What the CMS Guidance Means for People Who Inject Drugs

By Magalie Lerman December 14, 2015

NASTAD applauds the Centers for Medicare and Medicaid Services (CMS) commitment to providing access to curative hepatitis C (HCV) treatment to those in need. As outlined in guidance CMS released November 5, 2015, state Medicaid programs and Medicaid Managed Care Organizations (MCOs) are prohibited from restricting access to certain drugs unless the restrictions are clinically based. This guidance, a response to widespread reports of discriminatory utilization management practices, represents an important step toward maximizing equitable access to treatment for the estimated 578,000 Medicaid beneficiaries living with HCV. Objectionable practices include abstinence requirements, prescriber limits and rationing treatment to those who already have experienced liver damage. Specifically, the guidance notes:

  • State Medicaid programs and MCOs may not require that a patient have advanced fibrosis, resulting in scarring of the liver, in order to qualify for HCV treatment. Waiting to treat people until they are seriously ill is bad individual and public health policy. In addition to reducing individual quality of life, denied access to treatment means an increased probability of transmission to others. In an era of treatment as prevention, studies have found that HCV treatment, in combination with syringe access and medication assisted therapies, are necessary to eliminate HCV.
  • State Medicaid programs and MCOs may not impose sobriety requirements that mandate abstinence from alcohol and drugs for a specified period before and during treatment. No medical evidence supports this requirement; rather, evidence suggests that people who inject drugs (PWID), when given access to non-judgmental curative treatment, have high rates of treatment adherence and low rates of reinfection.
  • State Medicaid programs and MCOs may not require referrals from specialists as a condition of treatment. Imposing provider restrictions are not clinically based and only serve to limit access.  

CMS recognizes that these restrictions are rooted in stigma and financial insecurity, and encourages Medicaid programs to negotiate with drug manufacturers to lower treatment cost. 

CMS calls upon states to lift discriminatory policies that limit access to HCV cures and will be monitoring states for compliance. State health departments can work with community advocates to use the CMS Guidance in letters or meetings with state Medicaid Directors. Communities of PWID and allies are well positioned to organize local strategies aimed at gaining treatment access. An effective response must be multi-faceted. With the CMS Guidance as another tool in our tool box, we can remove systemic barriers that impede drug user health.

Action Steps

Below are action steps that health departments can take to ensure implementation of this important guidance in their jurisdiction:

  1. Review your state’s pharmacy benefit policies for compliance with the guidance. Key considerations include:
    1. Is access to treatment based on beneficiary liver fibrosis scoring? This practice is explicitly banned in the guidance.
    2. Is access to treatment based on an abstinence requirement? Again, this practice is also now banned.
    3. Does your Medicaid program limit the types of providers that are able to prescribe HCV treatment? If so, first verify that the program has referenced a clinically-appropriate justification for this practice. Next, advocate for a policy that places no prescriber limits on providers
  2. Use the template created by the Hepatitis Education Project to advocate for better access to HCV treatment.
  3. Contact Magalie Lerman at mlerman@NASTAD.org if you have any questions or comments.