7 insurers agree to expand coverage of chronic hepatitis C treatment, New York AG says

NYS Attorney General Eric Schneiderman. Photo by Casino.org

New York state and seven health insurance companies have come to an agreement that ensures patients with chronic hepatitis C get coverage whether the members develop advanced signs of the infection or not, New York Attorney General Eric T. Schneiderman announced Tuesday.

Prior to the agreement, many health plans limited coverage unless there was advanced disease, such as liver scarring or other complications.

The agreements affect nearly all commercial health insurance plans in New York State, but does not include Capital District Physician's Health Plan, according to the insurer and the AG's office.

"Our lawsuit against CDPHP remains active and ongoing," said Nick Benson, senior deputy press secretary for the Attorney General's Office.

Two weeks ago, Schneiderman said a lawsuit had been filed in New York Supreme Court against CDPHP, alleging the insurer unlawfully restricted coverage of treatment for chronic hepatitis C infection. The lawsuit said CDPHP denied coverage for such treatment unless the member demonstrated advanced disease – such as moderate to severe liver scarring.

"CDPHP currently covers hepatitis C prescription drug treatments in a manner comparable to virtually every other health plan – and in some cases our coverage goes further," CDPHP said at the time.

On Tuesday, CDPHP said it had developed a policy for hepatitis C coverage in conjunction with local physicians, the New York State Department of Health, and other members of the industry that  mirrors that of the other health plans in the state.

[Also: Medicaid denies 46 percent of pricey hepatitis C drug prescriptions, study finds]

CDPHP expressed a willingness to join the state agreement after it learned the AG had opened discussions with other health plans to negotiate proposed policy changes, according to Chief Strategy Officer Robert R. Hinckley.

"However the AG refused to allow our participation," Hinckley said.

Hinckley said in Tuesday's statement, "After the Attorney General's initial inquiry, we made it clear that CDPHP was willing to work with his office and our principal regulators, the Department of Health and the Department of Financial Services, to change the policy."

The AG chose to commence legal action instead, he said.

Two weeks ago, the AG's office said CDPHP's restriction of treatment for hepatitis C is inconsistent with the prevailing treatment guidelines.

Further, the complaint alleged that CDPHP may have restricted coverage treatment because of the potential expense, yet its plan documents never disclosed to current or potential members that it considered cost when deciding whether treatment for a disease would be covered by the plan. 

"By failing to disclose that cost is a consideration in making determinations as to whether and when treatment is deemed 'medically necessary,' and by failing to cover treatment for hepatitis C even when it meets the plan's definitions of 'medically necessary,' the lawsuit alleges that CDPHP is misleading its members about the scope of their coverage," the AG's office said in filing the lawsuit.

[Also: Medicare spends $4.5 billion on Hepatitis C drugs in 2014]

The lawsuit further alleges that by failing to fully disclose the definition of "medically necessary" used in determining when benefits will be covered, CDPHP violated New York State Insurance Law and Public Health Law.

CDPHP has approximately 450,000 members in New York State and provides service to 24 counties throughout the Capital Region, North Country, Hudson Valley, Central New York, and the Southern Tier. 

Tuesday's agreement includes insurers Affinity Health Plan, Empire BlueCross BlueShield, Excellus Health Plan, HealthNow, Independent Health, United Healthcare/Oxford and MVP Health Plan, the AG's office said Tuesday.

Prior to the agreement, five of the seven insurers limited chronic hepatitis C coverage to members with advanced liver scarring or other complications, the AG's office said. Four of the insurers previously denied coverage of treatment based on a member's use of alcohol or other drugs, and three of the insurers only permitted specialists to authorize treatment, the AG said.

Under the agreement, the plans will not deny coverage because a covered member uses alcohol or drugs, or because the authorizing physician is not a specialist, Schneiderman said.

"By removing these three restrictive criteria, the insurers' hepatitis C coverage policies will more closely reflect evidence-based guidelines for treatment of chronic hepatitis C infection," Schneiderman said.

The seven health plans must fully implement the revised criteria within 45 days of the agreement and will send notices to members who were denied coverage who may now be eligible for treatment, he said.

Several medications are currently available that can completely cure Hepatitis C, the AG said.

Hepatitis C is contracted through blood, including through intravenous needles, contaminated blood products -- before blood was routinely screened starting in 1992 -- and, less commonly, through sexual intercourse, according to the AG's office.

Approximately 3.5 million Americans suffer from a chronic hepatitis C viral infection, and it is estimated that 25,000 individuals become infected with hepatitis C each year.

Chronic hepatitis C infection can cause liver failure, liver cancer, brain damage, and kidney failure, and, if left untreated, can result in cirrhosis and be fatal. Chronic liver disease/cirrhosis is the twelfth leading cause of the death in the United States, according to the AG's office. 

Twitter: @SusanJMorse