The Final Rule released on April 4th detailed updates to criteria utilized for MTM Program enrollment effective January 1, 2025. The finalized changes will result in a smaller-than-predicted increase in MTM eligibility as CMS only proceeded with some of the criteria changes proposed. In this post, Outcomes compiles the details, responds to frequently asked questions, provides links to related content, and addresses our readiness for these changes.
Q: Where can I find the Final Rule?
A: Final Rule: https://www.federalregister.gov/public-inspection/2024-07105/medicare-program-medicare-advantage-and-the-medicare-prescription-drug-benefit-program-for-contract
Q: What did CMS finalize in the Final Rule related to MTM?
A: The Final Rule included a few MTM-related provisions, first with MTM eligibility criteria changes and second with the transition of the CMR Completion Rate measure to Display. All these changes will take effect January 1, 2025.
The MTMP eligibility changes include:
- All core chronic disease states must be included in the targeting criteria, including the addition of HIV
- All Part D maintenance drugs are to be utilized to calculate the drug count
- Drug Cost threshold will be reduced to the average cost of 8 generic drugs ($1623)
- Note: CMS did not include the decrease in the max # of Part D drugs from 8 to 5 in the Final Rule changes for CY2025
CMS estimates MTM enrollees will increase from 7% to 13% eligibility rate which is lower than what was originally proposed. Because the finalized criteria changes will result in a substantive change, CMS has moved the CMR Completion Rate measure to the display for CY25 and CY26 measurement years. The measure will return as a new measure to the Star Ratings program no earlier than the 2027 measurement year for 2029 Star Ratings.
Q: What does it mean for a measure to be on the display page?
A: Data for display page measures will continue to be collected and monitored, and poor scores on display measures are subject to compliance actions by CMS. – CMS Display Measure Technical Notes
Q: What is Outcomes opinion of the Final Rule?
A: Outcomes supports expansion of MTMP criteria to increase the scope of population that could be positively impacted by MTM services. These changes are a step in the right direction to address health equity concerns that we have expressed with the historical eligibility criteria. However, the most substantive change in reducing max drug count from 8 to 5 was not adopted by CMS, so we do not anticipate seeing as significant an increase in eligibility had the entire set of proposed changes been adopted. Given the expected change in eligibility is not as drastic, Outcomes has concerns with the movement of the CMR Completion Rate measure to the display page for 2025 and 2026.
Outcomes is prepared to support plans and partners in the required criteria adjustments as those fit within our existing targeting capabilities. With our scalable platform and network delivery channel, Outcomes is uniquely positioned to manage the increased need for MTM service delivery. We acknowledge plans will be assessing the impact of these changes on their budget, and we are excited to partner to deliver desired performance in a cost-effective manner while also surfacing the value of expanded MTM access through other drivers beyond CMR completion rate. In addition to continued support of MTM program administration, Outcomes is also prepared to support plans and partners to improve performance on other quality measures such as adherence, polypharmacy, transitions of care and SDOH screening.
Q: When does the Final Rule become effective?
A: January 1, 2025
Q: What impact will this have on the total enrollment for MTM program?
A: CMS previously estimated a 2-3x increase in member eligibility for MTMP, but given the drug count criteria was not modified in the final ruling, the increase in membership will be less significant. Outcomes can partner with plans to calculate how criteria changes will impact their MTMP-eligible population for 2025.
Q: What impact will the proposed identification criteria have on MTM service participation?
A: Outcomes is optimistic that beneficiaries not previously eligible for MTM will be interested in the opportunity to review their medications with a pharmacist, identify any potential related problems, and look for opportunities to optimize their medication regimen. While we have concerns that the drug count of 8 will still prevent the program from reaching patients most vulnerable to medication non-adherence, we look forward to helping plans engage members not previously reached by the MTM program through our vast network of community pharmacists. Providing more patients with the opportunity to review their medications with their personal pharmacist will allow plans to address not only medication-related needs but also social risks and barriers to care access, critical for plan performance in today’s landscape.
Q: Does Outcomes have any concerns with meeting or using the new MTM program targeting criteria?
A: The criteria modifications fit within Outcomes existing identification capabilities. We are eager to work with plans to modify and design targeting strategies within the new and expanded criteria framework that helps them drive and meet their strategic priorities.
Q: How is Outcomes planning/preparing for the expected volume increase with the CMS Final Rule?
A: Historical precedent has continued to show that more opportunities available to the Outcomes network result in increased performance. The CMS Final Rule is igniting conversations with our network about increased participation and engagement to prepare for growth in the population of beneficiaries eligible for MTM services. With the largest network of MTM providers in the country, we are uniquely prepared to scale to meet an increased need for MTM service delivery.
Q: How will Outcomes redesign programs to meet Star Rating targets while the CMR Completion Rate Star measure is on display for 2 years?
A: The sweeping changes to Star Ratings codified in the rule present a whole new landscape for plans to navigate. With the Health Equity Index replacing the Reward Factor, plans will need to leverage the powerful relationship and impact of a trusted partner like Outcomes. No other partner provides access to a vast network of community pharmacists, in-home providers, and clinicians necessary to maintain 4+ star ratings. Outcomes sees this as a great opportunity to make sure the focus of the CMR and TMR interventions isn’t just a completion checkmark. These services bear a meaningful impact on many measures bearing heavy impact for plans to be able to maintain their desired ratings in a re-leveled playing field.
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