Complaint Filed Against Alabama Medicaid for Hepatitis C Coverage

Editor's Note 05/13/2022: This article has been corrected to indicate that AIDS Alabama and CHLPI filed an administrative complaint against Alabama Medicaid. A previous version said that the organizations filed a lawsuit.

Editor's Note 10/06/2022: This article has been updated to reflect that the Alabama Medicaid agency responded to the complaint by removing the sobriety requirement.

The National Viral Hepatitis Roundtable (NVHR) has expressed its support for an administrative complaint against the Alabama Medicaid program, which argues that the Medicaid program has denied access to hepatitis C virus (HCV) treatment for patients with substance use disorders.

“It is encouraging to see AIDS Alabama and CHLPI stand up for Alabamians living with substance use disorder and fight for the right to access necessary HCV treatment,” Adrienne Simmons, director of programs at NVHR, said in the NVHR press release that HealthPayerIntelligence received by email. 

Simmons attributed Alabama’s low ranking on access to HCV treatment to certain sobriety restrictions. 

In December 2021, the state received a grade of D+ for its Medicaid program's policies around access to hepatitis C treatment on a scale of A to F, a downgrade from its ranking in the March 2021 report.

In Alabama, a prior authorization form for hepatitis C treatment requires confirmation that the individual has not used alcohol or illicit substances in the past half-year, along with a screening report as proof. Patients also have to agree not to use such substances during treatment, and the penalty for breaking that agreement is the withdrawal of Medicaid coverage for hepatitis C therapy.

“It’s critical that sobriety restrictions, which are primarily rooted in stigma, are lifted across the country to ensure that the most vulnerable populations can access life-saving treatment for hepatitis C. We implore all states who currently impose sobriety restrictions to reconsider their policies with haste,” said Simmons.

AIDS Alabama and the Center for Health Law and Policy Innovation (CHLPI) of Harvard Law School filed the complaint together.

The complaint argues that Alabama Medicaid imposes a blanket restriction from receiving HCV treatment against individuals with substance use.

The complainants point out that HCV treatment—specifically, direct-acting antiviral (DAA) treatment—is efficacious for patients with and without substance use disorders alike and that this treatment is considered medically necessary for drug users and alcohol users.

Slightly more than 9 percent—or 44,897—of Alabama Medicaid beneficiaries had a substance use disorder in 2018, the complaint noted. With the high rate of HCV among drug users, the complainants argued that it is likely that blanket denials of HCV treatment for drug users have blocked access to care for thousands of Medicaid beneficiaries.

Treatment denials can have serious downstream health implications. The US Preventive Services Task Force (USPSTF) expanded the age for hepatitis C screening in order to protect against such a scenario. But the current lawsuit argues that Alabama’s Medicaid program’s policies might exacerbate negative patient outcomes.

“Sobriety restrictions on hepatitis C treatments hinder our ability to properly address the viral hepatitis and overdose syndemic,” said Daniel Raymond, director of policy at NVHR. “Eliminating these restrictions for Medicaid recipients in Alabama and other states will allow greater access to treatment for people who need it the most, namely people with substance use disorder and people who use drugs.”

Raymond argued for harm reduction programs for individuals with substance use disorders and hepatitis C.

The complaint also argues that the policy violates the Americans with Disabilities Act (ADA).

The complainants call on Alabama’s Medicaid program to remove the question regarding illicit drug use or alcohol use and screening requirements from the prior authorization form. Alabama’s Medicaid program should also drop the blanket denial of HCV treatment coverage for patients with substance use disorders and HCV.

Moreover, the complainants argue that Alabama’s Medicaid program should educate providers and Medicaid staff about substance use disorders, DAA treatment efficacy for those with substance use disorders, and how to reduce discrimination against patients with substance use disorders.

Alabama is not the only state that hinges Medicaid coverage for hepatitis C treatment on drug and alcohol disuse. According to NVHR’s press release, seven states deny hepatitis C treatment coverage for patients who have used drugs or alcohol within a specified timeframe.

States face a number of considerations around coverage for HCV treatment. Washington and Louisiana have both pursued subscription-based payment models in order to facilitate access to treatment for larger populations—specifically, for patients in the justice system. A study of these models in 2021 revealed that the efforts yielded mixed results on access to HCV medication.

Alabama Medicaid did not respond to a request for comment prior to publication.

On September 27, 2022, the Alabama Medicaid Agency announced that it would remove the sobriety requirement on the prior authorization.

"The Alabama Medicaid Agency will remove the requirement of absence of alcohol and illicit drug use by recipients for the prior approval of antiviral drugs used in the treatment of hepatitis C. A copy of the patient’s drug and alcohol screening lab report will no longer be required," the agency's notice explained. 

"All other criteria remain, including the patient consent form with the patient’s and physician’s signature, which must be submitted with requests."