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Panel I Hon. Herb B. Kuhn Deputy Administrator Centers for Medicare and Medicaid Services |
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May 082008
Per-patient-per-month drug costs in Medicare Part D protected classes.
Medicare News, Syndicated
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Aug 042007
Pharmacoeconomics, Vol. 24 Suppl 3 (2006), pp. 79-84.
OBJECTIVE: The objective of this study was to estimate the per-patient-per-month (PPPM) costs of medications in the six Medicare Part D protected classes based on findings among Medicare and dual eligible beneficiaries with drug coverage before the enactment of the benefit. DESIGN: Data were from the Thomson Medstat MarketScan Medicare and Medicaid claims databases. The study sample was constructed by identifying patients who were enrolled either in Medicare or dually in Medicare and Medicaid. PPPM costs were calculated for each protected class. Drugs covered under Part B were excluded. OUTCOMES MEASURE: PPPM aggregated costs within each class. RESULTS: The classes in which generic formulations are available (antidepressants and anticonvulsants) show low PPPM costs ($ US 45.31 and $ US 50.97, respectively). The most expensive class is the antiretrovirals ($ US 829.73). This class is the costliest for all dual eligible patients including those aged 64 years and under. Among the dual eligible aged 65 years and older, the immunosuppressants are the most expensive class. The same result is seen qualitatively in the Medicare group. CONCLUSIONS: PPPM costs are not uniformly high among the protected classes. The claims data in this study allowed a 'real world' check of how much the protected classes may impact the finances of Part D. There are differences within the classes between the dual eligible and Medicare patients, and also within the dual eligible by age. This is an important message to policy makers that a change to the structure of the protected classes in Part D may have differential effects across classes and also within classes.
L Mucha, NA Masia, KJ Axelsen
OBJECTIVE: The objective of this study was to estimate the per-patient-per-month (PPPM) costs of medications in the six Medicare Part D protected classes based on findings among Medicare and dual eligible beneficiaries with drug coverage before the enactment of the benefit. DESIGN: Data were from the Thomson Medstat MarketScan Medicare and Medicaid claims databases. The study sample was constructed by identifying patients who were enrolled either in Medicare or dually in Medicare and Medicaid. PPPM costs were calculated for each protected class. Drugs covered under Part B were excluded. OUTCOMES MEASURE: PPPM aggregated costs within each class. RESULTS: The classes in which generic formulations are available (antidepressants and anticonvulsants) show low PPPM costs ($ US 45.31 and $ US 50.97, respectively). The most expensive class is the antiretrovirals ($ US 829.73). This class is the costliest for all dual eligible patients including those aged 64 years and under. Among the dual eligible aged 65 years and older, the immunosuppressants are the most expensive class. The same result is seen qualitatively in the Medicare group. CONCLUSIONS: PPPM costs are not uniformly high among the protected classes. The claims data in this study allowed a 'real world' check of how much the protected classes may impact the finances of Part D. There are differences within the classes between the dual eligible and Medicare patients, and also within the dual eligible by age. This is an important message to policy makers that a change to the structure of the protected classes in Part D may have differential effects across classes and also within classes.
L Mucha, NA Masia, KJ Axelsen
Per-patient-per-month drug costs in Medicare Part D protected classes.
Medicare News, Syndicated
Comments Off
Aug 042007
Pharmacoeconomics, Vol. 24 Suppl 3 (2006), pp. 79-84.
OBJECTIVE: The objective of this study was to estimate the per-patient-per-month (PPPM) costs of medications in the six Medicare Part D protected classes based on findings among Medicare and dual eligible beneficiaries with drug coverage before the enactment of the benefit. DESIGN: Data were from the Thomson Medstat MarketScan Medicare and Medicaid claims databases. The study sample was constructed by identifying patients who were enrolled either in Medicare or dually in Medicare and Medicaid. PPPM costs were calculated for each protected class. Drugs covered under Part B were excluded. OUTCOMES MEASURE: PPPM aggregated costs within each class. RESULTS: The classes in which generic formulations are available (antidepressants and anticonvulsants) show low PPPM costs ($ US 45.31 and $ US 50.97, respectively). The most expensive class is the antiretrovirals ($ US 829.73). This class is the costliest for all dual eligible patients including those aged 64 years and under. Among the dual eligible aged 65 years and older, the immunosuppressants are the most expensive class. The same result is seen qualitatively in the Medicare group. CONCLUSIONS: PPPM costs are not uniformly high among the protected classes. The claims data in this study allowed a 'real world' check of how much the protected classes may impact the finances of Part D. There are differences within the classes between the dual eligible and Medicare patients, and also within the dual eligible by age. This is an important message to policy makers that a change to the structure of the protected classes in Part D may have differential effects across classes and also within classes.
L Mucha, NA Masia, KJ Axelsen
OBJECTIVE: The objective of this study was to estimate the per-patient-per-month (PPPM) costs of medications in the six Medicare Part D protected classes based on findings among Medicare and dual eligible beneficiaries with drug coverage before the enactment of the benefit. DESIGN: Data were from the Thomson Medstat MarketScan Medicare and Medicaid claims databases. The study sample was constructed by identifying patients who were enrolled either in Medicare or dually in Medicare and Medicaid. PPPM costs were calculated for each protected class. Drugs covered under Part B were excluded. OUTCOMES MEASURE: PPPM aggregated costs within each class. RESULTS: The classes in which generic formulations are available (antidepressants and anticonvulsants) show low PPPM costs ($ US 45.31 and $ US 50.97, respectively). The most expensive class is the antiretrovirals ($ US 829.73). This class is the costliest for all dual eligible patients including those aged 64 years and under. Among the dual eligible aged 65 years and older, the immunosuppressants are the most expensive class. The same result is seen qualitatively in the Medicare group. CONCLUSIONS: PPPM costs are not uniformly high among the protected classes. The claims data in this study allowed a 'real world' check of how much the protected classes may impact the finances of Part D. There are differences within the classes between the dual eligible and Medicare patients, and also within the dual eligible by age. This is an important message to policy makers that a change to the structure of the protected classes in Part D may have differential effects across classes and also within classes.
L Mucha, NA Masia, KJ Axelsen
Transition to Medicare Part D: an early snapshot of barriers experienced by younger dual eligibles with disabilities.
Medicaid News, Syndicated
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Aug 042007
Am J Manag Care, Vol. 13, No. 1. (January 2007), pp. 14-18.
OBJECTIVE: This study assessed the impact of transition from Medicaid drug coverage to Medicare Part D on a sample of dually eligible adults younger than age 65 years with disabilities. STUDY DESIGN: Telephone survey of employed adults participating in the Kansas Medicaid Buy-In program, Working Healthy, about their experiences in accessing medications after their transition to Part D. METHODS: A total of 328 (55%) individuals from a random sample of 600 agreed to participate in a survey administered by a university-based research unit during February and March 2006, which included 18 questions with yes/no, multiple choice, and open-ended responses. Participants resembled other Kansas dual eligibles demographically and medically, other than having slightly higher rates of mental illness and lower rates of mental retardation and some physical conditions. Participants' 2004 Medicare and Medicaid claims data were analyzed to obtain an overview of their comorbidities and previous prescription use. RESULTS: Twenty percent of participants reported difficulty obtaining medications, including drugs in Part D-protected classes; 13% were required to switch medications; and 8% stopped taking at least 1 medication. More than half did not know they could change plans monthly, potentially improving their access to medications. CONCLUSION: The high incidence of access problems despite Centers for Medicare & Medicaid Services (CMS) safeguards points to the need for ongoing monitoring of Part D. If the problems persist, CMS must be willing to modify the program and/or better enforce the rules already in place to avoid adverse outcomes for beneficiaries with disabilities.
JP Hall, NK Kurth, JM Moore
OBJECTIVE: This study assessed the impact of transition from Medicaid drug coverage to Medicare Part D on a sample of dually eligible adults younger than age 65 years with disabilities. STUDY DESIGN: Telephone survey of employed adults participating in the Kansas Medicaid Buy-In program, Working Healthy, about their experiences in accessing medications after their transition to Part D. METHODS: A total of 328 (55%) individuals from a random sample of 600 agreed to participate in a survey administered by a university-based research unit during February and March 2006, which included 18 questions with yes/no, multiple choice, and open-ended responses. Participants resembled other Kansas dual eligibles demographically and medically, other than having slightly higher rates of mental illness and lower rates of mental retardation and some physical conditions. Participants' 2004 Medicare and Medicaid claims data were analyzed to obtain an overview of their comorbidities and previous prescription use. RESULTS: Twenty percent of participants reported difficulty obtaining medications, including drugs in Part D-protected classes; 13% were required to switch medications; and 8% stopped taking at least 1 medication. More than half did not know they could change plans monthly, potentially improving their access to medications. CONCLUSION: The high incidence of access problems despite Centers for Medicare & Medicaid Services (CMS) safeguards points to the need for ongoing monitoring of Part D. If the problems persist, CMS must be willing to modify the program and/or better enforce the rules already in place to avoid adverse outcomes for beneficiaries with disabilities.
JP Hall, NK Kurth, JM Moore
Transition to Medicare Part D: an early snapshot of barriers experienced by younger dual eligibles with disabilities.
Medicaid News, Syndicated
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Aug 042007
Am J Manag Care, Vol. 13, No. 1. (January 2007), pp. 14-18.
OBJECTIVE: This study assessed the impact of transition from Medicaid drug coverage to Medicare Part D on a sample of dually eligible adults younger than age 65 years with disabilities. STUDY DESIGN: Telephone survey of employed adults participating in the Kansas Medicaid Buy-In program, Working Healthy, about their experiences in accessing medications after their transition to Part D. METHODS: A total of 328 (55%) individuals from a random sample of 600 agreed to participate in a survey administered by a university-based research unit during February and March 2006, which included 18 questions with yes/no, multiple choice, and open-ended responses. Participants resembled other Kansas dual eligibles demographically and medically, other than having slightly higher rates of mental illness and lower rates of mental retardation and some physical conditions. Participants' 2004 Medicare and Medicaid claims data were analyzed to obtain an overview of their comorbidities and previous prescription use. RESULTS: Twenty percent of participants reported difficulty obtaining medications, including drugs in Part D-protected classes; 13% were required to switch medications; and 8% stopped taking at least 1 medication. More than half did not know they could change plans monthly, potentially improving their access to medications. CONCLUSION: The high incidence of access problems despite Centers for Medicare & Medicaid Services (CMS) safeguards points to the need for ongoing monitoring of Part D. If the problems persist, CMS must be willing to modify the program and/or better enforce the rules already in place to avoid adverse outcomes for beneficiaries with disabilities.
JP Hall, NK Kurth, JM Moore
OBJECTIVE: This study assessed the impact of transition from Medicaid drug coverage to Medicare Part D on a sample of dually eligible adults younger than age 65 years with disabilities. STUDY DESIGN: Telephone survey of employed adults participating in the Kansas Medicaid Buy-In program, Working Healthy, about their experiences in accessing medications after their transition to Part D. METHODS: A total of 328 (55%) individuals from a random sample of 600 agreed to participate in a survey administered by a university-based research unit during February and March 2006, which included 18 questions with yes/no, multiple choice, and open-ended responses. Participants resembled other Kansas dual eligibles demographically and medically, other than having slightly higher rates of mental illness and lower rates of mental retardation and some physical conditions. Participants' 2004 Medicare and Medicaid claims data were analyzed to obtain an overview of their comorbidities and previous prescription use. RESULTS: Twenty percent of participants reported difficulty obtaining medications, including drugs in Part D-protected classes; 13% were required to switch medications; and 8% stopped taking at least 1 medication. More than half did not know they could change plans monthly, potentially improving their access to medications. CONCLUSION: The high incidence of access problems despite Centers for Medicare & Medicaid Services (CMS) safeguards points to the need for ongoing monitoring of Part D. If the problems persist, CMS must be willing to modify the program and/or better enforce the rules already in place to avoid adverse outcomes for beneficiaries with disabilities.
JP Hall, NK Kurth, JM Moore
Variation in estimated Medicare prescription drug plan costs and affordability for beneficiaries living in different states.
Medicare News, Syndicated
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Aug 042007
J Gen Intern Med, Vol. 22, No. 2. (February 2007), pp. 257-263.
BACKGROUND: Medicare Part D prescription drug plans (PDPs) implemented in January 2006 are designed to improve beneficiaries' access to pharmaceuticals and use market competition to yield affordable drug costs. Variations in estimated PDP costs for beneficiaries living in different states have not previously been characterized. OBJECTIVE: To describe variations in the estimated costs of PDPs (plan premium, copays, and coinsurance) within and across states. DESIGN: To estimate PDP costs based on 4 actual patient cases that exemplify common conditions and prescription drug combinations for Medicare beneficiaries, we used the online tool provided by the Centers for Medicare and Medicaid Services. MEASUREMENTS: Principal study outcomes included (a) variation across states in the estimated annual cost of the lowest-cost PDP for each case and (b) variation in the estimated affordability of the lowest-cost PDPs across states, based on cost-of-living-adjusted median income for zero-earner households. RESULTS: For all 4 patient cases, we found substantive within-state and between-state differences in the estimated costs of Medicare PDPs incurred by beneficiaries. The estimated annual costs to beneficiaries of the lowest-cost PDPs varied across states by as much as $320 for medications in the least expensive scenario, and by as much as $13,000 for the most expensive scenario. On average across states, a beneficiary with cost-of-living-adjusted median income would expect to spend 3%-28% of annual income to pay for medications in the lowest-cost PDPs in the 4 patient cases. The affordability of the lowest-cost plans varied across states, and for 2 of the 4 cases the lowest-cost PDP estimates were negatively correlated with cost-of-living-adjusted median income. CONCLUSIONS: Substantive differences in estimated PDP costs are evident across states for patients with common Medicare conditions. Importantly, the lowest-cost plans were not proportionally affordable with respect to state-specific cost-of-living-adjusted median income. Refinement of the Medicare drug program may be needed to improve national balance in PDP affordability for beneficiaries living in different states.
MM Davis, MS Patel, LK Halasyamani
BACKGROUND: Medicare Part D prescription drug plans (PDPs) implemented in January 2006 are designed to improve beneficiaries' access to pharmaceuticals and use market competition to yield affordable drug costs. Variations in estimated PDP costs for beneficiaries living in different states have not previously been characterized. OBJECTIVE: To describe variations in the estimated costs of PDPs (plan premium, copays, and coinsurance) within and across states. DESIGN: To estimate PDP costs based on 4 actual patient cases that exemplify common conditions and prescription drug combinations for Medicare beneficiaries, we used the online tool provided by the Centers for Medicare and Medicaid Services. MEASUREMENTS: Principal study outcomes included (a) variation across states in the estimated annual cost of the lowest-cost PDP for each case and (b) variation in the estimated affordability of the lowest-cost PDPs across states, based on cost-of-living-adjusted median income for zero-earner households. RESULTS: For all 4 patient cases, we found substantive within-state and between-state differences in the estimated costs of Medicare PDPs incurred by beneficiaries. The estimated annual costs to beneficiaries of the lowest-cost PDPs varied across states by as much as $320 for medications in the least expensive scenario, and by as much as $13,000 for the most expensive scenario. On average across states, a beneficiary with cost-of-living-adjusted median income would expect to spend 3%-28% of annual income to pay for medications in the lowest-cost PDPs in the 4 patient cases. The affordability of the lowest-cost plans varied across states, and for 2 of the 4 cases the lowest-cost PDP estimates were negatively correlated with cost-of-living-adjusted median income. CONCLUSIONS: Substantive differences in estimated PDP costs are evident across states for patients with common Medicare conditions. Importantly, the lowest-cost plans were not proportionally affordable with respect to state-specific cost-of-living-adjusted median income. Refinement of the Medicare drug program may be needed to improve national balance in PDP affordability for beneficiaries living in different states.
MM Davis, MS Patel, LK Halasyamani
Medicare Part D: successes and continuing challenges. Impact of Medicare Part D on Massachusetts health programs and beneficiaries.
Medicare News, Syndicated
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Aug 042007
Issue Brief (Mass Health Policy Forum), No. 32. (30 May 2007), pp. 1-32.
On January 1, 2006, the Centers for Medicare and Medicaid Services (CMS) implemented the Medicare Drug Benefit, or "Medicare Part D." The program offers prescription drug coverage for the one million Medicare beneficiaries in Massachusetts. Part D affects Massachusetts state health programs and beneficiaries in a number of ways. The program: (1) provides prescription drug insurance, including catastrophic coverage, through a choice of private prescription drug plans (PDPs) or integrated Medicare Advantage (MA-PD) health plans; (2) shifts prescription drug coverage for dual-eligible Medicare / Medicaid beneficiaries from Medicaid to Medicare Part D drug plans; (3) requires a maintenance-of-effort, or "clawback" payments from states to CMS designed to capture a portion of states' Medicaid savings to help finance the benefit; (4) offers additional help for premiums and cost sharing to low income beneficiaries through the Low Income Subsidy (LIS); and (5) provides a subsidy to employer groups that maintain their own prescription drug coverage for retired beneficiaries. This paper summarizes the activities involved in implementing Medicare Part D, the impact it has had on Massachusetts health programs, and the experiences of beneficiaries and others conducting outreach and enrollment. The data are drawn from interviews with officials and documents provided by state health programs, CMS and the Social Security Administration, and representatives of provider and advocacy groups involved in the enrollment and ongoing support of Medicare beneficiaries.
CP Thomas, J Sussman, ,
On January 1, 2006, the Centers for Medicare and Medicaid Services (CMS) implemented the Medicare Drug Benefit, or "Medicare Part D." The program offers prescription drug coverage for the one million Medicare beneficiaries in Massachusetts. Part D affects Massachusetts state health programs and beneficiaries in a number of ways. The program: (1) provides prescription drug insurance, including catastrophic coverage, through a choice of private prescription drug plans (PDPs) or integrated Medicare Advantage (MA-PD) health plans; (2) shifts prescription drug coverage for dual-eligible Medicare / Medicaid beneficiaries from Medicaid to Medicare Part D drug plans; (3) requires a maintenance-of-effort, or "clawback" payments from states to CMS designed to capture a portion of states' Medicaid savings to help finance the benefit; (4) offers additional help for premiums and cost sharing to low income beneficiaries through the Low Income Subsidy (LIS); and (5) provides a subsidy to employer groups that maintain their own prescription drug coverage for retired beneficiaries. This paper summarizes the activities involved in implementing Medicare Part D, the impact it has had on Massachusetts health programs, and the experiences of beneficiaries and others conducting outreach and enrollment. The data are drawn from interviews with officials and documents provided by state health programs, CMS and the Social Security Administration, and representatives of provider and advocacy groups involved in the enrollment and ongoing support of Medicare beneficiaries.
CP Thomas, J Sussman, ,
Medicare Part D: successes and continuing challenges. Impact of Medicare Part D on Massachusetts health programs and beneficiaries.
Medicare News, Syndicated
Comments Off
Aug 042007
Issue Brief (Mass Health Policy Forum), No. 32. (30 May 2007), pp. 1-32.
On January 1, 2006, the Centers for Medicare and Medicaid Services (CMS) implemented the Medicare Drug Benefit, or "Medicare Part D." The program offers prescription drug coverage for the one million Medicare beneficiaries in Massachusetts. Part D affects Massachusetts state health programs and beneficiaries in a number of ways. The program: (1) provides prescription drug insurance, including catastrophic coverage, through a choice of private prescription drug plans (PDPs) or integrated Medicare Advantage (MA-PD) health plans; (2) shifts prescription drug coverage for dual-eligible Medicare / Medicaid beneficiaries from Medicaid to Medicare Part D drug plans; (3) requires a maintenance-of-effort, or "clawback" payments from states to CMS designed to capture a portion of states' Medicaid savings to help finance the benefit; (4) offers additional help for premiums and cost sharing to low income beneficiaries through the Low Income Subsidy (LIS); and (5) provides a subsidy to employer groups that maintain their own prescription drug coverage for retired beneficiaries. This paper summarizes the activities involved in implementing Medicare Part D, the impact it has had on Massachusetts health programs, and the experiences of beneficiaries and others conducting outreach and enrollment. The data are drawn from interviews with officials and documents provided by state health programs, CMS and the Social Security Administration, and representatives of provider and advocacy groups involved in the enrollment and ongoing support of Medicare beneficiaries.
CP Thomas, J Sussman, ,
On January 1, 2006, the Centers for Medicare and Medicaid Services (CMS) implemented the Medicare Drug Benefit, or "Medicare Part D." The program offers prescription drug coverage for the one million Medicare beneficiaries in Massachusetts. Part D affects Massachusetts state health programs and beneficiaries in a number of ways. The program: (1) provides prescription drug insurance, including catastrophic coverage, through a choice of private prescription drug plans (PDPs) or integrated Medicare Advantage (MA-PD) health plans; (2) shifts prescription drug coverage for dual-eligible Medicare / Medicaid beneficiaries from Medicaid to Medicare Part D drug plans; (3) requires a maintenance-of-effort, or "clawback" payments from states to CMS designed to capture a portion of states' Medicaid savings to help finance the benefit; (4) offers additional help for premiums and cost sharing to low income beneficiaries through the Low Income Subsidy (LIS); and (5) provides a subsidy to employer groups that maintain their own prescription drug coverage for retired beneficiaries. This paper summarizes the activities involved in implementing Medicare Part D, the impact it has had on Massachusetts health programs, and the experiences of beneficiaries and others conducting outreach and enrollment. The data are drawn from interviews with officials and documents provided by state health programs, CMS and the Social Security Administration, and representatives of provider and advocacy groups involved in the enrollment and ongoing support of Medicare beneficiaries.
CP Thomas, J Sussman, ,
Impact of Medicare changes in pharmacy reimbursement on patient care: two case reports.
Medicare News, Syndicated
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Aug 042007
Am J Health Syst Pharm, Vol. 64, No. 15 Suppl 10. (1 August 2007)
PURPOSE: Two case reports illustrate the impact of changes in pharmacy reimbursement associated with the Medicare Prescription Drug Improvement and Modernization Act (MMA) on patient care. SUMMARY: The Medicare Part D benefit is complex and difficult for patients to understand. A patient's personal financial situation and quality of life issues may enter into decisions about enrolling in Part D and the use of drug therapy. Local coverage decisions by the Centers for Medicare and Medicaid Services can limit access to drug therapy and raise ethical dilemmas. CONCLUSION: Changes in pharmacy reimbursement associated with MMA has the potential to markedly impact patient care and outcomes.
J Siegel
PURPOSE: Two case reports illustrate the impact of changes in pharmacy reimbursement associated with the Medicare Prescription Drug Improvement and Modernization Act (MMA) on patient care. SUMMARY: The Medicare Part D benefit is complex and difficult for patients to understand. A patient's personal financial situation and quality of life issues may enter into decisions about enrolling in Part D and the use of drug therapy. Local coverage decisions by the Centers for Medicare and Medicaid Services can limit access to drug therapy and raise ethical dilemmas. CONCLUSION: Changes in pharmacy reimbursement associated with MMA has the potential to markedly impact patient care and outcomes.
J Siegel
Guidelines for medication therapy management services in long-term care facilities.
Medicare News, Syndicated
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Jul 312007
Consult Pharm, Vol. 22, No. 4. (April 2007), pp. 355-361.
American Society of Consultant Pharmacists Guidelines Included in the Medicare prescription drug benefit (Medicare Part D) was a provision that sponsors of Medicare Part D prescription drug plans (PDP) provide a medication therapy management (MTM) program for "targeted beneficiaries." Medicare beneficiaries who reside in long-term care facilities also are eligible for Medicare Part D and these MTM services. Long-term care facilities encompass skilled nursing facilities and any medical institution or nursing facility for which payment is made for institutionalized individuals under Medicaid, as defined in section 1902(q)(1)(B) of the Social Security Act, and other payer sources. The design and implementation of MTM services for Medicare beneficiaries who reside in long-term care facilities is complicated because of the Centers for Medicare and Medicaid Services' (CMS) requirement of medication regimen review (MRR) for nursing facility residents. MRR is a broader, yet similar, competing clinical requirement. Moreover, it is newly defined, recently updated, and expanded in Appendix PP of the State Operations Manual (SOM) under "Guidance to Surveyors of Long Term Care Facilities." Changes to Appendix PP were effective December 18, 2006. The American Society of Consultant Pharmacists (ASCP) considers MRR and MTM to be distinct processes even though they share common goals regarding quality, safety, and cost-effectiveness. This document differentiates MTM services from MRR services and establishes guidelines by which MTM can be performed in the long-term care setting.
American Society of Consultant Pharmacists Guidelines Included in the Medicare prescription drug benefit (Medicare Part D) was a provision that sponsors of Medicare Part D prescription drug plans (PDP) provide a medication therapy management (MTM) program for "targeted beneficiaries." Medicare beneficiaries who reside in long-term care facilities also are eligible for Medicare Part D and these MTM services. Long-term care facilities encompass skilled nursing facilities and any medical institution or nursing facility for which payment is made for institutionalized individuals under Medicaid, as defined in section 1902(q)(1)(B) of the Social Security Act, and other payer sources. The design and implementation of MTM services for Medicare beneficiaries who reside in long-term care facilities is complicated because of the Centers for Medicare and Medicaid Services' (CMS) requirement of medication regimen review (MRR) for nursing facility residents. MRR is a broader, yet similar, competing clinical requirement. Moreover, it is newly defined, recently updated, and expanded in Appendix PP of the State Operations Manual (SOM) under "Guidance to Surveyors of Long Term Care Facilities." Changes to Appendix PP were effective December 18, 2006. The American Society of Consultant Pharmacists (ASCP) considers MRR and MTM to be distinct processes even though they share common goals regarding quality, safety, and cost-effectiveness. This document differentiates MTM services from MRR services and establishes guidelines by which MTM can be performed in the long-term care setting.
