What Private Providers Should Know About MTM for Non-Medicare Populations

People with private insurance, Medicaid, employer-sponsored health plans, and no or not enough insurance are all starting to use MTM principles, even though MTM is most often associated with Medicare Part D. Private providers need to know how to use MTM for these groups.

Why MTM Outside Medicare Matters

• Many people, not just older adults, have many chronic diseases. Younger patients with diabetes, asthma, high blood pressure, mental health issues, and other conditions have similar problems with managing their medications.

• Employer-sponsored plans and private insurance plans are under pressure to improve outcomes and lower costs. MTM adds value by lowering hospital stays, lowering medication errors, and improving quality of life.

• Addressing disparities: certain racial/ethnic and socioeconomic groups may have less access to MTM under standard Medicare eligibility; offering MTM more broadly helps reduce inequities.

How Eligibility & Models Differ in Non-Medicare Settings

The eligibility criteria and models for MTM programs differ significantly when they are not part of Medicare. Many private and non-Medicare MTM programs don't have the same eligibility rules as Medicare Part D. Medicare usually has requirements like

• Having more than one long-term illness

• Taking more than one Part D drug

• Going over a certain amount of drug use or cost

Private plans may set different thresholds or none at all. They may target high-risk patients via claims data (frequent hospitalizations, polypharmacy, frequent ER use) rather than age. Some employers or state Medicaid health programs are more flexible when it comes to MTM or similar models.


What Private Providers Need to Know to Use MTM

1.Making the Program

• Find candidates by looking at their prescriptions, chronic diagnoses, gaps in refills, frequent trips to the hospital or ER, and so on.

• Partnerships: Pharmacists are crucial. Think about whether to include MTM services in your clinic, hire pharmacy services, or use telehealth.

• Main Parts:Even outside Medicare, follow best practices: comprehensive reviews, action plans, follow-up, and documentation.

2.  Measuring Outcomes

• Clinical markers (A1C, BP, lipids)

• Safety measures: adverse drug events, interactions, and duplicate therapy

• Use: going to the hospital or the emergency room

• Rates of adherence, patient happiness

3. Things to think about when it comes to money and getting paid back

• Many private payers see MTM as a way to save money, but the amount they pay back may be different. Some employers may pay for things if they see benefits like fewer sick days and less use.

•  Showing ROI is important: savings from fewer hospitalizations, fewer bad drug events, and better control of chronic diseases.

4. Rules and Policies for the Environment

• Learn about state laws, such as the scope of practice for pharmacists, telehealth rules, and collaborative practice agreements.

• Insurance rules include what payers cover, how much the patient has to pay, and the terms of the contract.

5. Teaching and getting patients involved

• Tailor communication: many patients outside Medicare may not expect or know about MTM.

• Use technology like apps, phones, and portals to make it easier to send reminders and follow-ups.

Evidence & Examples

A study of pharmacist-led MTM in various settings outside Medicare showed improved blood pressure, cholesterol, diabetes control, and reductions in ER/hospital utilization. MTM programs in Medicaid or employer settings have been successful when targeted appropriately.


Conclusion

MTM isn’t just a Medicare benefit—it’s a healthcare best practice. For private providers, using MTM in groups that don't receive Medicare can lead to safer care, better results for people with chronic diseases, lower costs that could be avoided, and happier patients. To be successful, you need to design well, measure what matters, obtain reimbursement or cost-sharing models, and ensure that patients are involved. As healthcare moves toward value and outcomes, MTM for all patients with chronic diseases becomes not only possible but also necessary.

How HealthArc Can Help

We make MTM easier for providers at HealthArc.io for all types of patients. Our platform brings together medication therapy management (MTM), chronic care management (CCM), and remote patient monitoring (RPM) into one smooth system. HealthArc helps you cut down on negative events, speed up workflows, and make the most of reimbursement opportunities by giving you built-in compliance tools, the ability to share data in real time, and ways to get patients involved. HealthArc gives your care team the tools they need to provide safer, more effective, and financially sound medication management for patients with Medicare, Medicaid, or private insurance.