2716.1 Medication Therapy Management (MTM) services are services provided by a pharmacist to a beneficiary to optimize the therapeutic outcomes for that beneficiary. MTM is a patient-centered service that assesses a patient's entire drug regimen and accounts for patient-centered risk factors, such as concurrent diseases, drug interactions, and lifestyle. MTM services are separate from the pharmacy counseling services required under the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508; 104 Stat. 1388) (OBRA '90)), which requires patient consults at prescription pickup.

2716.2 MTM services include:

1. (a) Development of a medication treatment plan;
2. (b) Monitoring and evaluating the beneficiary's response to medications, including safety and efficacy;
3. (c) Conducting a comprehensive review of the beneficiary's medications and immunizations to identify, resolve, and prevent medication-related problems;
4. (d) Documenting the care delivered and communicating with the beneficiary's primary care providers;
5. (e) Providing education and training to enhance beneficiary understanding and appropriate use of prescribed medications;
6. (f) Providing information, support services, and resources to enhance adherence to the beneficiary's drug regimens; and
7. (g) Coordinating and integrating MTM services with other health care services being provided to the beneficiary.

2716.3 MTM services are limited to one (1) initial visit and three (3) follow-up visits per calendar year and may be provided in-person or by telehealth in accordance with the requirements of 29 DCMR § 910.

2716.4 MTM services shall be billed in fifteen (15) minute interval units. Providers meeting the requirements of Section 2716.4 may bill up to five (5) units during a single visit, as follows:

1. (a) The first fifteen (15) minute unit shall be billed for the type of encounter (first encounter or follow-up encounter);

(b) Any additional time beyond the first fifteen (15) minutes spent with the beneficiary shall be billed in additional fifteen (15)-minute-interval units; provided, that a provider shall not bill more than four (4) units of additional fifteen (15) minute intervals.

2716.5 To be eligible for MTM services, a Medicaid beneficiary must:

1. (a) Be in an outpatient setting (not inpatient or institutional setting);
2. (b) Be ineligible for Medicare Part D; and
3. (c) Have been prescribed ten (10) or more medications per month.

2716.6 To provide MTM services, a provider must meet the following qualifications:

1. (a) Have an active and unrestricted pharmacy license in the District of Columbia, consistent with the requirements outlined in 17 DCMR Chapter 65;
2. (b) Have an active pharmacist National Provider Identifier (NPI);
3. (c) Be enrolled as a DC Medicaid provider;
4. (d) Meet the provider participation requirements outlined in 29 DCMR § 2701;
5. (e) Use the electronic MTM system, identified by DHCF in District of Columbia Pharmacy Benefit Manager Services Fee-for-Service (FFS) Provider Manual and MTM transmittals, to document provided services;
6. (f) Complete an MTM training program identified by DHCF in the District of Columbia Pharmacy Benefit Manager Services Fee-for-Service (FFS) Provider Manual and MTM transmittals.

2716.7 Reimbursement rates for MTM services can be found in the online fee schedule at www.dc-medicaid.com.

2716.8 For calendar year 2024, providers may bill for MTM services provided on or after July 1, 2024.

SOURCE: Final Rulemaking published at 72 DCR 002353 (March 7, 2025).