Mo. Code Regs. tit. 13 § 70-20.330

Current through Register Vol. 49, No.12, June 17, 2024

Section 13 CSR 70-20.330 - Medication Therapy Management (MTM) Program

PURPOSE: This rule establishes the regulatory basis for the administration of the MO HealthNet Medication Therapy Management (MTM) program, including designation of professional persons who may perform medication therapy management services and defined covered services within the program.

PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The Medication Therapy Management (MTM) program shall be administered by the Department of Social Services, MO HealthNet Division. The MTM services covered, the program limitations, and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO HealthNet Division and shall be included in the pharmacy provider manual and provider bulletins, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at dss.mo.gov/mhd/index.htm, September 1, 2015. This rule does not incorporate any subsequent amendment or additions.

(2) Persons Eligible. A person who is eligible for Title XIX (Medicaid) or Title XXI (State Children's Health Insurance Program) or Blind Pension and who meets certain disease-based criteria included in their health profile.

(3) Provider Participation. To be eligible for participation in the MO HealthNet MTM program, a provider must be a qualified Missouri licensed pharmacist and have an active MO HealthNet provider status, and must have successfully completed two (2) hours of ACPE (Accreditation Counsel for Pharmacy Education) accredited continuing education focused on the administration of MTM approved by the MO HealthNet Division.

(4) Medication Therapy Management Services. MTM Services are available to any currently eligible non-managed care MO HealthNet participant for whom the qualifying pharmacist receives a MO HealthNet directed electronic drug utilization review (DUR) message through a Point-of-Sale transaction. MO HealthNet uses a clinically based rules engine that juries which participants require MTM interventions based on nationally accepted evidence-based guidelines. Pharmacists are then messaged about only those participants who are identified for one (1) or more issues pertinent to the evidence-based criteria. The rules engine uses current nationally accepted evidence-based guidelines for clinically appropriate drug therapy, and applies this criteria to thirty-six (36) months of paid participant claims data which includes drugs, diagnoses, and procedures. When an eligible participant meets certain disease-based criteria a pharmacist may perform a wide variety of MTM services directed by MO HealthNet to address specific treatment needs, such as:

(A) Counseling participants on the importance of medication adherence (alerting participants to missed dosages and refills);

(B) Providing medication education;

(C) Providing self-care education for specific chronic conditions;

(D) Contacting physicians to schedule diagnostic testing;

(E) Contacting physicians to make drug therapy recommendations; or

(F) Connecting participants with other community-based resources as needed.

(5) The service is comprised of the following components:

(A) Assessing a participant's health status;

(B) Developing a medication treatment plan;

(C) Monitoring and evaluating a participant's response to therapy;

(D) Providing a comprehensive medication review to identify, resolve, and prevent medication-related problems;

(E) Documenting the care provided and communicating essential information to a participant's primary care providers;

(F) Providing oral education and training to enhance participant understanding and appropriate use of medications;

(G) Providing information, support services, and resources to enhance participant adherence to therapeutic regimens; and

(H) Coordinating and integrating MTM services within the broader health care services provided to a participant.

(6) Reimbursement. Pharmacists will receive the payment for participating in MTM. The payment is contingent upon the provider logging on to the electronic web tool to view, reserve, and complete interventions. Once an intervention is complete, providers will submit an electronic medical claim to MO HealthNet. The payment status of these claims will be reflected on the provider's remittance advice. The fee schedule is available at dss.mo.gov/mhd/providers/pages/cptagree.htm.

13 CSR 70-20.330

Adopted by Missouri Register December 15, 2015/Volume 40, Number 24, effective 1/30/2016