Hep C Discussion Forum

I know some are having difficulty in getting approval for the new DAA HCV drugs via Medicaid. I think most of the problem lies at the State level not at the Fed level.

Here's a "Communication" from Medicaid (the Feds) and I think there is little doubt that they intend for Medicaid patients to have access to these new drugs.  (I think they see the scope of the Hepatitis C epedemic and see the implications nationwide, where states concentrate more on local budgets without viewing things from this nationwide perspective).

https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/prescription-drugs/hcv-communication.html

Note: There is a link there to the letter that addresses DAA HCV drug access (I already posted a direct link to that letter in another thread).

I bring this up again because I think it's important for every Medicaid patient diagnosed with HCV to have this letter in their arsenal and have access to the new DAA HCV drugs.

 ... Excerpt from the letter:

"CMS is concerned that some states are restricting access to DAA HCV drugs contrary to the statutory requirements in section 1927 of the Act by imposing conditions for coverage that may unreasonably restrict access to these drugs." (By "Act" they are referring to the Social Security Act, the act that governs the operations of Medicaid)

I think that this letter addresses three key things that states are currently using to deny Medicaid patients access to the drugs.

1)   state Medicaid programs are limiting treatment to those beneficiaries whose extent of liver damage has progressed to metavir fibrosis score F3, while a number of states are requiring metavir fibrosis scores of F4

2)   States are requiring a period of abstinence from drug and alcohol abuse as a condition for payment for DAA HCV drugs

3)   In addition, several states are requiring that prescriptions for DAA HCV drugs must be prescribed by, or in consultation with specific provider types, like gastroenterologists, hepatologists, liver transplant specialists, or infectious disease specialists in order for payments to be provided for the drug.

The letter goes on to state that "As such, the effect of such limitations should not result in the denial of access to effective, clinically appropriate, and medically necessary treatments using DAA drugs for beneficiaries with chronic HCV infections."

Observations about this letter:

The letter uses words like "should" rather than "shall" (which legally makes a difference ... but I think when it comes to legal, the governing document will be the 1927 Social Security Act which this letter refers to.

I look at this letter as a "shot across the bow" of individual states, in essence saying mind your P's and Q's because lying somewhere ahead may be a law suit or act of Congress if you are found to not be in compliance with the associated sections of the 1927 Social Security Act. It's my opinion that it's going to come down to state by state and likely involve individual law suits that set precedence in the courts. Once that happens, individuals in other states will follow. This could take a while but if I'm right, that may be the direction this all will eventually go.

inUntil such time, having this letter in your back pocket at an appeal can't hurt anything.

Linuxter