IOWA MEDICAID IS VIOLATING FEDERAL LAW

WHEN IT COMES TO TREATING HEPATITIS C

Hepatitis C is a liver disease caused by the hepatitis C virus. It is transmitted through blood, primarily via injection drug use.

If untreated, it leads to liver cancer, liver failure, and ultimately death. People with advanced stage disease are often given liver transplants. Fortunately, hepatitis C can be completely cured with treatment. However, the treatment does not reverse damage already done to the liver.

Risks associated with hepatitis C

Liver cancer

Liver failure

Death

HCV in young adults ages 30 and under is on the rise in Iowa

Hepatitis C is a national epidemic, and kills more people than the next sixty leading infectious diseases, combined. It is also a serious public health problem for Iowans.

The Iowa Department of Public Health estimates that there are between 39,215 – 149,173 Iowans living with the virus, but 85% do not know that they are infected. In Iowa, the majority of new hepatitis C infections are in people under age 40 who inject opioids or methamphetamine. Most patients with hepatitis C who need treatment are enrolled in Iowa Medicaid (a study from the University of Iowa found that over 50% of hepatitis C patients were Medicaid beneficiaries).

Iowa Medicaid does not provide hepatitis C treatment coverage for all patients.

Currently, the state requires patients to have advanced stage liver disease and be abstinent from illegal drugs to receive treatment. In a December 2017 letter from Iowa Medicaid to the Legislative Services Agency, the Iowa Department of Human Services writes that “prior authorization criteria” are used to evaluate whether or not patients may qualify for treatment.

Iowa Medicaid’s failure to provide treatmentto people with Hepatitis C is illegal.

Section 1927 of the federal Social Security Act contains rules regarding Medicaid drug coverage. The Centers for Medicare and Medicaid Services (CMS), part of the U.S. Dept. of Health and Human Services, issued guidance to state Medicaid programs in November 2015 to clarify the law and how it applies to hepatitis C medication coverage:

State Medicaid programs may only use prior authorization criteria if a drug is being prescribed for a “non-medically accepted indication.” But the medications that cure hepatitis C have no other use: hepatitis C is the medical indication.

Bottom line

Iowa Medicaid uses prior authorization criteria to keep hepatitis C patients from accessing treatment, but CMS says that this violates federal law, and that prior authorization criteria does not apply to hepatitis C drugs.

Treating Medicaid patients for hepatitis C is expensive. But with early therapy, the need for liver transplants and cancer therapies can be avoided, resulting in massive cost savings to Medicaid programs

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