Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 20 - Pharmacy Program › Section 13 CSR 70-20.330 - Medication Therapy Management (MTM) Program

Current through Register Vol. 49, No. 14, July 15, 2024
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.