Does Medicare Cover Hepatitis C Screenings?
Medicare will cover the full costs of a hepatitis C screening if your doctor or other qualified health care provider orders one and you meet other criteria related to your age or risk factors for having hepatitis C. If you meet Medicare’s requirements, you will pay nothing for the hepatitis C screening.
What Is Hepatitis C?
Hepatitis C is a viral infection that if left untreated can cause liver cancer, liver failure or cirrhosis of the liver. It is the leading cause of serious liver conditions in the United States.
It spreads through contact with contaminated blood and there is no vaccine to protect against hepatitis C. The virus usually does not present any symptoms, so most people who have it don’t realize they’re infected for years or even decades.
Hepatitis C screenings can tell you if you have the virus and allow you to seek treatment before it causes cancer or other serious liver damage.
Why Older Americans Are at Risk for Hepatitis C
People born as part of the baby-boom generation have been at the greatest risk of having hepatitis C lurking in their bodies. Much of this is because of the era in which they have lived and changes in culture and medical science.
The years between 1960 and 1980 were the period of the highest transmission of hepatitis C in the United States, according to University of Iowa Health Care.
- Less advanced surgical sterilization procedures
- Spread through transfusion and transplants due to lack of widespread blood supply screening prior to 1992
- Rise of recreational drug use from the 1960s through 1980s
The U.S. Centers for Disease Control and Prevention set up hepatitis C testing guidelines based on risk factors. The CDC estimated that more than 3 percent of baby boomers were infected with HCV — five times higher than any other age group at the time and roughly 75 percent of all hepatitis C cases in the United States.
Medicare expanded its coverage based on those CDC guidelines.
While the opioid crisis has led to younger demographics in recent years and the CDC reports a new wave of HVC infections, hepatitis C still remains a serious, “silent” killer for Americans born from 1945 through 1965.
Does Medicare Cover Hepatitis C Screenings?
Original Medicare — Medicare Part A and Part B — will only cover the cost of your hepatitis C virus (HCV) screening if your primary care doctor or other primary care provider orders one and you meet one or more of three other criteria that Medicare requires.
- You were born between 1945-65.
- You received a blood transfusion before 1992.
- You have used or are still using illicit injected drugs.
If you meet Medicare’s requirements, it will pay the full cost of the hepatitis C screening. You will pay nothing out-of-pocket so long as the doctor or other health care provider accepts the screening’s Medicare-approved cost.
Medicare Coverage for Single and Repeated Hepatitis C Screenings
Depending on your situation, Original Medicare will cover a one-time screening or repeated hepatitis C screenings.
- Single Hepatitis C Screening Coverage
- Original Medicare covers a single screening for beneficiaries born from 1945 through 1965 but do not have other high-risk factors.
- Repeated Hepatitis C Screening Coverage
- Original Medicare covers repeated hepatitis C screenings for certain high-risk beneficiaries. These include people who have used illicit injectable drugs in the past or for those who have received a blood transfusion prior to 1992. Medicare will pay for annual screenings for people still using illicit injectable drugs since their last negative screening.
Your doctor or other primary care provider will determine whether you are at high risk for HCV based on your medical history. This assessment typically comes as part of your Medicare annual wellness visit and the development of the comprehensive prevention plan you and your doctor create.
Medicare Coverage for Hepatitis C Treatments
Hepatitis C is treatable and can be cured with medication in most cases if it’s caught early. Waiting too long may require liver transplant.
- Antiviral Drug Treatment
- Treatment with antiviral drugs can take three months and has a 95 percent success rate. Medicare Part D prescription drug plans can help pay for treatment medications, but they are still expensive. Medicare requires all Medicare Part D formularies to cover at least one hepatitis C antiviral drug.
- Liver Transplant
- If your hepatitis C is not detected until you’ve suffered serious liver damage, you may require a liver transplant. Medicare covers many transplant costs, but you will still have to pay out-of-pocket expenses for some transplant services and drugs. A liver transplant typically does not cure hepatitis C. You may still need antiviral drug treatment to prevent damage to your new liver.
While there is no hepatitis C vaccine, your doctor may recommend vaccinations against hepatitis A and hepatitis B. These are other viruses that can also cause liver damage as well as complicating your case of hepatitis C.
7 Cited Research Articles
- U.S. Centers for Disease Control and Prevention. (2020, April 9). Beyond Baby Boomers: Hepatitis C Now Heavily Impacting Multiple Generations. Retrieved from https://www.cdc.gov/nchhstp/newsroom/2020/hepatitis-c-impacting-multiple-generations-press-release.html
- Mayo Clinic. (2020, March 20). Hepatitis C. Retrieved from https://www.mayoclinic.org/diseases-conditions/hepatitis-c/diagnosis-treatment/drc-20354284
- Chung, R. (2019, May 1). Baby Boomers and Hepatitis C: What’s the Connection? Retrieved from https://www.health.harvard.edu/blog/baby-boomers-and-hepatitis-c-whats-the-connection-2019050116532
- Gunderson, A.E. (2017, September). Ask an Expert: Why Should Baby Boomers Get Tested for Hepatitis C? Retrieved from https://uihc.org/health-topics/ask-expert-why-should-baby-boomers-get-tested-hepatitis-c
- U.S. Centers for Medicare & Medicaid Services. (2014, June 14). Screening for Hepatitis C Virus (HCV) in Adults – Implementation of Additional Common Working File (CWF) and Shared System Maintainer (SSMs) Edits. Retrieved from https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/mm9200.pdf
- U.S. Centers for Medicare & Medicaid Services. (2014, June 2). Decision Memo for Screening for Hepatitis C Virus (HCV) in Adults (CAG-00436N). Retrieved from https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=272
- U.S. Centers for Medicare & Medicaid Services. Hepatitis C Screening Tests. Retrieved from https://www.medicare.gov/coverage/hepatitis-c-screening-tests