CY2013 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

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CY 2014 MTMP - Review Tool
Contract:

Z0001 – Example Contract

Group ID:

325

Version:

4

Cycle:

Annual Review Cycle

Submitted Due to: Resubmission Request
Current Status:

In Desk Review

Date Submitted:

6/15/2013 9:50:33 AM

Date Due:

6/17/2013
Review Check: Targeting Criteria

MTM Program offered to:

Only enrollees who meet the specified targeting criteria per CMS
requirements

Multiple Chronic Diseases
Requirement 1: Your MTM program targets beneficiaries who have multiple chronic diseases in order to meet the criteria
for the MTM program.
Satisfied
Not Satisfied
Requirement 2: Your MTM program defines the criteria for multiple chronic diseases as no more than 3 chronic diseases as
the minimum number of multiple chronic diseases.
Minimum number of chronic diseases:

2

Satisfied

Not Satisfied
Requirement 3: Your MTM program targets at least 5 of the core chronic diseases.
Satisfied
Chronic disease(s) that apply:

Any chronic
disease applies

Not Satisfied

Multiple Covered Part D Drugs
Requirement 4: Your MTM program targets beneficiaries who are taking multiple Part D drugs to meet the criteria for the
MTM program.
Satisfied
Minimum number of Covered Part D
Drugs:

2

Not Satisfied

Requirement 5: Your MTM program defines the criteria for multiple Part D drugs as no more than 8 Part D drugs as the
minimum number of multiple Part D drugs.
Satisfied
Type of Covered Part D Drugs that apply: Any Part D drug
applies

Not Satisfied

Incurred Cost for Covered Part D
Drugs
Requirement 6: Your MTM program describes the analytical procedure used to determine if a beneficiary is likely to incur
annual costs for covered Part D drugs in accordance with the specified level.
Specific Threshold and Frequency
Incurred one-fourth of specified annual cost threshold in
previous three months

Satisfied
Not Satisfied

Requirement 6a: Provide a description of the analytical procedure used to determine if the total annual cost of
a beneficiary's covered Part D drugs is likely to equal or exceed the specified annual cost threshold. When
applicable, this should include the specific thresholds and measurement period, the complete formula or
statement which may detail a condition that must be met or exceeded, or a detailed description of your model.

Satisfied
Not Satisfied

Review Check: Targeting Frequency
Targetin
g
Requirement 7: Your MTM program targets beneficiaries for enrollment at least quarterly during the program year.
Frequency:

Daily

Data evaluated for targeting:

Drug
claims

Satisfied
Not Satisfied
Review Check: Opt-out Enrollment

Enrollment/Disenrollm
ent
Requirement 8: Your MTM program enrolls targeted beneficiaries using only an opt-out method.
Satisfied
Method of enrollment:

Opt-Out
only

Not Satisfied
Review Check: Interventions

Interventio
ns
Requirement 9: Your MTM program offers a minimum level of MTM services including interventions for both beneficiaries
and prescribers, an annual, comprehensive medication review, which includes an interactive person-to-person or
telehealth consultation and an individualized written summary in CMS' standardized format, and quarterly targeted
medication reviews with follow-up interventions when necessary.

Recipient of interventions:
Beneficiary
Prescriber
Specific beneficiary interventions:
Interactive, Person-to-Person, Comprehensive Medication
Review, annual
Interactive, person-to-person or telehealth consultation
Face-to-face
Materials delivered to beneficiary after the interactive,
person-to-person CMR consultation
Individualized, written summary of CMR in CMS'
standardized format (includes beneficiary cover letter,
medication action plan, and personal medication list)
Wallet card
Delivery of individualized written summary of CMR in
CMS' standardized format:
Mail
Targeted medication reviews, at least quarterly, with
follow-up interventions when necessary
Refill reminder, beneficiary

Satisfied
Not Satisfied

Specific prescriber interventions:
Prescriber interventions to resolve medication-related
problems or optimize therapy
Phone consultation
Patient Medication list
Description:

qwert
y

Requirement 9a: The MTM program requirements state that all targeted beneficiaries should be offered a
Comprehensive Medication Review (CMR) and that quarterly targeted medication reviews should be performed
for all targeted beneficiaries enrolled in the MTM program. Targeted beneficiaries may refuse the CMR or another
follow-up intervention. Even if a beneficiary declines the CMR, sponsors should perform quarterly targeted
medication reviews for all targeted beneficiaries to assess medication use on an on-going basis and offer
interventions to the prescriber. Your MTM submission contains contradictory language; clarify in your
resubmission that your MTM program meets these requirements.

Satisfied
Not Satisfied

Requirement 9b: Your MTM program submission indicates a method for the CMR consultation that is a noninteractive method. The MTM program requirements state that sponsors must offer to provide to each targeted
beneficiary enrolled in the MTM program an interactive, person-to-person or telehealth consultation performed
by a qualified provider. This real-time interaction may be face-to-face or through other interactive methods such
as the telephone or through telehealth technologies. Mail-based or other non-interactive interventions may be a
part of your overall MTM program, but do not satisfy the interactive CMR requirement. Correct your selection for
method of providing the interactive CMR consultation. This correction could include removing your noninteractive selection as a method for the interactive CMR consultation and adding additional information in the
Intervention description.
Requirement 9c: A detailed description of how your program will provide the MTM interventions, describing
interventions for both beneficiaries and prescribers, an annual comprehensive medication review, which includes
an interactive, person-to-person or telehealth consultation and an individualized, written summary in CMS'
standardized format, and quarterly targeted medication reviews with follow-up interventions when necessary,
was not included. Revise your MTM program Intervention description and provide more details about your
program.

Satisfied
Not Satisfied

Satisfied
Not Satisfied

Review Check: Fees Established
Requirement 10: Your MTM program establishes fees for pharmacists and other resources. The fee or payment structure
takes into account the resources used and the time required for providing MTM services.
Resourc
es
Provider of MTM services:
In-house staff
Pharmacist
Qualified Provider of Interactive, Person-to-Person
CMR with written summaries:
Local Pharmacist
Outcomes
Measured
Part D Reporting Requirements
Diabetes medication dosing
measure

Satisfied
Not Satisfied

Requirement 10a: A detailed description of fees was not provided for pharmacists or other providers of MTM
program services. A description of fees is required if using outside personnel. This description should include the
specific amount of management, fees or other payment such as fee ($X) per hour, per service, per diem, per
member per month (PMPM), etc.

Satisfied
Not Satisfied

Review Check: Description
No Additional
Information 1
No Additional
Information 2
Review Check: Additional Deficiencies
Additional Deficiency
Code

AD1

AD2

AD3

Requirement

Additional Deficiency Code Text

Spans 1-6, include as Additional
deficiency

Your MTM program describes more than one set
of eligibility criteria. Plans must establish one set
of eligibility criteria per program. A minimum
level of MTM must be offered to each beneficiary
that meets the 3 eligibility criteria.

Spans 1-6, include as Additional
deficiency

Your MTM program described more than one set
of eligibility criteria based on the beneficiary's
setting. Plans must establish one set of eligibility
criteria per program. A minimum level of MTM
must be offered to each beneficiary that meets
the 3 eligibility criteria.

Additional deficiency

Your MTM program indicates that a beneficiary
may qualify for MTM based on a referral. Per the
CMS statutory requirements for MTM, a
beneficiary must meet all three eligibility criteria
to be targeted for the MTM program. Therefore,
a self-referral or a provider referral alone is not
sufficient for qualification in the MTM program.

Select
Satisfied
Not Satisfied

Satisfied
Not Satisfied

Satisfied
Not Satisfied

Additional deficiencies

Review Status
Select a Status

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There are dependencies between the parent (6,9,10) and the child (6a, 9a,
9b, 9c, 10a). If “Satisfied” is selected, the child element(s) will be disabled.