Hepatitis C virus (HCV) is a blood-borne pathogen that primarily targets the liver, often leading to chronic liver disease, cirrhosis, and liver cancer if left untreated. Many infected individuals remain asymptomatic for decades, often unaware they have the infection until significant liver damage occurs. Since modern treatment can cure the infection in most cases, screening is a powerful tool for early detection and intervention. The federal health insurance program, Medicare, provides coverage for this preventive service for eligible beneficiaries.
Medicare Coverage for Hepatitis C Screening
Hepatitis C screening is covered under Medicare Part B, the component of Original Medicare that covers outpatient care and preventive services. Classified as a preventive benefit, the screening is covered to identify the presence of the virus before symptoms develop. The Centers for Medicare & Medicaid Services (CMS) formally added this benefit through a National Coverage Determination (NCD 210.13), effective in 2014, following recommendations from the U.S. Preventive Services Task Force (USPSTF).
The covered service involves an initial blood test designed to look for antibodies to the Hepatitis C virus. The presence of these antibodies indicates that a person has been exposed to HCV at some point in their life. This initial antibody test is performed when ordered by the beneficiary’s primary care physician or practitioner within a primary care setting.
Specific Eligibility Criteria for Screening
Medicare provides coverage for the HCV screening test based on specific risk factors and an individual’s birth year. One eligibility criterion is a one-time screening for all adults born between 1945 and 1965, often referred to as the “baby boomer” cohort. This single lifetime screening is offered regardless of whether the beneficiary reports any specific risk factors for infection.
Coverage is also provided for individuals who have a current or past history of illicit injection drug use, which remains a significant route of transmission. A covered screening is also available for beneficiaries who received a blood transfusion before July 1992, as widespread, reliable screening of the blood supply for HCV did not begin until that time.
If a beneficiary meets any of these conditions, the screening is covered, provided the test is ordered by a qualified healthcare provider. The provider must use these defined conditions to ensure the service meets the coverage guidelines set by CMS.
Frequency of Testing and Coverage Limitations
The frequency with which Medicare covers Hepatitis C screening depends upon the beneficiary’s risk status. For individuals covered solely because they were born between 1945 and 1965 and who have no other high-risk factors, Medicare covers the screening one time only. If that initial antibody test is negative, no further routine screening is covered under the birth cohort criterion.
A different rule applies to beneficiaries who have continued high-risk factors, such as ongoing illicit injection drug use. For these individuals, Medicare will cover a repeat screening test annually, provided the previous test result was negative.
If the initial antibody screening test returns a positive result, Medicare covers follow-up testing, such as a confirmatory nucleic acid test (NAT) or PCR test, to determine if the infection is current and active. The initial antibody test only shows exposure, while the NAT is necessary to confirm the presence of the virus itself, which is required before beginning curative treatment.
Patient Costs and Financial Responsibility
The Hepatitis C screening is covered as a preventive service under Original Medicare Part B. If the screening test is correctly ordered by a primary care provider and meets the eligibility criteria, the service is covered at 100% of the Medicare-approved amount. This means beneficiaries pay nothing out-of-pocket, as the Part B deductible and coinsurance are waived for this preventive service.
This full coverage applies only if the healthcare provider or facility accepts Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment. If the provider does not accept assignment, the beneficiary may face some charges. Beneficiaries should confirm their provider’s participation status before receiving the service.
If a beneficiary is enrolled in a Medicare Advantage Plan (Part C), the plan must cover the screening service at least as well as Original Medicare, offering it at no cost when criteria are met. However, Medicare Advantage plans may have specific network requirements, meaning beneficiaries must use in-network providers to ensure the test remains free. Costs for subsequent diagnostic tests or treatment will vary based on the specific structure of the individual Part C plan.