The state expanded coverage of prior authorization criteria to include all levels of liver scarring and substance use without regard to the specialty of the provider, increasing access to hepatitis C treatments for more Texans.
The Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) and the National Viral Hepatitis Roundtable (NVHR) today recognize Texas Medicaid for removing minimum fibrosis, sobriety, and prescriber requirements for hepatitis C treatment as of September 1, 2021. As a result of this policy improvement, Texas’ score on its “Hepatitis C: State of Medicaid Access” scorecard has improved to A. Prior to this change, Texas was one of three states that required advanced liver scarring and one of 13 states that required patients seeking treatment to abstain from drugs and alcohol to receive treatment. Lifting these restrictions will increase access to the hepatitis C cure for the thousands of Texas Medicaid recipients that are living with hepatitis C.
The Texas Medicaid policy change was made thanks to CHLPI’s class action lawsuit with the Edwards Law Firm and Latham & Watkins on behalf of three Texas Medicaid enrollees infected with hepatitis C who were denied access to a cure. CHLPI and the litigation team secured a settlement with the Texas Health & Human Services Commission, which administers the state’s Medicaid program, that required the state to eliminate treatment criteria based on disease severity and substance use.
“The Texas Medicaid program had some of the most restrictive hepatitis C treatment criteria in the country, so we are glad to see the program take steps to make these highly effective treatments available to those who need them most,” said Phil Waters, Staff Attorney at CHLPI.
Cases of hepatitis C, a viral infection that causes liver inflammation and is one of the leading causes of liver disease, have been increasing since 2010 due to the ongoing opioid crisis. Complications from hepatitis C can be fatal if left untreated, however innovative direct-acting antiviral drugs can cure most people in 8-to-12 weeks. Yet barriers to this treatment persist across the country.
“This is an important step in addressing the alarming rise in hepatitis C cases in Texas, and slowing the rate of liver cancer, of which Texas has one of the highest rates in the country,” said Dr. Mamta Jain, an infectious disease specialist in Dallas, TX. “Access to treatment is critical, and we must turn our attention to strengthening our efforts to increase screening for HCV. As providers bring more people in to get screened, having the tools to treat them without these barriers will be crucial. This is a huge win for patients, and as a provider, it brings me hope that we can continue down the path to eliminating hepatitis C in the future.”
Texas Medicaid’s decision to remove restrictions to hepatitis C treatments will have real impacts on Texas families, including one mother whose 9 year-old son is living with hepatitis C. “This decision is huge for my son and our family,” she says. “Previously, due to Medicaid’s restrictive criteria, it would have cost us tens of thousands of dollars out-of-pocket for treatment, a price we would have been unable to afford. This has put a new lease on his life, and cements his future that he will get treatment and be cured.”
“It is encouraging to see Texas eliminate its discriminatory prior authorization requirements for hepatitis C treatment in accordance with evidence-based treatment guidelines,” said Adrienne Simmons, Director of Programs at NVHR. “NVHR stands ready to assist the state in helping Medicaid beneficiaries who were previously denied treatment get cured.”
Prior authorization is a process whereby health care providers must get advance approval before a payor will decide whether to cover a medication or service. For more information about hepatitis C treatment access barriers, please visit www.stateofhepc.org.
Food Law & Policy, Commentary
A grounding legal education in the Food Law and Policy Clinic
May 18, 2023