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 amendments 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 diseasebased
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.
