative measures to reach out to and engage both beneficiaries and prescribers. CMS believes the model will allow PDP sponsors to leverage their core competencies, pharmacy networks, and prescribers “to accurately identify and effectively intervene with beneficiaries whose issues with medication management have caused, or are likely to cause, adverse outcomes and/or significant non-drug program utilization and costs.” Participating PDPs are expected to test new approaches for integrating pharmacists into physician medication management workflows.

The Enhanced MTM model relaxes the MTM regulations or, as described by CMS, “provides regulatory flexibility” and payment incentives for basic stand-alone PDPs, including:

  • Ability to offer different MTM services to individuals based on their level of medication-related risk, with customized interventions to meet specific barriers to improvement;
  • Ability to offer a more expansive set of MTM-related items and services as well as cost sharing reductions to financially needy beneficiaries;
  • Flexibility to experiment with alternative communication strategies to improve beneficiary, pharmacist, and medical provider coordination and engagement;
  • A plan-specific prospective payment to support more extensive MTM interventions outside of a plan’s annual Part D bid and, therefore, will not impact premiums.
  • Opportunity to qualify for increased beneficiary premium subsidy (future years) for plans that achieve a 2% reduction in expended beneficiary fee-for-service expenditures (net of model prospective payments);
  • Ability to request beneficiary-level Parts A and B claims data from CMS to assist with identification and care coordination of at-risk individuals; and
  • New MTM encounter data collection effort to develop MTM-specific code sets to support the Office of Health Information Technology for prescription drug data interoperability.

The model imposes various beneficiary benefits and protections as well, such as limiting the MTM-related items and services and lowering cost sharing to “targeted financially needy beneficiaries” and prohibiting benefit designs or cost sharing that discourage use of medically necessary prescription drugs as a model intervention. Eligible beneficiaries will have an option to opt out of any offered assistance at any time.

CMS intends to monitor the PDPs to ensure compliance and will periodically compare the performance of the PDPs against historical data and non-selected PDPs.


This article was originally published as an email alert by The American Health Lawyers Association (AHLA) Payers, Plans, and Managed Care Practice Group. The content was written by Rosmond J. Dolen and reviewed by David E. Kopans.

To learn more about Rosmond J. Dolen and her practice, please visit her profile.

  • Of Counsel

    Rosmond is a member of the firm's Corporate Services Department and focuses her practice on compliance matters, including insurance regulatory issues, licensing, state mandates, provider network administration and ...

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