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MTM & Star Ratings: Preparing Your Health Plan for Potential Changes

MTM & Star Ratings: Preparing Your Health Plan for Potential Changes

In early April 2023, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Medicare Advantage and Part D Final Rule. Most of us expected it to finalize several significant changes related to the Part D Medication Therapy Management (MTM) Program, most notably the eligibility criteria. These revised eligibility requirements, outlined in the 2024 proposed rule, would dramatically alter the MTM Program and the delivery of MTM services, including substantially increasing Part D population enrollment in MTM from 4.5 million members (9% of all members) to 11 million members (23% of all members). This provision also happens to be the biggest proposed cost driver over the next 10 years.  

Unfortunately, we will all have to wait a little bit longer to find out what CMS decides related to MTM. After reading all 724 pages of the final rule, it was evident that MTM was notably missing. In fact, there were several provisions that weren't finalized, and we found out that we get to look forward to a second final rule!  

"CMS intends to address all of the remaining proposals from the December 2022 proposed rule in subsequent rulemaking. Therefore, CMS plans to make provisions adopted in the subsequent, second final rule applicable to coverage beginning no earlier than January 1, 2025. 

While we wait in anticipation, let's dive into the significant proposed changes concerning MTM and talk about what you can do to prepare for them now.  

Medication Therapy Management Overview 

According to CMS, a Part D sponsor must have established an MTM program that delivers the following: 

  • ensures optimum therapeutic outcomes for targeted beneficiaries through improved medication use; 
  • reduces the risk of adverse events; 
  • is developed in cooperation with licensed and practicing pharmacists and physicians; 
  • describes the resources and time required to implement the MTM Program if using outside personnel and establishes the fees for pharmacists or others; 
  • may be furnished by pharmacists or other qualified providers; 
  • may distinguish between services in ambulatory and institutional settings; and 
  • is coordinated with any care management plan established for a targeted individual under a chronic care improvement program (CCIP). 

CMS goes on to note, "Each Part D Sponsor is required to incorporate a medication therapy management (MTM) program into their plans' benefit structure. Annually, sponsors must submit an MTM program description to CMS for review and approval. A CMS-approved MTM program is one of several required elements in the development of a sponsor's bid for the upcoming contract year." 

Part D sponsors are aware that back in 2016, CMS added a Stars measure called "Medication Therapy Management Program Completion Rate for Comprehensive Medication Review (CMR)." This measure requires your Medicare members (18-plus years old) who are enrolled in the MTM Program for at least 60 days to receive a CMR at any time in the reporting period.  

You'll want to pay close attention to how the program is likely to change and how these changes will require you to revise your strategy for delivering MTM services and conducting CMR appropriately for a growing eligible member population. 

3 Key Medication Therapy Management Changes to Know 

The following is a summary of three of the biggest medication therapy management requirement changes included in the December 2022 proposed rule.

1. Plans will need to target all core chronic conditions, including HIV/AIDS.
Part D sponsors may require no more than three chronic diseases or can elect to cover MTM for any set of chronic diseases but must include
at least five of the core chronic conditions below for targeted enrollment. However, the proposed rule calls for expanding this list to include HIV/AIDS, for a total of 10 core chronic conditions and all 10 core chronic conditions must be targeted. These are as follows:

  • Alzheimer's disease 
  • Bone disease/arthritis 
  • Congestive heart failure 
  • Diabetes 
  • Dyslipidemia 
  • End-stage renal disease (ESRD) 
  • Hypertension 
  • Mental health 
  • Respiratory disease 

2. The qualifying number of Part D drugs to enroll in MTM is decreasing.
Part D sponsors cannot require that members are taking more than eight Part D drugs to qualify for MTM services. CMS proposes lowering this requirement to five Part D drugs and including all Part D maintenance drugs. 

3. The annual cost threshold will be lowered.
The biggest driver of increased eligibility is a lowered cost threshold. For 2023, this figure is nearly $5,000 ($4,935). CMS wants to lower the cost to the average of five generic drugs, given the increased utilization and lower cost of generics. Using 2020 prescription drug event data, this figure is $1,004, or close to $4,000 lower than the current annual cost threshold.

Preparing for the Expansion of Medication Therapy Management 

When CMS developed the MTM Program, it expected 25% of the Part D population would be eligible. However, that number has declined to only 8% as of 2020. The changes outlined in the 2024 proposed rule represent the agency's efforts to meet that eligibility expectation.  

These proposed changes are significant, and health plans with MTM programs must begin working to determine what will be required to effectively and appropriately reach out to and support an increasing volume of qualified members. Failure to do so could lead to declines in Medicare Star ratings and member satisfaction. 

Here are some critical steps health plans should take to help reshape their MTM strategy to account for the expanding program. 

Determine the impact 

"What do these changes mean to us?" This is the biggest question health plans must answer. Whether a health plan uses an external vendor for MTM services (more than 90% do) or provides services via internal staff, health plans should evaluate how the new requirements will affect their membership and service delivery. This includes the capacity to support what could likely be a significant increase in the number of eligible members and the ability to at least maintain or hopefully improve performance and member experience. 

Crunch the numbers 

To effectively understand the impact, you will need to estimate your health plan's potential increased eligibility for MTM based on the proposed changes. Work with your data analytics team to determine this figure, then be prepared to rerun the numbers if the specifications in the second final rule differ from what has been proposed.  

If you work with a MTM vendor, keep in mind that the company likely provides services to other health plans, so you'll want to communicate your estimates with them and discuss their capacity to support your members. 

Inform executive leadership team 

Compliance with these new requirements and meeting this increased demand will require an investment. A health plan's executive leadership team — those tasked with decision-making and financial allocations — should understand the impact of changes and what will be needed from them to support and secure the necessary resources to address the new requirements.  


It's essential to engage in conversations with the various teams involved in the medication therapy management process — everyone from vendors to pharmacy departments to customer service — about how these changes will affect them and how they to best communicate that internally and with members. Make sure these teams understand the rule changes and implications, including capacity to support the surge in eligible members and ability to effectively perform comprehensive medication review. These teams should also be informed about the current CMR performance and the impact a decline in CMR performance can have on overall rates.  

It is imperative to allocate adequate time and resources to getting your customer service teams prepared for the changes, helping them understand what the changes mean, and ensuring they understand the importance of their interactions with members. Your member-focused teams must be ready to answer questions regarding Part D benefits and MTM services, all while providing a great member experience.  

Carefully consider the audience 

Many of the members who will now be eligible for medication therapy management may have had little communication with their health plan and may not know about MTM. Health plans will need to take that into consideration when outreaching to this new membership and figure out engagement, education, and culturally competent strategies that lead to a positive experience to meet the member's needs. Consider the Medicare population's increased awareness around phishing and other scams: Newly eligible members may question the legitimacy of their enrollment. Be prepared to speak to these concerns. 

Coordinate outreach  

A key to success is ensuring there is a coordinated, streamlined plan across all staff and departments involved in member outreach efforts, and not just for MTM. This can include care managers, customer service representatives, provider relations staff, and external vendors — everyone across every campaign that could touch a member for any service. When members experience any touch point with their health plan, it doesn't matter who is reaching out to them on behalf of the health plan. From the member perspective, it is the health plan outreaching to them. Uncoordinated outreach efforts that do not provide a positive experience can contribute to abrasion and negatively impact the member's perception of your plan which ultimately could be reflected in your member experience measures. 

What's Next for Medication Therapy Management? Stay Tuned! 

Hopefully this information is useful and helps you better understand how to prepare for and communicate on these potentially significant MTM changes within your own organization.  

If you have questions about how the rule changes are likely to affect your organization or the MTM Program in general, we invite you to schedule a consultation with an MTM expert at Cureatr. To stay current on future changes and announcements concerning medication therapy management, follow Cureatr on social media: LinkedIn, Facebook, and Twitter. 

Improving Patient Care and Quality Ratings With Medication Management


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