Fillable Hepatitis C- Medicaid Affinity Group Expression Of Interest Form (Health and Human Services)

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Hepatitis C- Medicaid Affinity Group Expression Of Interest Form (Health and Human Services)

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Hepatitis C Medicaid Affinity Group:
Overview and Expression of Interest Form
Hepatitis C Medicaid Affinity Group Overview
The Hepatitis C Medicaid Affinity Group aims at increasing the number and percentage of
Medicaid patients diagnosed with hepatitis C virus (HCV) infection that are successfully treated
and cured. These outcomes have substantial benefits to the health and wellbeing of persons
living with HCV as well as significant social value including preventing transmission, early
mortality, productivity loss and substantial direct healthcare costs.
Participation in the Affinity Group is voluntary. The Office of HIV/AIDS and Infectious Disease
Policy (OHAIDP) in the Office of the Assistant Secretary for Health at Department of Health and
Human Services (HHS) will coordinate the HCV Medicaid Affinity Group in active collaboration
with CMS, CDC, and HRSA. Subject Matter Experts (SME) from collaborating federal partners
will support the Affinity Group by providing technical assistance, consultation, and feedback.
Benefits to State Participants:
Direct technical assistance that supports improved HCV-related outcomes among Medicaid
enrollees through better coordination, delivery, and assessment of high quality HCV prevention,
treatment and cure
Opportunity for states to learn and share best and promising approaches to improve health
outcomes and reduce costs by successfully treating and curing Medicaid enrollees diagnosed
with HCV
Stronger collaborative relationships among state Medicaid programs, and other state partners
(public or private) who are well positioned to advice and support efforts for maximum impact
The expectation is that the most viable and effective solutions and innovations will be
generated by states themselves while working collaboratively with their state colleagues as a
team, stakeholders in the state, and federal partners. Active participation in monthly Hepatitis
Hepatitis C Medicaid Affinity Group:
Overview and Expression of Interest Form
C Medicaid Affinity Group conference calls with other states and federal partners is an essential
requirement for success. In order to participate, states must submit a completed Expression of
Interest Form which seeks basic information such as:
1. The impact of HCV on the State Medicaid Population: number of persons in the state
Medicaid program, HCV prevalence (number and rate) in the state Medicaid population,
number and percentage of the Medicaid population diagnosed with HCV who have then
been treated and cured.
2. Barriers that have limited the number of individuals diagnosed with HCV in the state
Medicaid program who have been offered treatment and cured
3. State activities to date and preliminary strategies on how to address these barriers in
their state Medicaid program and the expected results
4. Names, titles, and contact information for the members of the state team that will
participate in this workgroup. Please indicate the lead or point of contact for the state
team.
The Expression of Interest form is due back to Corinna.Dan@hhs.gov on Friday,
November 3, 2017 at 5:00 PM EST.
A limited number of states will be able to participate. 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, evaluation of local efforts, and the
composition of the proposed state team.
For more information about affinity groups go to:
https://www.medicaid.gov/medicaid/benefits/prevention/index.html.
Hepatitis C Medicaid Affinity Group:
Overview and Expression of Interest Form
STATE:
A. Your Project and Goals
The goal of the Hepatitis C Medicaid Affinity Group is to increase the number and percentage of
Medicaid enrollees diagnosed with HCV infection that are successfully treated and cured. To be
considered for participation, please respond to the following items and attach additional pages
as needed.
1. In the past five years, has your state Medicaid program undertaken work on HCV? If
yes, please describe efforts to date, current status, and which state partners and the
extent to which they have been involved.
2. Provide the current number of Medicaid enrollees diagnosed with HCV infection and
the percentage of the total number of enrollees they represent in your state. If
available, provide the number and percentage of Medicaid enrollees with HCV
infection who have been treated and cured or an estimate of same. If you do not have
information about treated and cured patients available currently and your state is
selected to participate, this information will be requested to be provided within 30 days
of notice of selection. This information will be used as a baseline for your state in
measuring strategy success.
3. Is there any specific technical assistance your state will need? If so, please describe.
4. Are there barriers to success that your state has encountered or anticipates? If so,
please describe.
Hepatitis C Medicaid Affinity Group:
Overview and Expression of Interest Form
5. Briefly describe your state’s proposed project strategy/ies to achieve the goal set by
this Affinity Group. (limit length to one page)
Name Title Agency/
Department
Phone Number Email Address
6. What results does your state hope to achieve by December 2019 using the selected
strategy/ies? Please define your measures clearly.
7. Briefly describe the impact the opioid epidemic is having in your state.
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.
2. Which of these individuals will be the lead contact for your state team:
_________________________________
Hepatitis C Medicaid Affinity Group:
Overview and 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 equivalent AND the State Public Health Official OR
Hospital Association Director to demonstrate the state’s interest in achieving the project’s
goals. Please indicate the names of the supporting officials below.
Medicaid Official
Name ________________________________________________________________________
Signature
Title _________________________________________________________________________
Agency _______________________________________________________________________
_____________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
State Public Health Official/State Hospital Association Director
Name
Signature _____________________________________________________________________
Title
Agency _______________________________________________________________________
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Hepatitis C- Medicaid Affinity Group Expression Of Interest Form (Health and Human Services)

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Completed 20 July 2020

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