Individuals with Hepatitis C in the Missouri Medicaid program filed this lawsuit in response to the denial of authorization from MO HealthNet for medications prescribed to cure their infections. MO HealthNet denied authorization of medication to plaintiffs based on their fibrosis scores (a measure for severity of Hepatitis C). After being prescribed medication for their Hepatitis C but denied prior authorization for the medication from Missouri’s Medicaid program, two Medicaid recipients initiated this lawsuit on October 18, 2016 in the U.S. District Court for the Western District of Missouri. The plaintiffs alleged that MO HealthNet’s policies resulted in the denial of medically necessary treatment to Medicaid beneficiaries infected with Hepatitis C, discriminated against similarly situated Medicaid beneficiaries on the basis of their fibrosis score even though Hepatitis C guidelines recommend treatment regardless of their score, and violated the “reasonable promptness” requirement of the Social Security Act by requiring individuals to wait until they had developed more severe liver damage before getting treatment. The plaintiffs brought their claims against the Director of the Missouri Department of Social Services and the Director the of MO HealthNet under Title XIX of the Social Security Act, § 1983, and the Medicaid Act. Represented by legal services, a law school clinic, and the National Health Law Program, the plaintiffs sought declaratory relief, attorneys’ fees and costs, and preliminary and permanent injunctive relief to prohibit the defendants from implementing and following their current Hepatitis C treatment policy, as well as enjoin the defendants from refusing to provide Medicaid coverage of medically necessary Hepatitis C drug and require notice to all Medicaid beneficiaries denied coverage under the current policy.
The case was automatically referred to mediation on October 18, 2016 and assigned to Judge William A. Knox. On January 30, 2017, the case was reassigned to an outside mediator.
On February 2, 2017, Judge Stephen R. Bough granted the plaintiffs’ request for a preliminary injunction in part to prohibit the defendants from requiring three months of negative drug and alcohol screens prior to submitting requests for approval of their Hepatitis C medications. The defendants had also agreed that the plaintiffs were entitled to a preliminary injunction to prohibit the drug and alcohol screens. The Court declined to rule on the request to prohibit defendants from applying policies based on fibrosis score until an evidentiary hearing had occurred because at least two factual disputes remained. The Court found that there was enough controversy surrounding the medical necessity of treatment regardless of fibrosis score and conflicting information on whether or not the defendants’ would deny authorization to patients with low fibrosis scores.
On the same day, Judge Bough also denied the defendants’ motion to dismiss for failure to state a claim. Judge Bough rejected the defendants' argument that there was no individualized federal right to reasonable Medicaid standards enforceable under 42 U.S.C. § 1983 because this mischaracterized the plaintiffs’ allegations. The plaintiffs’ alleged that the standards denied medically necessary treatment and Judge Bough noted that this was a valid claim because the Eighth Circuit previously held that the limiting of Medicaid coverage to those recipients meeting certain conditions or criteria violated Medicaid law and 42 U.S.C. §1983.
After the evidentiary hearing, Judge Bough denied the plaintiffs’ remaining request for a preliminary injunction on April 24, 2017, which would have prohibited the defendants from applying policies based on fibrosis scores. The plaintiffs did not show they were likely to succeed on the merits to the degree necessary to merit an injunction or any likelihood of immediate irreparable harm.
The plaintiffs amended the complaint June 6, 2017 to add another Medicaid recipient to the claim who was similarly denied authorization for prescribed Hepatitis C medication. Additionally, plaintiffs’ amended complaint alleged the defendants violated due process for failing to use reasonable, ascertainable, non-arbitrary standards and procedures for determining eligibility for medical assistance, procedural due process for failing to provide notice of the reasons for the denial of coverage, and the American with Disabilities Act for discrimination on the basis of their disability (Hepatitis C).
After MO HealthNet modified its preferred drug list and prior authorization criteria for certain medications, the defendants filed a motion for summary judgment claiming the case was moot. On November 20, 2017, the plaintiffs’ filed a motion to dismiss without prejudice because the claims were mooted by the new policy that no longer included restrictions based on fibrosis scores or abstinence. All three plaintiffs began to receive treatment for their Hepatitis C. Judge Bough granted the plaintiffs’ motion and denied the motion for summary judgement. The case was dismissed without prejudice with each party to bear its own fees and costs on November 20, 2017. The case is now closed.
Emily Kempa - 03/10/2019
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