10.3 CMS Part D MTM Targeting Requirements

10.3 CMS Part D MTM Targeting Requirements

Quick Answer: CMS requires Part D sponsors to offer MTM to targeted beneficiaries who meet plan criteria within CMS bounds for multiple chronic diseases, multiple Part D drugs, and likely annual Part D drug costs ≥ the CMS cost threshold (published annually), plus at-risk beneficiaries under drug management programs. Technicians help identify and track eligibles; they do not rewrite CMS rules.

Domain 3 expects you to know CMS requirements for offering MTM services—especially who must be targeted. Official CMS materials live at CMS Medication Therapy Management and in annual HPMS memoranda such as the Contract Year MTM Program Guidance and Submission Instructions.

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Regulatory Frame: What Sponsors Must Establish

Under 42 CFR § 423.153(d), a Part D sponsor must have an MTM program that:

• Ensures covered Part D drugs for targeted beneficiaries are used to optimize therapeutic outcomes
• Is designed to reduce adverse events, including adverse drug interactions
• May be furnished by a pharmacist or other qualified provider
• May distinguish ambulatory vs institutional settings
• Must be developed in cooperation with licensed and practicing pharmacists and physicians

Sponsors submit MTM program descriptions to CMS annually (via HPMS) for review and approval. A CMS-approved MTM program is part of developing the sponsor’s bid for the upcoming contract year. Requirements apply to PDPs, MA-PDs, and Medicare-Medicaid Plans as described in CMS guidance; CMS notes special applicability nuances for certain plan types (for example, encouragement rather than the same mandate for some MA-PFFS contexts)—exam items usually focus on the standard Part D sponsor duty to offer MTM to targeted enrollees.

CMS describes MTM as patient-centric and comprehensive, with high-touch interventions engaging beneficiaries and prescribers. Sponsors must offer each enrollee in the MTM program the same minimum level of services specified in regulation (interventions for beneficiaries and prescribers; annual CMR with standardized written summary; quarterly TMRs with follow-up when necessary; controlled-substance safe-disposal information). Chapter 11 deep-dives CMR/TMR/billing; this section focuses on who gets into the program.

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Who Is a Targeted Beneficiary?

Per 42 CFR § 423.153(d)(2) and CMS annual guidance, targeted beneficiaries are enrollees who meet at least one of the following groups:

Group 1 — Chronic diseases + multiple Part D drugs + cost threshold

All three of the following (A, B, and C) apply together:

A) Multiple chronic diseases

• Sponsors may set the minimum number of chronic diseases at two or three
• Sponsors cannot require more than three chronic diseases as the minimum for eligibility
• Beginning with changes implemented for CY 2025, sponsors must include ten core chronic diseases in targeting criteria (CMS codified nine longstanding cores and added HIV/AIDS), and may include additional diseases

B) Multiple Part D drugs

• Sponsors set a minimum drug count from 2 up to a maximum of 8 (eight is the maximum number a sponsor may require as the minimum for targeting)
• Sponsors must include all Part D maintenance drugs when counting, using a widely accepted commercial or public drug database (CMS examples include databases such as Medi-Span or First Databank), and may include all Part D drugs

C) Annual Part D drug cost threshold

• Beneficiaries must be likely to incur annual costs for covered Part D drugs greater than or equal to the CMS MTM cost threshold
• Beginning January 1, 2025, the threshold methodology is set at the average annual cost of eight generic drugs, determined from PDE data under the regulation
• CMS publishes the dollar amount for each contract year—do not memorize a single lifetime number as if it never changes

Dated CMS figures (for study context—verify current year on CMS.gov before real-world use):

Costs considered in the projection include ingredient cost, dispensing fees, sales tax, and vaccine administration fees when applicable, and include both plan-paid amounts and enrollee cost sharing. Projections may use claims from the current program year or historical claims from the prior year.

Exam strategy: Know the three conceptual pillars (diseases, drugs, cost). If an item asks for a dollar figure, prefer the answer that matches a clearly dated CMS value or the answer that says CMS updates the threshold annually—never invent a stale unofficial number.

Group 2 — At-risk beneficiaries (ARBs)

All at-risk beneficiaries as defined at 42 CFR § 423.100—beneficiaries with an active coverage limitation under a drug management program (DMP)—must be targeted for MTM enrollment. Overlap with Group 1 is possible; sponsors must still identify everyone who qualifies under either pathway and must not use discriminatory exclusion criteria.

CMS targeting rules are a minimum. Sponsors may offer MTM to expanded populations beyond the regulatory criteria.

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Enrollment Mechanics Technicians Should Recognize

If a targeted beneficiary declines a CMR, the plan must document the offer and refusal and continue other required MTM activities (such as quarterly TMRs and interventions)—a frequent exam trap.

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Technician Support Role: Eligible Enrollee Identification

Pharmacists and plan clinical leaders own criteria design within CMS bounds. Technicians and MTM operations staff often perform the identification support work that makes targeting real.

High-value technician tasks

1. Run or monitor targeting reports at least as often as the plan’s quarterly (or more frequent) cycle
2. Validate inputs: chronic condition flags/ICD mappings used by the plan, maintenance-drug counts from the designated database logic, and cost projections feeding the threshold test
3. Reconcile ARB/DMP lists so at-risk beneficiaries are not missing from MTM queues
4. Process opt-out and decline documentation with accurate dates and channels
5. Queue newly identified enrollees for CMR outreach timelines and TMR workflows
6. Escalate anomalies (implausible drug counts, missing disease data, deceased/disenrolled members still on lists) to the pharmacist or plan MTM lead
7. Support customer-service literacy: staff should be able to explain that MTM is part of the Part D quality program for targeted enrollees—not a random sales call

Scenario — Identification support

A quarterly file shows Mr. Nguyen with diabetes and CHF (two core diseases), seven Part D maintenance drugs, and projected annual Part D costs above the current CMS threshold. He is not on the DMP list. The technician confirms he meets Group 1 criteria under the plan’s “minimum two diseases / minimum five drugs” settings, enrolls him via the opt-out process, documents the welcome/CMR offer attempt, and places him on the TMR monitoring list. When Mr. Nguyen declines the CMR phone appointment, the technician documents the decline and keeps the TMR and prescriber-intervention workflows active per CMS expectations.

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How Targeting Connects to Interventions and Documentation

Targeting is not paperwork for its own sake. Once enrolled, the beneficiary should receive the minimum service set—including interventions for beneficiaries and prescribers and follow-up after TMRs when needed. Identification errors create either:

• Missed care (eligible member never offered MTM), or
• Compliance findings (services claimed/reported for members who were not properly targeted/enrolled)

Documentation of how and when a member was identified, offered services, and opted out/declined individual services is part of audit readiness from Section 10.2.

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Rapid Review Table

Common Exam Traps for CMS Targeting

• Thinking eligibility requires the patient to pay full retail cash for all drugs (not a CMS targeting criterion)
• Believing any Medicare Advantage enrollee automatically gets Part D MTM regardless of criteria
• Forgetting that ARBs under DMP are a separate mandatory targeting pathway
• Treating the cost threshold as a forever-fixed dollar amount without CMS’s annual update
• Assuming declining a CMR removes the member from all MTM obligations for the year

If you can explain the three pillars, the opt-out/quarterly identification rules, and the technician’s identification-support role, you are ready for the CMS offering-requirements items in Domain 3.