CMS proposes requiring expansion of Part D MTM benefits

Agency issues proposed rule to revise Medicare Advantage, Part D regulations

CMS proposed requiring an expansion of Medicare Part D medication therapy management (MTM) benefits to a considerably larger pool of beneficiaries in a proposed rule released yesterday.

CMS has long encouraged Part D sponsors to cover MTM for more beneficiaries, but has not proposed requiring expanding Part D coverage until now. “This is going to codify what CMS expects Plan D sponsors to cover for MTM,” said Jillanne Schulte, JD, APhA Director of Regulatory Affairs. “We’re very pleased that CMS has recognized explicitly the importance of MTM.”

The 678-page proposed rule—for contract year 2015 policy and technical changes to the Medicare Advantage and Part D prescription drug benefit programs—will be published in the Federal Register on Friday. Comments are due March 7, and APhA will comment to CMS on the proposed rule.

“At the start of the Part D program, we believed that 25 percent of enrollees would qualify for MTM services. However, analysis revealed that MTM program enrollment was well below that level,” CMS wrote in the proposed rule (starting on page 131). The agency cited “additional evidence that the program improves quality and generates medical savings,” and stated that it’s “exploring new ways to improve access to MTM services for Part D enrollees.”

APhA is also pleased with the proposed rule’s changes to mail-service pharmacy copayment rules, which will help community pharmacies to keep pace with mail-service pharmacies, according to Schulte. “That’s been an expanding area of concern for a lot of pharmacies—and this should also help secure patient access to medications.”

It’s not all good news, however.

APhA has some concerns on the proposed rule’s increased emphasis on fraud and abuse in Part D related to overpayments and opioid prescribing and dispensing. “Pharmacists who work with Part D can expect an increased emphasis on fraud and abuse and compliance in the coming years based on the [proposed] new regulatory language,” Schulte said.

Watch for a more detailed analysis of the proposed rule in the near future.