The Tennessee Pharmacists Association (TPA) has been instrumental in advocating for expanded roles for pharmacists within the healthcare system. Their efforts led to the establishment of Public Chapter 363, which mandates the creation of the Pharmacist-Provided Medication Therapy Management (MTM) in Medicaid Pilot Program. This innovative program, recognized nationally, aims to improve patient access to pharmacist-provided care within Medicaid, integrating pharmacists as crucial medical providers. Launched on January 1, 2018, the Tennessee MTM in Medicaid Pilot Program represents a significant step forward in patient care.
Pharmacist Participation is Key to Program Success
The TPA is actively seeking member pharmacists interested in participating in this vital Pilot Program. If you are a pharmacist in Tennessee and wish to contribute, please express your interest by emailing MTMpilot@localhost. Eligibility will be determined by TennCare based on factors such as location and adherence to program requirements. Direct inquiries regarding the selection process can be addressed to TennCare at [email protected].
Who Can Participate? Pharmacist Qualifications
The MTM in Medicaid Pilot Program is open to qualified, Tennessee-licensed pharmacists operating under collaborative practice agreements with prescribing physicians. This inclusivity extends to community pharmacists, health-system pharmacists, long-term care pharmacists, and other pharmacy professionals. The program is designed to leverage the expertise of pharmacists across various practice settings.
Patient Eligibility: Identifying Those Who Benefit Most
Eligible TennCare patients for pharmacist-provided MTM services are those with multiple chronic conditions and complex medication regimens. These patients are enrolled in TennCare Patient Centered Medical Homes (PCMH Wave 1 or PCMH Wave 2) or Tennessee HealthLink organizations. The program specifically targets:
| Medium-High, High, and Critical Risk Patients Identified Through Risk Stratification | Patients With Targeted Disease States – Pediatric Asthma – Pediatric DM |
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Reimbursement for MTM Services: A Breakdown
The MTM in Medicaid program provides a structured reimbursement methodology for pharmacist-provided services, recognizing the value of their interventions.
| Service Description | Modifier Code | Case Rate | Payment Limits | Units |
|---|---|---|---|---|
| Targeted Disease States (Juvenile Asthma and Diabetes) | U1 | $55.00 | 2 Months | 1 unit for each case rate |
| Medium-High Risk | U2 | $55.00 | 3 Months | 1 unit for each case rate |
| Critical, High Risk | U3 | $75.00 | 6 Months | 1 unit for each case rate |
| Exceptions (Requires appropriate approval) | U4 | Rate based on level of care modifier | Limit based on appropriate approval | 1 unit for each case rate |
These case rates are associated with specific CPT codes, further clarifying the billing process for different types of MTM services:
| CPT Code | CPT Code Description |
|---|---|
| 99605 | Medication therapy management service(s) provided by pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; new patient visit, initial 15 minutes |
| 99606 | Medication therapy management service(s) provided by pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; established patient visit, initial 15 minutes |
| 99607 | Add-on code for each additional 15-minute increment |
| 98966 | Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient. 5-10 minutes |
| 98967 | Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient. 11-20 minutes |
| 98968 | Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient. 21-30 minutes |
For detailed information on reimbursement, please CLICK HERE to access the comprehensive Reimbursement Summary document.
Image alt text: Collaborative healthcare team meeting to discuss Medication Therapy Management within the Tennessee Medicaid Pilot Program.
Steps to Participate: A Guide for Pharmacists
To participate in the Pilot Program, pharmacists should follow these steps. While steps 1-5 can be initiated immediately, step 6 depends on enrollment procedures from participating entities, which are expected to be finalized soon. TPA will provide updates as soon as this information becomes available.
| Steps 1-5 below can be completed now, however, not all entities listed in Step 6 have their enrollment procedures in place. This should be resolved shortly, and TPA will update members at that time. You should then be able to complete Step 6 relatively quickly. | TennCare will determine pharmacists’ eligibility for participation based on numerous factors. If you have specific questions about TennCare’s selection process, email TennCare directly at [email protected]. |
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The TPA is dedicated to facilitating pharmacist participation in the MTM in Medicaid Pilot Program. They continue to collaborate with TennCare to gather contact information from interested pharmacists and will disseminate updates as the program evolves. Tools like Altruista Care Coordination Tool, while not explicitly mentioned in this program description, represent the kind of innovative technology that could further enhance the efficiency and effectiveness of MTM programs by streamlining communication and data sharing among care team members. As healthcare moves towards more integrated and coordinated models, understanding and utilizing such tools will be increasingly important for pharmacists and other healthcare providers.
Image alt text: Button link to Collaborative Pharmacy Practice Resources for Tennessee pharmacists participating in MTM programs.
