HCV Testing and Coverage Impact of Health Care Reform Carl Schmid - - PowerPoint PPT Presentation

HCV Testing and Coverage – Impact of Health Care Reform

Carl Schmid

Deputy Executive Director The AIDS Institute Washington, DC July 10, 2014

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• Why Hepatitis Screening is Important
• The USPSTF
• Hepatitis C Testing Grade
• Prevention and the ACA
• Coverage by each payer
• Medicare
• Private Insurance
• Medicaid
• Next Steps

Outline

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Why HCV Testing is Important

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Source: Yehia BR, Schranz AJ, Umscheid CA, Lo Re V III (2014) The Treatment Cascade for Chronic Hepatitis C Virus Infection in the United States: A Systematic Review and Meta-Analysis. PLoS ONE 9(7): e101554. doi:10.1371/journal.pone.0101554

• Sponsored by Agency for Healthcare Research and Quality

(AHRQ) at the HHS

• Leading independent panel of private-sector experts in

prevention and primary care

• “Conducts rigorous, impartial assessments” of evidence for

effectiveness of clinical preventive services, including screening, counseling, and preventive medications

• Key to coverage determinations, particularly in health reform

implementation

US Preventive Services Task Force (USPSTF)

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USPSTF Grades

Grade Definition Suggestions for Practice A USPSTF recommends the service. There is a high certainty that the net benefit is substantial. Offer or provide this service. B USPSTF recommends the service. There is a high certainty that the net benefit is moderate or there is a moderate certainty that the net benefit is moderate to substantial. Offer or provide this service. C USPSTF recommends against routinely providing the

• service. There may be considerations that support

providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. (Previously no recommendation for/against). Offer or provide this service only if other considerations support

• ffering or providing the service

to an individual patient. D USPSTF recommends against the service. There is no moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service. I

Statement

USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the

• service. Evidence is lacking, of poor quality, or

conflicting, and the balance of benefits and harms cannot be determined.

Read the clinical considerations of the USPSTF Recommendation

• Statement. If the service is offered,

patients should understand the uncertainty about the balance of benefits and harms.

• Alcohol misuse counseling
• Blood pressure screening
• Cervical cancer screening
• Chlamydial infection

screening*

• Cholesterol abnormalities*
• Colorectal cancer screening*
• Depression screening
• Gonorrhea screening*
• Healthy diet counseling*
• Hepatitis B & C screening*
• HIV Screening
• STI counseling*
• Syphilis screening*
• Tobacco counseling &

screening

USPSTF Grade A & B Recommendations

(Partial List) * For “at risk” or certain sub-populations only (e.g. pregnant women, 50+)

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USPSTF & HCV Screening

• Prior to June 2013, USPSTF grades were:
• “D” – against screening adults not at-risk; and
• “I” – insufficient evidence for or against screening adults at high

risk

• In July 2012, USPTF proposed revisions:
• “B” – in favor of screening at-risk adults
• “C” – against screening adults not at-risk, but recognizing

possibility of individual indications where testing would be appropriate.

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• CDC Issued Revised testing recommendations in

August 2012

• “Adults born during 1945-1965 should receive
• ne-time testing for HCV without prior

ascertainment of HCV risk.”

• In reaction, and after much advocacy and new data

USPSTF reconsidered its recommendation

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USPSTF & HCV Screening

• Final recommendation is a “B” grade
• One-time screening of adults born 1945-1965 (Baby Boomers,

ages 49-69)

• Screening for people who are at risk of HCV infection.
• Persons at continued risk should be screened “periodically.”
• Published in June 2013

USPSTF & HCV Screening

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According to the USPSTF “at risk” for HCV is defined as :

• “persons with a current or past history of illicit injection drug use; and

persons who have a history of receiving a blood transfusion prior to 1992.”

• USPSTF also cites as additional risk factors:
• Long-term hemodialysis
• Being born to an HCV-infected mother
• Incarceration
• Intranasal drug use
• Getting an unregulated tattoo, and other percutaneous exposures.

Who is “At Risk for HCV?”

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• While much of the focus has been on expanded

coverage for care and treatment through private insurance plans & Medicaid, the ACA includes preventive services-for people who have coverage:

• Medicare
• Private Insurance
• Medicaid
• Based on USPSTF grades

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The ACA & Preventive Services

• Covers Preventive services with USPSTF “A” and “B” grades
• Medicare Improvements for Patients and Providers Act of 2008

(MIPPA)

• Covered by Medicare after national coverage determination

(NCD) process

• The ACA removed any beneficiary cost sharing
• Medicare initiated NCD process in September 2013 and

issued proposed NCD in March 2014 for HCV testing

• During comment period, many comments received urging Medicare

coverage per USPSTF recommendation

Medicare

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Medicare

• Coverage Determination finalized June 2014
• Medicare now covers HCV screening with no cost-sharing:
• One-time screening of adults born 1945-1965 (Baby Boomers)
• Screening for people who are at risk of HCV infection; annual

screening for people whose risk is ongoing.

• Medicare defines risk as “current or past illicit drug use” or having had

a blood transfusion prior to 1992

• Only in primary care settings

• Under the ACA most plans required to cover A & B

Services, without cost-sharing (Began September 2010)

• Applies to plans inside and outside of the marketplace (unless

grandfathered)

• Beginning the new plan year starting on or after June 30, 2014

(one year after the new USPSTF recommendation), plans will be required to cover HCV screening

• One-time screening of adults born 1945-1965 (Baby Boomers)
• Periodic screening for people who are at risk of HCV infection

Private Insurance

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Non-grandfathered private individual and small group plans (inside and

• utside of exchanges) must provide 10 categories of Essential Health

Benefits (EHB):

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use

disorder services, including behavioral health treatment

• Prescription drugs
• Rehabilitative and habilitative

services and devices

• Laboratory services
• Preventive and wellness services

and chronic disease management

• Pediatric services, including oral

and vision care

“A” & “B” graded USPSTF services are also included through the preventive benefit category, as are other services.

Private Insurance and Health Reform

• Must cover medically necessary HCV testing under Social

Security Act

• State decision to cover other HCV testing if not medically

necessary, such as one-time screening in Baby Boomer age- group

• CA, NY, OR and TX report that they cover “routine” HCV testing
• FL does not

Traditional Medicaid

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• ACA incentivizes states to cover USPSTF “A” & “B” services
• - 1% increase in federal match for cost of covering all “A”

& “B” and other preventive services

• Began January 1, 2013
• States that fully align their Medicaid expansion package with

traditional Medicaid will need to add these services

• Participating so far: CA, CO, HI, KY, NH, NJ, NV, NY,

OH, WI

Traditional Medicaid

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• ACA envisioned all states would expand their Medicaid

programs to include those up to 138% FPL

• Supreme Court decision made expansion a state decision
• Many states remain undecided or against but hope to see

a phasing in of acceptance as with Medicaid and CHIP in the past

Medicaid Expansion

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State Decisions on Medicaid Expansion

Source: Center on Budget and Policy Priorities. “Status of the ACA Medicaid Expansion” http://www.cbpp.org/files/status-of-the-ACA-medicaid-expansion-after-supreme-court- ruling.pdf, accessed June 19, 2014.

• Expanded Medicaid plans (Alternative Benchmark Plans)

beginning January 1, 2014

• Required to cover all “A” and “B” grade services
• Through the essential health benefits preventative service category
• No cost sharing
• In states that opt to expand Medicaid, enrollees in newly

covered group will have access to HCV screening at no cost:

• If at higher risk for HCV, or
• Born between 1945 and 1965 – one-time testing

Medicaid Expansion

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Summary of Coverage

• Medicare
• At-risk or one-time if born 1945-1965
• No cost-sharing
• Primary care settings only
• Private Insurance – including ACA Marketplace plans
• At-risk or one-time if born 1945-1965
• No cost-sharing
• Traditional Medicaid
• If medically necessary
• State option for “routine,” i.e., not medically necessary
• Some states may require copayments
• Expanded Medicaid
• At-risk or one-time if born 1945-1965
• No cost-sharing

The AIDS Institute

The AIDS Institute

• ACA has improved access to reimbursable HCV testing and
• ther preventive services across all payers
• USPSTF grades are critical to coverage
• Coverage varies by payer and state
• State advocacy needed for coverage of Traditional Medicaid

beneficiaries

• Need states to expand Medicaid
• Availability of coverage does not automatically translate into

usage

• Need for education and outreach in order to implement
• Entities must develop tools for billing
• CDC funding for hepatitis testing is extremely limited

Next Steps

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• President Obama’s FY14 Budget included $10 million in existing

CDC HIV funding to develop billing systems

• In March 2014, Health Departments were instructed to Redirect 19% of

their Expanded HIV Testing funding to develop capacity for billing

• Includes related co-infections such as HCV & STDs
• President’s FY15 budget includes $8 million in existing funding

for same purposes

• Still need CDC appropriated funding for HCV testing
• Coverage is for those with health insurance
• Reimbursement is for the actual test
• Need to pay for outreach, staffing, linkage to care, and other services

Next Steps

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• Opportunities through the ACA, together with the USPSTF

grade change, can help increase HCV screening but still must operationalized on the ground

• HCV community will need to work with federal partners,

state and local health departments, private payers, and providers to increase testing and reimbursement practices

Conclusion

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• USPSTF: http://www.ahrq.gov/clinic/uspstfix.htm
• A & B services:

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

• HCV Screening:

http://www.uspreventiveservicestaskforce.org/uspstf/uspshepc.htm

• Medicare National Coverage Determination: http://go.cms.gov/1mzmLa1
• The AIDS Institute’s HCV Testing Coverage Guide: http://bit.ly/1vY8uGW
• Healthcare.gov Prevention Section: https://www.healthcare.gov/prevention/
• Prevention of HIV/AIDS, Viral Hepatitis, STDs, and TB Through Health Care:

http://www.cdc.gov/nchhstp/PreventionThroughHealthCare/Index.htm

Resources

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THANK YOU

Carl Schmid – cschmid@theaidsinstitute.org 202-835-8373 www.theaidsinstitute.org

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