CMS finalized expanded Medication Therapy Management (MTM) Program eligibility for program year 2025 which was intended to “ensure more consistent, equitable and expanded access to MTM services.” In order to expand the population eligible for MTM, CMS modified criteria requirements by establishing an expanded list of targeted disease states and reducing the drug spend threshold. Initial estimates from CMS suggested an increase in eligible members from 7% to 13% of Part D beneficiaries. After the ruling was finalized in April 2024, many plans ran analyses to understand how the criteria changes would impact their population, and some results had even further increased than CMS estimated. Now that a few rounds of MTMP identification have occurred for the year 2025 program, Outcomes was eager to see how those estimations compared to reality.
Outcomes evaluated identification results from 2024 and 2025 for a regional MAPD plan to see how the expanded criteria affected identification rates. Similar to many other health plans, this specific plan targeted patients on any 2 of 6 specific disease states who also had at least 7 chronic medications and an annual drug spend of $5330. In 2025, the health plan shifted criteria to align with the new CMS requirements and targeted patients on any 3 of 10 core disease states who also had at least 8 chronic medications and an annual drug spend of $1623. After facilitating 2 rounds of 2025 identification:
- More members hit criteria in within the first two rounds of identification in 2025 than met criteria in all of 2024.
- The targeting rates in 2025 were double what they were in 2024 for the first two runs of the calendar year.
- 59% of members eligible in 2024 already hit the new expanded criteria in 2025, indicating that members are qualifying for MTMP earlier than prior year.
- There are also many new members qualifying that did not meet criteria in prior year. 48% of qualified members so far this year did not meet criteria in 2024. This is a whole new set of members who are eligible for a comprehensive medication review and targeted medication reviews that have never received them before.
The significant decrease in the drug spend threshold was assumed to be a major driver of increased eligibility, and this has been confirmed by the identification process that has taken place so far in 2025. Across the entire population from this sample health plan, 24% of members met the drug spend threshold in 2024, while 32% of members met the threshold in 2025. This represents a 37% increase in members qualifying for the MTM program due to the lowered drug spend threshold.
The other major change was the requirement to include all 10 core disease states which had long been a means of controlling the volume of targeted members by limiting to lower prevalence disease states. By requiring all 10 core disease states, health plans were forced to include disease states that are more frequently occurring within a population, like Diabetes, Hypertension and Dyslipidemia. The sample population went from including 6 disease states to including all 10 core disease states for 2025. In 2024, 66% of the sample population met criteria for the more limited grouping of disease states, while in 2025, 72% of the population met criteria with the more expanded list of disease states.
Although the analysis was conducted on a sample health plan population, similar trends are emerging across the industry. With the targeted population already doubled in 2025, Outcomes is eager to observe how eligibility continues to grow throughout the year and how newly targeted members respond to the offer for MTM services.
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