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Issue Alert - New DHHS Policy for treating Hepatitis C

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Date:

Aug 05, 2016

Program Area:

Medicaid

Issue Summary:

Michigan Department of Health and Human Services (MDHHS) has a new policy of covering new direct-acting antiviral (DAA) treatment that cures hepatitis C. Patients and advocates should be aware of the new policy, and refer patients denied DAA treatment to the Center for Civil Justice or another legal services program for assistance.

Persons Affected:

Individuals receiving Medicaid with a hepatitis C virus infection

For More Information:

Marie DeFer Center for Civil Justice 436 S. Saginaw St., Suite 400 Flint, MI 48502 (810) 244-8044 mdefer@ccj-mi.org


Background

New direct-acting antiviral (DAA) treatment can cure hepatitis C virus (HCV) infections. The Michigan Department of Health and Human Services (MDHHS) has a new policy of covering DAA treatment for certain Medicaid patients with HCV infections.

 

The Centers for Medicare and Medicaid Services (CMS) issued guidance that warns against state Medicaid restrictive DAA treatment policies. According to CMS and some federal district courts, restrictive treatment criteria includes but is not limited to: limiting DAA treatment to individuals with Metavir scores less than F3 or F4, requiring a period of abstinence from drug and alcohol abuse, and requiring that prescriptions for DAA treatment be prescribed by specialist physicians. CMS warned state Medicaid agencies that policies should not unreasonably restrict coverage of effective treatment using new DAA drugs to treat and cure HCV.

 

The Center for Civil Justice believes MDHHS policy unfairly restricts access to DAA treatment and violates federal law.

 

 

What's Happening?

Effective March 2016, MDHHS will cover DAA treatment approved by the Food and Drug Administration (FDA) for treatment of chronic HCV infected patients in certain situations. MDHHS requires patients to use a prior authorization to gain access to DAA treatment. A prior authorization (sometimes also called a prior approval or precertification) is an individualized process where MDHHS determines whether a patient’s health care services are medically necessary before each patient receives the requested services. Once MDHHS determines the service is medically necessary, MDHHS will approve coverage of the service. Patients and their physicians should work together to submit the prior authorization application to MDHHS.  

 

With the assistance of a physician, patients must meet specific criteria for MDHHS to approve the prior authorization for DAA treatment. MDHHS’s prior authorization requirements can be found at the following link: https://michigan.fhsc.com/Downloads/HepC_PAFax_MMA_201605a.pdf

 

 Further Information

 

 

For additional information on MDHHS’s new policy, please review the following external links and information.

 

  • MDHHS Non-Preferred DAA Agent (as of August 1, 2016): Olysio®

What Should Advocates Do?

  1. Encourage clients receiving Medicaid with a HCV infection to seek treatment from a gastroenterologist, hepatologist, liver transplant, or infectious disease physician.
  2. If a client’s physician recommends DAA treatment, encourage the client and physician to submit prior authorization to Medicaid regardless if the client meets all required criteria set forth in MDHHS’s policy.
  3. If client’s prior authorization is denied, help the client request a hearing, and alert the Center for Civil Justice at 810-244-8044 or 800-724-7441. 

What Should Clients Do?

  1. Seek treatment from from your physician if you have a HCV infection diagnosis.
  2. If your physician recommends DAA treatment, work with your physician to submit required documentation to Medicaid for prior authorization, regardless if you meet all required criteria set forth in MDHHS’s policy.
  3. If you are denied DAA treatment, request a hearing, and contact an attorney.
  4. The Center for Civil Justice is interested in hearing about these cases and may be able to assist you. You may reach the Center for Civil Justice at 810-244-8044 or 800-724-7441.
  5. Your local legal service office is also a good source for advice and possible representation.

 

 

Finding Help

Most legal aid and legal services offices handle these types of cases, and they do not charge a fee. You can locate various sources of legal and related services, including the free legal aid office that serves your county, at MichiganLegalAid.org. You can also look in the yellow pages under "attorneys" or call the toll-free lawyer referral number, (800) 968-0738.
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