For people with Medicare, getting the most out of prescription medications requires using them properly and consistently. Medication Therapy Management (MTM) is a free program offered by Medicare Part D plans to certain members. The goal is to help improve older adults’ 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)
- A face-to-face or telehealth consultation
- A written summary provided by a pharmacist or other qualified health provider (e.g., physician)
- Quarterly follow-ups for ongoing monitoring and assistance
If an enrollee is unable to participate in the CMR, their caregiver or authorized agent may participate on their behalf.
How can MTM programs help people with Medicare?
MTM services can improve medication use and adherence and promote health quality outcomes. For example, they may 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 reduces overall Part D program costs. These 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 for Medication Therapy Management?
Plans have some flexibility to determine which Part D members to target for MTM services. Current federal guidelines require plans to target members who:
- Have multiple chronic conditions (at least three or more of the “core” chronic conditions; see list below)
- Take two to eight Part D-covered drugs
- Are likely to spend more than $5,330 in 2024 in annual out-of-pocket costs for covered Part D drugs
Additionally, plans are encouraged to offer MTM services to members who 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 guidelines, Part D plans can determine their own MTM criteria, such as deciding which chronic conditions they want to focus 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 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 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. With that in mind, 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 Medication Therapy Management programs from their plan, through the annual Medicare & You handbook, and online at the Medicare Plan Finder under “Your Plan Details”.
