The state Attorney General’s Office announced Thursday that it is suing Albany-based health insurer CDPHP over its coverage of treatment for chronic hepatitis C patients.
The lawsuit contends that Capital District Physicians’ Health Plan illegally restricted coverage for treatment for the potentially life-threatening condition.
It charges that CDPHP requires its members in the early stages of a chronic hepatitis C infection to monitor their disease, and wait until they develop liver scarring or other signs of advanced disease before it will pay for their treatment.
Hepatitis C facts
-- There is no vaccine. The best preventative measure is risk avoidance.
-- The virus is transmitted by blood, most often through intravenous drug abuse, less frequently through sex or personal items such as razors.
-- Symptoms include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain and yellow skin or eyes.
-- Symptoms appear two weeks to six months after exposure, but many patients don’t show symptoms.
-- It is the leading cause of liver cirrhosis and liver cancer and the most common reason for liver transplants.
-- About 15,000 Americans die annually from long-term complications.
-- A dozen treatments were approved by the FDA as of May 2015.
Source: U.S. Centers for Disease Control and prevention
Ali Skinner, spokeswoman for CDPHP, defended the insurer’s coverage guidelines in a statement Thursday, saying they were developed in consultation with physicians and are equal to what many other insurers offer.
“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,” she said. “Our policies are developed by an independent medical policy committee which, in collaboration with our community physicians, determines the scope of coverage, utilizing scientific and evidence-based analysis.”
According to the federal Centers for Disease Control and Prevention, the hepatitis C virus results in about 30,000 acute liver infections a year, many of which will become chronic infections. It said about 3.5 million Americans suffer from chronic hepatitis C, which can cause long-term health problems or death, even though the majority of patients experience few or no symptoms.
The CDC indicates that about 25 percent of patients will clear the virus from their body without treatment while it is still an acute infection, and 15 percent to 25 percent will clear it without treatment even after it becomes a chronic infection. It says experts don’t understand why this happens for some people.
New York Attorney General Eric T. Schneiderman said in a news release Thursday that several medications are currently available that can cure Hepatitis C. His lawsuit alleges that CDPHP is denying coverage for such treatment until the disease is advanced.
“When consumers purchase health insurance, they rightfully expect that if they are diagnosed with a serious, potentially life threatening disease like Hepatitis C, treatment will be considered ‘medically necessary’ and covered by their insurance,” Schneiderman said. “Forcing patients to wait for care, risking internal organ damage, is unconscionable and, as we allege in our lawsuit, violates the law and the company’s own policies.”
He noted that because of higher rates of infection seen in the baby boom generation, New York state since 2014 has required medical providers to offer hepatitis C screening to patients born between 1945 and 1965 and to provide or make a referral for follow-up health care to patients with a positive test result.
The lawsuit also alleges that CDPHP is misleading its members about the scope of their coverage and not telling members that a treatment’s cost is a factor in whether CDPHP will cover the treatment. The lawsuit also alleges CDPHP is violating the New York State Insurance Law and Public Health Law by failing to fully disclose the definition of “medically necessary” used in determining when benefits will be covered.
Skinner at CDPHP further rebutted the allegations.
“[Our] guidelines for coverage are comparable with the state’s own guidelines for Medicaid,” she said. “Despite an ongoing dialogue between the entire industry and the state, the Attorney General’s Office has chosen CDPHP, a national leader in quality and customer satisfaction, to initiate litigation on this matter. Our coverage decisions are made based upon the use of evidence-based clinical criteria, not upon political agendas or actions.”