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For Medicare Advantage and Part D plans it’s time to think about your Medication Therapy Management program design and submission.  While CMS is not mandating a lot of program changes this year, it appears they will focus more on the quality of how the program is administered.  This next month will be a good time to give some consideration to how your medication management program is managed.  Are there aspects you should “upgrade”?  Do you need more flexibility in you program description to give you some mid-year options for augmenting CMR rates?  Clinical Support Services has reviewed the recently released “CY 2017 Medication Therapy Management Program Guidance and Submission Instructions” and highlighted some of the new or changed items for the CY 2017 program.

  • There is a new component for your CY 2017 submission.  Plan sponsors are required to submit an MTM program attestation signed by the CEO, COO or CFO of your organization in addition to the program submission.   The CY 2017 MTM Program Attestation Deadline is May 18, 2016.  MTM resubmissions due to contract exceptions, change requests, and resubmission requests will require a re-attestation as well.  The user completing the MTM submission and attestations in HPMS must have the authority to attest on behalf of the organizations
  • The current MTM requirements are waived for the PBPs approved to participate in the Enhanced MTM Model and data on participating PBPs must not be reported per the Part D Reporting Requirements under the current MTM program.
  • Beneficiary Opt- out. Chapter 7 of the Prescription Drug Benefit Manual provides guidance on permanent opt out from the MTM program.  A plan’s method for permanently opting a member out of a program will likely be a focus of upcoming CMS audits.
  • Rollover.  CMS recommends that members enrolled in the MTM program in a previous year are automatically re-enrolled for the next program year, however they do not require a rollover.  While rollover is not required it could be a strategy for enhancing CMR rates.
  • Disease Criteria.  Similar to 2016, Part D Sponsors need to set the minimum disease criteria at 2 or 3 chronic conditions and must select at least 5 of the nine core chronic diseases.  In the near future CMS will likely be evaluating the scope and impact of the MAP produced as a result of a CMR.  To enhance the effectiveness of the MTM program plan sponsors may want to assure that their current disease selections respect the distribution of disease in the population.
  • Part D Covered Drugs.  Similar to 2016, eight Part D drugs is the maximum number of drugs a Part D plan sponsor may require as the minimum number of Part D drugs that a beneficiary must be taking for targeted enrollment.  Selecting the number of Part D covered drugs is a critical balancing act – too low a number and you will include members who have no significant drug therapy problems, too high of a number and you eliminate members who might benefit from MTM.  Sponsors may want to assure that the number of Part D covered drugs selected, optimizes member selection with regard to remediable drug therapy problems.
  • Cost Threshold. The MTM program annual cost threshold is updated for 2017 using the annual percentage increase of 11.75%, and the MTM program annual cost threshold is $3,919.  The drug costs used to determine if the total annual cost of a beneficiary’s covered Part D drugs is likely to equal or exceed the specified annual cost threshold for MTM program eligibility include the ingredient cost, dispensing fee, sales tax, and vaccine administration fee, if applicable.
  • Cognitive Impairment of MTM Eligible Members. With an increased focus on identifying beneficiaries with cognitive impairment or otherwise unable to accept the offer to participate, the pharmacist or other qualified provider may perform the CMR with the beneficiary’s prescriber, caregiver, or other authorized individual such as the resident’s health care proxy or legal guardian,  and this needs to be documented.  In the event the program staff are unable to identify another individual who is able to participate in the CMR, a CMR cannot be performed, but sponsors are required to perform TMRs at least quarterly.  Plans should assure that their MTM program is capable of interacting with caregivers and their infrastructure is capable of collecting and housing these data elements.
  • Expanded MTM.  CMS encourages sponsors to expand MTM programs beyond the minimum qualifications.  Sponsors may also offer MTM services to an expanded population of beneficiaries who do not meet the eligibility criteria under §423.153(d).  Many plans have achieved medical and/or pharmacy cost savings by expanding MTM into non-MTM eligible populations.  However, a sponsor who does not include a method for identifying an expanded population in its CMS submission, cannot include evidence of MTM interventions in its year end BLR.
  • Million Hearts.  Sponsors are also encouraged, but not required, to offer MTM services or other interventions to beneficiaries who fill at least one prescription for an anti-hypertensive medication to support the Millions Hearts initiative.
  • Opioids.  Over utilization of opioids continues to be a significant concern, especially in the treatment of patients with chronic non cancer pain. CMS encourages, but does not require, sponsors to also offer MTM services to beneficiaries who meet the sponsor’s internal criteria for retrospective identification of opioid over utilization, but do not otherwise qualify for MTM.  Also, CMS has identified a number of opioid use quality measures which will begin to be introduced into the Medicare program in 2017.  Housing a pilot Opioid medication management program within your MTM program provides the plan with a low overhead option for exploring opioid management techniques.
  • Audits.  Beginning with 2017 audits, CMS will release the next year’s protocols in July 2016 as opposed to late fall. This earlier release date will have an impact on two new audit protocols – Medication Therapy Management (MTM) and Provider Network Adequacy (PNA).  CMS recognizes that in order to release audit protocols in July 2016, it will not have gathered enough information from the MTM and PNA pilot programs to implement these audit protocols for 2017; therefore, CMS will continue piloting these audit protocols in 2017 in an effort to gather enough feedback to facilitate any changes necessary.
  • Drug Related Display measures.  2017 will bring a big change with regard to drug related Display measures.  Plans may want to prepare for assessing and addressing these measures within the context of their medication management programs.    Again, the MTM program provides a perfect “house” for pilot quality measure improvement efforts.  New measures which will be introduced in 2017 include:
    • Medication Reconciliation Post Discharge (Part C)
    • Statin Therapy for Patients with Cardiovascular Disease (Part C)
    • Asthma Measures (Part C)
      Statin Use in Persons with Diabetes (SUPD) (Part D)
    • Please call your account manager to discuss adding one or more of these measures to your MTM program

There is less than a month to prepare your MTM submission.  The CY 2017 MTM program submission deadline is May 2, 2016 for all Part D sponsors.

I would be happy to discuss any of these thoughts in greater detail. Feel free to reach out by phone or e-mail.

Jim Notaro
716.541.0273 x101

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