The NYS Medicaid Medication Therapy Management Pilot Program
Effective January 6, 2010, the Medicaid Program implemented a pilot Medication Therapy Management (MTM) Program to improve therapeutic outcomes by optimizing responses to medication, managing treatment-related interactions or complications, and improving adherence to drug therapy.
The Medicaid MTM pilot program is taking place in the Bronx. Medicaid enrollees eligible to receive program services have been identified through a review of medication and facility (emergency department and in-patient) Medicaid claims and have been invited to join the program. Patient enrollment is voluntary. MTM services are provided at designated pharmacies located in the Bronx by qualified Medicaid MTM pharmacists who possess a New York State license to practice pharmacy. MTM services are billed by and paid to pharmacies that employ a qualified Medicaid MTM pharmacist.
The services provided to enrollees by qualified Medicaid MTM pharmacists include:
- Patient assessment (medical history as related by the patient);
- Comprehensive patient medication therapy review;
- Personal medication record (retained by the patient);
- Medication action plan (for the patient to follow);
- Assistance in finding a primary care physician (if needed);
- Documentation of problems, resolutions, education and evaluation of patient response to medication therapy, including adverse events, and;
- Follow-up to ensure patient adherence with medication action plan and encourage patient self-management.
Medicaid enrollees eligible to receive MTM services are allowed one new patient visit and up to six established patient visits annually. MTM services are provided on a one-on-one, face-to-face basis, in a separate and private consultation area within a community pharmacy. Qualified Medicaid MTM pharmacists are required to establish and maintain a working relationship with the enrollee's primary health care providers (PCP) including linking the enrollee to a PCP when necessary.
MTM Provider Manual
MTM Provider Manual (PDF, 808KB, 75pg.)
PHARMACY REIMBURSEMENT
Payment for Medicaid MTM services will be made to NYS Medicaid MTM-designated pharmacies that employ or contract with the Medicaid MTM pharmacist(s) who provided the services. Pharmacies participating in the Medicaid MTM program must submit electronic claims using an NCPDP 5.1 format using the following CPT code(s).
| CPT Code | Service Description | Frequency | Maximum Reimbursement |
|---|---|---|---|
| 99605 | Medication therapy management service(s) provided by a pharmacist, individual, face-to-face, with patient, initial 15 minutes, with assessment, and intervention if provided; initial 15 minutes, new patient. | Once | $ 35.00 |
| 99606 | Initial 15 minutes, established patient visit. | 6 / year | $ 25.00 |
| 99607 * *Use 99607 in conjunction with 99605, 99606 | Each additional 15 minutes. List separately in addition to code for the primary service. | 12 / year | $ 15.00 |
The program will not be accepting any new providers or enrollees while in the pilot phase. Program evaluation will occur this year and future plans will be determined at that time.
Questions regarding this program can be emailed to the Medicaid Pharmacy Program at PPNO@health.state.ny.us.
