The recent final rule for the 2025 contract year issued by the Centers for Medicare & Medicaid Services (CMS) carries significant implications for Health Plans and Pharmacy Benefit Managers (PBMs) managing Medication Therapy Management (MTM) programs. This change marks a pivotal moment, introducing new elements that aim to enhance the effectiveness and reach of MTM services.
Key Changes and Their Impact
1. Expansion of MTM Eligibility Criteria: CMS has broadened the scope of MTM programs by including HIV/AIDS among the core chronic diseases. This expansion requires plan sponsors to incorporate all ten core chronic diseases in their MTM program criteria, ensuring a wider base of beneficiaries receives crucial medication management services.
2. Inclusion of All Part D Maintenance Drugs: The new rule mandates that plan sponsors include all Part D maintenance drugs in their MTM programs. This flexibility allows for a more comprehensive approach to medication therapy management, potentially increasing patient adherence and improving outcomes.
3. Revision of MTM Cost Threshold: The methodology for calculating the MTM cost threshold has been updated to align with the average annual cost of eight generic drugs, now set at $1,623 for CY 2025. This adjustment could change the demographics of MTM-eligible populations, impacting how programs are structured and delivered.
The role of Agadia’s RxMTM+ solution in enhancing MTM programs:
In light of these changes, Health Plans and PBMs need tools that not only comply with new regulations but also streamline MTM program management to enhance efficiency and outcomes. Agadia’s RxMTM+ serves as a crucial solution, equipped to handle these new regulatory demands.
Features of RxMTM+:
- Advanced Rules Engine: Automatically identifies MTM eligibility, incorporating both CMS and customizable criteria.
- Flexible Configuration: Allows customization across various disease states, enhancing the adaptability to new CMS rules.
- Streamlined Clinical Modules and Workflows: Enhances productivity and ensures that care meets regulatory guidelines efficiently.
- Integrated Communication Tools: Facilitates seamless interactions with vendors and beneficiaries, ensuring timely interventions and adherence to therapy.
- Comprehensive Reporting and Audit Tools: Prepares plans for CMS audits and provides essential reporting capabilities for effective management and oversight.
How Health Plans & PBMs benefit by using RxMTM+:
- Stability and Performance: RxMTM+ offers unparalleled stability with zero downtime, ensuring that the platform is always available when you need it. This reliability extends to the performance of the software, which is optimized to operate with minimal lag time.
- Scalability: RxMTM+ is designed to meet evolving demands without sacrificing performance. This scalability ensures that as your workload increases, whether it be through an uptick in patient numbers or through expansion into new services, RxMTM+ can handle the additional demands with the same efficiency and reliability.
- A Valued Partner: At Agadia, we view our relationship with customers as a partnership, not merely a business transaction. We understand that the landscape of healthcare, especially areas governed by intricate policies like Medication Therapy Management, is constantly evolving. As such, our commitment extends beyond providing software solutions; we actively collaborate with our clients to ensure that our products continually evolve to meet the latest industry standards and regulatory requirements set forth by CMS. By choosing Agadia, you’re not just selecting a software provider—you’re choosing a partner dedicated to enhancing the value and effectiveness of your MTM program, ensuring it delivers optimal outcomes for both your organization and the patients it serves.
- Streamlined workflow and clinical modules: RxMTM+ simplifies the tasks involved in conducting Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs), enabling health plans and PBMs to manage their time and resources more efficiently.
- Increased staff productivity: With RxMTM+, healthcare teams experience a boost in productivity due to automation and well-integrated processes. The system automates routine tasks and reduces the need for manual data entry, which minimizes errors and frees up staff to focus on more critical aspects of patient care and program management.
- Improved Quality of Care: By ensuring that all patient interactions and medication management processes are meticulously documented and accessible, RxMTM+ enhances the quality of care provided to patients. Better management of these therapies often results in improved patient outcomes, adherence, and overall satisfaction.
- CMS requirements met: RxMTM+ stays current with the continuous changes in regulations and standards set forth by the Centers for Medicare & Medicaid Services (CMS). The platform includes features that ensure compliance with CMS guidelines for MTM programs, which is crucial for health plans and PBMs subject to these regulations. By using RxMTM+, organizations can be confident that they are not only meeting but also maintaining compliance with all necessary legal and professional standards, thereby avoiding penalties and maximizing reimbursement opportunities.
As Health Plans and PBMs navigate these regulatory changes, leveraging a platform like RxMTM+ not only simplifies compliance but also elevates the standard of care delivered to beneficiaries. With its configurable and comprehensive features, RxMTM+ is designed to meet the challenges as they arise, ultimately leading to improved patient outcomes and streamlined MTM program operations.
In conclusion, the CMS 2025 final rule presents both challenges and opportunities for MTM programs. Health Plans and PBMs equipped with advanced tools like RxMTM+ are well-positioned to adapt effectively, ensuring optimal health outcomes for their members while adhering to regulatory demands.
Ready to transform your MTM program? Request a live demo of RxMTM+.
