Pennsylvania

Liver damage restrictions

Effective January 1, 2018, Fee-For-Service (FFS) eliminated its liver damage requirements: beneficiaries with no liver damage (F0 or greater) can qualify for treatment. Aetna Better Health, AmeriHealth Caritas Pennsylvania, Geisinger Health Plan, Keystone First Health Plan, Health Partners, UPMC for You and UnitedHealthcare Community Plan do not list minimum liver damage requirements. Gateway Health Plan still has a publicly available eligibility document clearly indicating that at least minor liver damage (F1 or greater) is required.

Sobriety restrictions

FFS and all MCOs require the prescriber to screen and counsel beneficiaries on alcohol and substance use as well as offer a referral for substance use treatment.

Prescriber restrictions

FFS does not impose prescriber restrictions. Five MCOs, Aetna, AmeriHealth, Gateway, Health Partners, and Keystone also do not impose prescriber restrictions. Three MCOs, Geisinger, UPMC, and UnitedHealtcare Community Plan, require a prescription from a specialist.

Recommendations

• Eliminate the requirement to screen beneficiaries for substance use.
• Ensure all MCOs comply with the hepatitis C coverage mandate to create equal access to medications across the Medicaid program and transparency regarding hepatitis C coverage criteria.
• Ensure transparency of requirements by MCOs.