Fillable EOI-Form-Year3 2020 Hepatitis C Medicaid Affinity Group: Expression of Interest Form

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EOI-Form-Year3 2020 Hepatitis C Medicaid Affinity Group: Expression of Interest Form

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2020 Hepatitis C Medicaid Affinity Group:
Expression of Interest Form
Overview
The Hepatitis C Medicaid Affinity Group was launched in December 2017 with the aim of
increasing the number and percentage of people diagnosed with hepatitis C virus (HCV) infection
who are successfully treated and cured. Eight states participated in Year 1 of the Affinity Group.
Nine states participated in Year 2, which had an optional focus on correctional settings. For the
third year (2020), the Affinity Group aims to support the continued efforts of states already
participating in the group and help new state participants develop and implement custom
strategies, including exploring issues and strategies related to hepatitis c screening and treatment
in substance use disorder (SUD) treatment sites if the state chooses this emphasis. The Affinity
Group aims to encourage collaboration between Medicaid, public health authorities, state
corrections agencies, and starting in 2020, state behavioral health agencies working on SUD
initiatives. We expect that each state will receive a stipend of approximately $5,000-$10,000 to
support coordination activities.
NAME OF YOUR STATE:
A. Your Project and Goals
To be considered for participation, please respond to the following items and attach additional
pages as needed.
1. In the past five years, what steps has your state Medicaid program undertaken to
improve hepatitis C-related prevention, care quality, and outcomes? Please describe
efforts to date, current status, state partners, and the extent to which partners have
been involved. Optional: Please describe state efforts related to hepatitis C prevention
in correctional settings or SUD treatment sites.
2. Briefly describe your state’s proposed strategy/ies to increase the number and percentage
of Medicaid beneficiaries diagnosed with chronic hepatitis C who are successfully treated and
cured. (Limit length to one page). Optional: Briefly describe your state’s proposed strategy/ies
to addressing hepatitis C prevention in correctional settings or SUD treatment sites.
3. What results does your state hope to achieve by December 2020 using the selected
strategy/ies? Please define your measures clearly.
2020 Hepatitis C Medicaid Affinity Group:
Expression of Interest Form
4. Briefly describe the impact of the opioid crisis and other substance use on your state and the
Medicaid and public health response.
5. Is there any specific technical assistance your state will need? If so, please describe.
6.
Provide the current number of Medicaid enrollees in your state and the number
diagnosed with current HCV infection (HCV RNA positive)*. If available, provide the
number of Medicaid enrollees positive for HCV RNA who have been treated or an
estimate of same.
Individuals enrolled in Medicaid
Total number
Total number with HCV RNA+
Total treated for hepatitis C
*If HCV RNA positivity prevalence is not available, please define the prevalence indicated (e.g., HCV antibody positivity; confirmed or
probable CSTE-defined cases)
B. State Team
1. Please list the individuals from your state who will participate in the Hepatitis C
Medicaid Affinity Group Project in the table below (add additional rows if
needed).
Name Title Agency/
Department
Phone Number Email Address
2. Which of these individuals will be the lead contact for your state team?
Totals
2020 Hepatitis C Medicaid Affinity Group:
Expression of Interest Form
C. Leadership Expression of Support
Each state team participating in the Hepatitis C Medicaid Affinity Group is expected to have the
support of the Medicaid Director or designee AND the Sta te Public Health Official or d esignee to
demonstrate the state’s interest in achieving the project’s goals. In addition, if the state choses to
participate in corrections or SUD-related activities, we encourage involvement of an appropriate
agency official. Please indicate the names of the supporting officials below.
Medicaid Official
Name
Signature
Title
Agency
State Public Health Official
Name
Signature
Title
Agency
Optional
Correctional Agency Official
Name
Signature
Title
Agency
Optional
Behavioral Health Agency Official
Name
Signature
Title
Agency
The Expression of Interest form is due back to Corinna Dan at Corinna.Dan@hhs.gov by Friday,
November 1, 2019 at 5:00 PM EST. Federal partners will review the Expression of Interest Form
and select states based on the estimated impact of their proposed strategies, demonstration of
support for the project, and the composition of the proposed state team. For more information
about the Hepatitis C Medicaid Affinity Group go to:
https://www.hhs.gov/hepatitis/action-plan/federal-response/hepatitis-c-medicaid-affinity-
group/ index.html
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EOI-Form-Year3 2020 Hepatitis C Medicaid Affinity Group: Expression of Interest Form

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Completed 23 February 2020

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