Several requirements and restrictions may block Medicaid from covering the cost of hepatitis C treatment. Coverage varies by state.
Hepatitis C is a disease caused by the hepatitis C virus (HCV). It causes liver inflammation.
Some people who contract the virus only develop a short-term acute infection, which often causes no noticeable symptoms and can go away on its own. However, about
If you have hepatitis C, antiviral treatment can reduce the amount of virus in your blood and cure the infection in most cases. Early treatment reduces your risk of liver damage and other complications.
The cost of your treatment will partly depend on whether you have insurance that covers it. Without insurance, antiviral treatment can cost anywhere from about $40,000 to $95,000, depending on which medication you use.
If you’re enrolled in Medicaid, hepatitis C treatment coverage varies from state to state.
Medicaid is a government-funded health insurance program that helps cover the cost of certain medical treatments for people who meet certain eligibility criteria.
The federal government sets out general rules for Medicaid, but each state operates its own program. That means that the treatment coverage, requirements, and restrictions vary from state to state.
If you have hepatitis C and you’re enrolled in Medicaid, your ability to access coverage for treatment depends on your state Medicaid agency’s specific treatment requirements and restrictions.
Some state Medicaid agencies have implemented more treatment requirements and restrictions for hepatitis C than others. Those requirements and restrictions can change over time.
To help people learn about these requirements and restrictions, the Center for Health Law and Policy Innovation (CHLPI) and National Viral Hepatitis Roundtable (NVHR) publish a yearly State of Medicaid Access report.
This report tracks multiple types of treatment requirements and restrictions for hepatitis C, including:
- Prior authorization requirements: In many states, doctors need to ask the state Medicaid agency for approval for hepatitis C treatment before prescribing it.
- Fibrosis restrictions: Some state Medicaid agencies restrict coverage for hepatitis C treatment to people with severe liver damage. This makes it harder to access early treatment.
- Substance use restrictions: Some state Medicaid agencies require enrollees to be screened for substances, get substance use counseling, and/or abstain from using drugs or alcohol to qualify for hepatitis C treatment.
- Prescriber restrictions: Some state Medicaid agencies only cover hepatitis C treatment when a doctor with specialized training prescribes the treatment or consults with the prescribing doctor.
- Retreatment restrictions: Some state Medicaid agencies apply more treatment restrictions to enrollees who already have received hepatitis C treatment in the past. This includes cases where the initial treatment didn’t work or the infection returned after treatment.
Some agencies also apply additional treatment restrictions or requirements that aren’t routinely tracked in the aforementioned access report. For example, your doctor might need to share certain test results with the agency or report how closely you follow your treatment plan.
Some agencies also outsource some services to managed care organizations or other private contractors. Those organizations may have additional treatment restrictions or requirements. For example, some managed care organizations may require drug testing even if the state Medicaid agency doesn’t require it.
In its report for 2022, the CHLPI and NVHR identified the following Medicaid treatment restrictions and requirements for hepatitis C:
|Prior authorization required for most enrollees||Fibrosis restrictions||Substance use restrictions||Prescriber restrictions||Retreatment restrictions|
|District of Columbia||X||X||X||X|
Not all of the restrictions and requirements are represented in this chart. Some state Medicaid agencies may apply additional treatment restrictions or requirements for hepatitis C. Some agencies also outsource services to managed care organizations or other private contractors that may have treatment restrictions or requirements of their own.
To learn more about your state Medicaid agency’s treatment restrictions and requirements:
- Contact your state Medicaid agency.
- Visit State of Medicaid Access to download a detailed report.
- Ask your doctor whether your treatment will be covered under Medicaid.
Your doctor may also refer you to a patient navigator or other support resources.
In some cases, you may be eligible for treatment coverage for certain types of hepatitis C medication but not others. Your doctor can help you understand the potential benefits and risks of taking a different medication.
If you’re not eligible for treatment coverage under Medicaid, you might qualify for a patient assistance or drug discount program that can help cover or reduce the cost of your care. For example, some states, pharmacies, drug manufacturers, and nonprofit organizations offer financial support to underinsured or uninsured people.
Early treatment for hepatitis C is important for reducing your risk of complications, like liver scarring.
If you’re enrolled in Medicaid, your hepatitis C treatment coverage will depend on the state you live in. The treatment requirements and restrictions vary from one state to another.
Your doctor or patient navigator can help you learn more about your treatment options and whether you qualify for coverage under Medicaid. If you don’t qualify for coverage under Medicaid, your doctor or patient navigator might recommend changes to your treatment or encourage you to explore other options for covering the costs of care.
In some cases, you might qualify for a patient assistance or drug discount program that can help lower or cover the cost of hepatitis C treatment.