Medicaid

Georgia Medicare Hepatitis C Screening 2026 Guide

Medicare covers Hepatitis C Virus (HCV) screening for eligible beneficiaries through National Coverage Determination (NCD) 210.13, established under Section 1861(ddd) preventive services authority.

Brevy Care Team

· 31 min read

By Brevy Care Team

Medicare covers Hepatitis C Virus (HCV) screening for eligible beneficiaries through National Coverage Determination (NCD) 210.13, established under Section 1861(ddd) preventive services authority. The original NCD 210.13 became effective June 2, 2014 following the 2013 USPSTF Grade B recommendation for HCV screening. The original NCD framework limited screening eligibility to specific high-risk categories and the 1945 to 1965 birth cohort. CMS reconsidered NCD 210.13 in March 2020 to align with the 2020 USPSTF Grade B recommendation update, which substantially expanded screening to one-time screening for all adults age 18 to 79 plus annual screening for ongoing high-risk beneficiaries. The expansion approximately doubled the eligible population and aligned Medicare coverage with the modern evidence-based screening framework.

For Georgia Medicare beneficiaries, HCV screening is a particularly consequential preventive service because the 1945 to 1965 birth cohort (also called the "Baby Boomer" generation) has substantially elevated HCV prevalence compared to other age groups in the United States. This cohort, now age 60 to 80 in 2026, intersects directly with the Medicare aging-in population. The CDC estimates that adults born between 1945 and 1965 account for a substantial majority of chronic HCV infections in the United States. Many of these infections are clinically silent and were acquired decades earlier through transfusions before 1992, injection drug use, or other exposures that may no longer be ongoing. Without screening, HCV infection can progress silently to cirrhosis, hepatocellular carcinoma, and death. With screening and modern direct-acting antiviral (DAA) treatment, HCV is curable in over 95 percent of treated patients. This guide explains the statutory framework, eligibility criteria including the substantial 2020 expansion, the high-risk categories that qualify for annual screening, HCPCS coding, cost-sharing under the ACA Section 4104 waiver, the screening-to-confirmatory-testing workflow, coordination with DAA treatment and hepatology referral, and the Georgia hepatology and infectious disease landscape.

Key Takeaways

Statutory authority: Section 1861(ddd) of the Social Security Act provides the preventive services authority allowing CMS to add coverage for additional preventive services with USPSTF Grade A or B recommendations. HCV screening was added through NCD 210.13 effective June 2, 2014.
2020 NCD expansion: CMS reconsidered NCD 210.13 in March 2020 to align with the 2020 USPSTF Grade B recommendation update. The expansion substantially broadened eligibility to all adults age 18 to 79 (one-time screening) plus annual screening for ongoing high-risk beneficiaries, approximately doubling the eligible population.
Current eligibility framework: One-time HCV screening for any adult age 18 to 79 who has not been previously screened, regardless of risk factors. Plus annual repeat screening for beneficiaries with continued risk including active injection drug use.
High-risk categories triggering annual screening: Past or current injection drug use (annual), HIV coinfection (annual), long-term hemodialysis (annual), other documented ongoing risk exposures.
HCPCS coding: HCV screening is billed under HCPCS G0472 (hepatitis C antibody screening).
ACA cost-sharing waiver: ACA Section 4104 eliminates Part B deductible and coinsurance for USPSTF Grade A and B preventive services. HCV screening is $0 for eligible beneficiaries when furnished according to NCD 210.13 requirements.
1945-1965 birth cohort: The "Baby Boomer" cohort has substantially elevated HCV prevalence relative to other age groups. Members of this cohort, now age 60 to 80 in 2026, are squarely within the universal one-time screening age window and are particularly important to screen.
Two-step screening with confirmatory testing: Initial screen uses HCV antibody test (G0472). A positive antibody result reflects current or past infection and requires confirmatory HCV RNA testing (typically CPT 87521 or 87522) to determine current infection.
DAA treatment cure rates: HCV is curable with direct-acting antiviral (DAA) regimens. Sustained virologic response (SVR, considered cure) is achieved in over 95 percent of treated patients with most current DAA regimens, typically over 8 to 12 weeks of oral therapy.
Georgia landscape: Major Georgia hepatology and infectious disease programs include Emory Hepatology, Wellstar Hepatology, Piedmont Hepatology, Augusta University Hepatology, Atrium Health Navicent, and FQHC-based HCV treatment programs. Georgia has elevated HCV prevalence requiring coordinated screening and treatment access including for rural and underserved populations.

Part 1: The Statutory and Regulatory Framework

Section 1861(ddd) Preventive Services Authority

Section 1861(ddd) of the Social Security Act provides the statutory authority for CMS to add Medicare coverage for "additional preventive services" beyond those specifically enumerated in the statute. The authority requires that the additional preventive service:

Is reasonable and necessary for the prevention or early detection of illness or disability.
Is recommended with a grade of A or B by the USPSTF.
Is appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

HCV screening qualifies under this framework because the USPSTF recommends HCV screening with Grade B and screening is highly appropriate for the Medicare population given the elevated 1945 to 1965 birth cohort prevalence.

Original NCD 210.13 (June 2014)

CMS issued the original NCD 210.13 effective June 2, 2014, following the 2013 USPSTF Grade B recommendation. The 2013 USPSTF recommendation framework was:

Birth cohort screening: one-time screening for adults born between 1945 and 1965.
Risk-based screening: screening for adults with current or past risk factors regardless of age.

The original NCD 210.13 incorporated this framework:

One-time birth cohort screening for adults born 1945 to 1965.
Risk-based screening including for past or present injection drug use, blood transfusion before 1992, and other specific risk factors.
Annual screening for continued high-risk individuals (e.g., current injection drug use).

March 2020 NCD 210.13 Reconsideration

The USPSTF released an updated HCV screening recommendation in March 2020, expanding the screening recommendation to all adults age 18 to 79 with Grade B (replacing the 2013 birth-cohort + risk-based framework). CMS reconsidered NCD 210.13 in March 2020 to align Medicare coverage with the updated USPSTF framework.

The current NCD 210.13 framework, post-March 2020 reconsideration:

One-time HCV screening for any adult age 18 to 79 not previously screened.
Annual repeat screening for beneficiaries with ongoing risk including continued injection drug use.
Coverage of confirmatory HCV RNA testing for positive antibody screens.

The expansion approximately doubled the eligible Medicare population because it removed the requirement of birth cohort or specific risk factors and made one-time screening universal for the 18 to 79 age range.

2020 USPSTF Recommendation Specifics

The 2020 USPSTF Grade B recommendation for HCV screening in adults age 18 to 79 is based on:

Effective and well-tolerated direct-acting antiviral (DAA) treatment with cure rates above 95 percent.
Substantial prevalence of undiagnosed chronic HCV in the general adult population, not limited to the historical birth cohort.
Clear clinical pathway from screening to confirmatory testing to treatment.
Long-term morbidity and mortality reductions from treatment of chronic HCV.

42 CFR 410.64 Implementing Regulations

The implementing regulations at 42 CFR 410.64 establish Medicare coverage of "additional preventive services" added through the Section 1861(ddd) framework. HCV screening operates under this regulatory framework.

ACA Section 4104 (Public Law 111-148) eliminates Part B deductible and coinsurance for USPSTF Grade A or B preventive services effective January 1, 2011. HCV screening received USPSTF Grade B in 2013 and the updated Grade B in 2020. Beneficiaries pay $0 for HCV screening when furnished according to NCD 210.13 requirements.

Part 2: Eligibility Criteria

One-Time Screening for All Adults Age 18 to 79

Under the current NCD 210.13 framework, any Medicare beneficiary age 18 to 79 who has not been previously screened for HCV is eligible for one-time HCV antibody screening. This is universal age-based eligibility, not requiring documentation of specific risk factors.

In practice, virtually all Medicare beneficiaries are within the 18 to 79 age window, with the upper boundary primarily applying to older beneficiaries. The one-time-lifetime nature of this benefit means a beneficiary who has previously received HCV screening (Medicare-covered or otherwise) does not get a repeat one-time screening, though high-risk annual screening eligibility remains separately available.

Annual Screening for High-Risk Beneficiaries

Beneficiaries with continued high-risk exposure are eligible for annual HCV screening. The principal high-risk category triggering annual screening is past or current injection drug use, with annual frequency reflecting the ongoing exposure risk.

Other categories that may support annual screening per NCD 210.13 and clinical context include:

HIV coinfection.
Long-term hemodialysis.
Documented ongoing risk exposures.

The 1945 to 1965 Birth Cohort

While the 2020 NCD expansion removed birth cohort as a separate eligibility requirement, the 1945 to 1965 birth cohort remains epidemiologically significant. Adults born between 1945 and 1965 are now age 60 to 80 in 2026 (with the youngest in this cohort being 61 and the oldest 81). Substantially elevated HCV prevalence in this cohort reflects:

HCV exposures from injection drug use during the 1960s and 1970s when HCV was not yet identified.
Blood transfusions before 1992 when HCV antibody screening of blood supply was not yet implemented (the HCV antibody test was approved in 1990; routine screening of donated blood began 1992).
Other exposures including healthcare-related transmission before universal precautions implementation.

For the Medicare population specifically, this cohort is overrepresented in HCV prevalence even relative to the general adult population, supporting the priority of screening for beneficiaries who have not previously been screened.

Specific Risk Factors

The original NCD 210.13 specified explicit risk factors triggering screening eligibility, many of which remain clinically relevant for annual or repeat screening:

Past or current injection drug use — the principal ongoing risk factor.
Receipt of blood transfusion before 1992 — historical exposure relevant for the 1945 to 1965 cohort.
Receipt of organ transplant before 1992 — similar historical exposure.
Long-term hemodialysis — ongoing exposure risk.
HIV coinfection — strong association.
Birth between 1945 and 1965 — the original birth cohort eligibility, now subsumed by the universal age 18 to 79 eligibility.
Healthcare or public safety worker with needlestick injury or mucosal blood exposure.
Children born to HCV-infected mothers (vertical transmission).
Persons with HIV infection.
Persons who have ever been incarcerated.
Persons with persistently elevated liver enzymes (transaminitis without identified cause).
Persons with chronic liver disease of unknown cause.

Frequency Determination

In practice, the frequency determination interacts with eligibility:

A beneficiary previously screened (one-time-lifetime element completed) but with ongoing high-risk exposure can receive annual repeat screening.
A beneficiary not previously screened in any setting (or whose screening history cannot be verified) is eligible for one-time screening regardless of current risk factors.
A beneficiary previously screened and without ongoing high-risk exposure is generally not eligible for additional Medicare-covered screening (the benefit has been used).

Part 3: HCPCS Coding and Service Delivery

HCPCS G0472 — Hepatitis C Antibody Screening for Individual at High Risk and Other Covered Indications

HCPCS G0472 is the specific code for Medicare HCV antibody screening under NCD 210.13. The code definition specifies "hepatitis C antibody screening, for individual at high risk and other covered indications."

Test Type — HCV Antibody Test

The G0472 screening uses an HCV antibody test (anti-HCV). The test identifies the presence of antibodies indicating exposure to HCV at some point. A positive antibody test does not distinguish between past resolved infection and current chronic infection; it indicates antibody presence indicating prior or current exposure.

Confirmatory Testing

Following a positive HCV antibody screen, confirmatory HCV RNA testing is needed to determine current infection. Confirmatory tests include:

CPT 87521 — HCV RNA, direct probe technique.
CPT 87522 — HCV RNA, amplified probe technique.

The HCV RNA test detects the presence of circulating HCV virus, distinguishing current chronic infection (HCV RNA positive) from cleared past infection (HCV antibody positive, HCV RNA negative). Confirmatory testing is typically reflexively ordered following a positive antibody screen.

The confirmatory HCV RNA test is covered as a diagnostic test under standard Part B (not under the NCD 210.13 screening cost-sharing waiver). Beneficiaries with positive antibody screens should expect standard Part B cost-sharing on the confirmatory RNA test, though many laboratories perform reflex confirmatory testing as a single integrated workflow.

Performing Provider and Setting

HCV screening (G0472) can be performed in primary care settings and by Medicare-enrolled laboratories. The screening test is typically a blood draw analyzed at a clinical laboratory.

Unlike the depression screening benefit which requires a primary care setting with staff-assisted depression care supports, HCV screening does not have a setting-specific requirement under NCD 210.13. Screening can occur during a primary care visit, an AWV, or any clinical encounter where the test is ordered.

Diagnostic Coding

HCV screening is typically submitted with diagnosis code Z11.59 (encounter for screening for other viral diseases) or Z11.6 (encounter for screening for other protozoal diseases and helminthiases). Risk-factor-specific codes may also be used (e.g., Z72.89 other problems related to lifestyle).

ACA Section 4104 waives Part B deductible and coinsurance for USPSTF Grade A or B aligned preventive services. HCV screening received USPSTF Grade B in 2013 and the updated Grade B in 2020. HCV antibody screening (G0472) is $0 for eligible Medicare beneficiaries.

Confirmatory HCV RNA testing following a positive antibody screen is a diagnostic test and is subject to standard Part B cost-sharing (Part B deductible if not previously met, plus 20 percent coinsurance on the Medicare-approved amount). In practice, when laboratories perform reflex confirmatory testing as a single integrated workflow, the confirmatory test may appear as a separate diagnostic line item on the Medicare Summary Notice.

Beneficiaries with Medicare Supplement (Medigap) insurance may have all or most of the confirmatory test cost-sharing covered. Dually eligible beneficiaries have Medicaid as secondary payer for Part B cost-sharing.

Subsequent Hepatology Evaluation and Treatment

Following confirmation of chronic HCV (positive antibody plus positive RNA), subsequent care is subject to standard Part A and Part B cost-sharing:

Hepatology consultation E/M visit.
Liver fibrosis assessment (FibroScan/transient elastography, FIB-4 calculation from labs, or liver biopsy).
Hepatitis A and Hepatitis B testing and vaccination (if not previously immune).
HIV testing.
Pre-treatment workup including HCV genotype testing.
DAA treatment course.

DAA treatment is covered under Medicare Part D as outpatient prescription medication. Specific DAA regimens (e.g., glecaprevir/pibrentasvir, sofosbuvir/velpatasvir) are subject to Part D plan formulary coverage and cost-sharing. Many Part D plans place DAAs on specialty tier with higher cost-sharing, though prior authorization typically applies and beneficiaries with low income may qualify for Extra Help / Low-Income Subsidy.

Treatment Cost Considerations

DAA treatment courses are expensive (often $20,000 to $30,000 per course at list price) but produce cure for the vast majority of treated patients. Medicare and Medicaid coverage substantially reduces beneficiary out-of-pocket cost, particularly with Low-Income Subsidy. Manufacturer patient assistance programs and 340B drug pricing arrangements at FQHCs and other safety-net providers provide additional access pathways.

Part 5: HCV Disease Background

What Is Hepatitis C?

Hepatitis C is a blood-borne viral infection affecting the liver. The HCV virus (a positive-sense RNA virus in the Flaviviridae family) was first identified in 1989. HCV antibody testing became available in 1990, and routine screening of donated blood began in 1992.

Transmission

HCV is primarily transmitted through blood-to-blood contact. Common transmission routes include:

Injection drug use (sharing needles or other equipment).
Receipt of blood transfusion or organ transplant before 1992 (when blood screening began).
Healthcare-related exposures (needlestick injuries in healthcare workers, less commonly through inadequate infection control).
Mother-to-child transmission (vertical transmission, ~5-6% per pregnancy).
Sexual transmission (less common than other routes; higher risk with HIV coinfection, multiple partners, men who have sex with men).
Tattoos or body piercings with unsterile equipment.
Other percutaneous exposures.

Natural History

After acute infection:

Approximately 20 to 30 percent of acutely infected individuals spontaneously clear the virus within 6 months. These individuals remain HCV antibody positive but HCV RNA negative.
Approximately 70 to 80 percent develop chronic HCV infection (defined as HCV RNA positive for more than 6 months).

Chronic HCV is typically clinically silent for decades. Over time, chronic infection can progress through:

Hepatic steatosis.
Hepatic fibrosis (graded F0 no fibrosis through F4 cirrhosis).
Cirrhosis.
Hepatocellular carcinoma (HCC).
Liver failure.

Approximately 20 to 30 percent of patients with chronic HCV develop cirrhosis over 20 to 30 years if untreated. Patients with cirrhosis have approximately 1 to 4 percent annual risk of HCC development. End-stage liver disease can require liver transplantation.

Why Treatment Matters

Untreated chronic HCV is a leading cause of cirrhosis, HCC, and liver-related death in the United States. With effective treatment achieving sustained virologic response (SVR, considered cure), the trajectory of liver disease progression is substantially arrested. SVR is associated with:

Reduction in hepatic fibrosis (potentially partial reversal of fibrosis).
Reduction in cirrhosis progression.
Substantial reduction in HCC incidence (though HCC risk persists in cirrhosis patients post-SVR).
Reduction in liver-related mortality.
Reduction in all-cause mortality.

Part 6: Direct-Acting Antiviral (DAA) Treatment

The DAA Era

DAAs have transformed HCV treatment. The first DAA (telaprevir, boceprevir) was approved in 2011. The first all-oral interferon-free DAA combination (sofosbuvir + simeprevir) was approved in 2014. The current generation of pangenotypic DAAs (effective across all HCV genotypes) achieves sustained virologic response in over 95 percent of treated patients with 8 to 12 weeks of oral therapy.

Current DAA Regimens

Common current DAA regimens include:

Glecaprevir / pibrentasvir (Mavyret) — pangenotypic, 8 weeks for most treatment-naive patients without cirrhosis.
Sofosbuvir / velpatasvir (Epclusa) — pangenotypic, 12 weeks.
Sofosbuvir / velpatasvir / voxilaprevir (Vosevi) — pangenotypic, 12 weeks, used in retreatment after DAA failure.
Ledipasvir / sofosbuvir (Harvoni) — genotype 1, 4, 5, 6.

The regimen choice depends on HCV genotype (largely simplified with pangenotypic regimens), prior treatment history, presence of cirrhosis, and renal function.

DAA Coverage Under Medicare

DAAs are covered under Medicare Part D as outpatient prescription medications. Coverage typically requires:

Prior authorization from the Part D plan.
Documentation of HCV diagnosis (positive RNA).
Documentation of treatment-experienced status if applicable.
Specific regimen selection consistent with plan formulary.

Part D plans typically place DAAs on specialty tier with associated cost-sharing structure. The Medicare Part D Inflation Reduction Act provisions (effective 2024 and 2025 with phased implementation) include a $2,000 out-of-pocket cap on Part D spending beginning 2025, substantially reducing the out-of-pocket cost burden for high-cost specialty medications including DAAs.

Treatment Workflow

The typical DAA treatment workflow includes:

Confirmation of chronic HCV — positive HCV antibody plus positive HCV RNA.
Pre-treatment workup — liver fibrosis assessment (FibroScan, FIB-4, or other non-invasive markers), HCV genotype testing, comprehensive metabolic panel, complete blood count, HIV testing, hepatitis A and B testing, pregnancy testing if applicable.
Regimen selection — based on genotype, prior treatment, cirrhosis, and renal function.
Prior authorization — through the Part D plan.
Treatment initiation — typically 8 or 12 weeks of oral therapy.
On-treatment monitoring — periodic labs, side effect assessment.
End-of-treatment HCV RNA test.
Sustained virologic response (SVR) assessment — HCV RNA test 12 weeks after end of treatment (SVR-12).

Post-SVR Care

After SVR (cure), patients require ongoing follow-up for:

HCC surveillance — patients with pre-treatment cirrhosis remain at elevated HCC risk and require ongoing surveillance (typically liver ultrasound and alpha-fetoprotein every 6 months).
Reinfection prevention — patients with ongoing risk factors (continued injection drug use, ongoing sexual transmission risk) may become reinfected. Annual rescreening of high-risk patients applies.
Liver disease management — patients with cirrhosis or significant fibrosis continue to need monitoring for portal hypertension, esophageal varices, and other complications.

Part 7: Coordination With Hepatology and Infectious Disease Care

Hepatology Referral

Beneficiaries with positive HCV RNA (confirmed chronic HCV) typically benefit from hepatology referral for:

Fibrosis assessment.
DAA regimen selection.
Complex cases (advanced cirrhosis, prior treatment failures, HCC risk, transplant evaluation).
HCC surveillance for cirrhotic patients.

In some primary care practices and FQHCs, primary care clinicians or other non-specialist providers manage HCV treatment with DAAs directly, sometimes through tele-hepatology consultation or via the Project ECHO model. This expanded HCV treatment capacity is particularly valuable in rural areas with limited hepatology access.

Infectious Disease Coordination

Beneficiaries with HCV/HIV coinfection benefit from coordinated care with infectious disease specialists managing both conditions. HIV coinfection accelerates HCV progression and complicates treatment.

Primary Care Continuity

Even with hepatology or infectious disease specialty involvement, primary care continues to coordinate the comprehensive health of the beneficiary including:

AWV/IPPE-aligned preventive services.
Cardiovascular risk management.
Tobacco cessation.
Alcohol use counseling (particularly important for liver disease).
Mental health screening and treatment.
Vaccination updates.

Part 8: Coordination With AWV, IPPE, and Other Preventive Services

AWV Coordination

The Annual Wellness Visit under Section 1861(hhh) is a natural venue for HCV screening eligibility assessment and ordering. The AWV health risk assessment captures medical history, lifestyle risk factors, and prior screening status, supporting identification of beneficiaries who have not yet received HCV screening or who have ongoing high-risk exposure warranting annual screening.

IPPE Coordination

The Initial Preventive Physical Examination under Section 1861(ww), the "Welcome to Medicare" visit, includes review of medical history, family history, and current risk factors. The IPPE is an appropriate venue for HCV screening referral for newly enrolled Medicare beneficiaries who have not yet been screened.

Coordination With Other Preventive Services

HCV screening coordinates with other Medicare-covered preventive services:

Hepatitis B screening for at-risk adults.
HIV screening under USPSTF Grade A.
Alcohol misuse screening and counseling (particularly important for liver disease risk).
Substance use disorder screening and treatment when applicable.

The bundled approach of multiple preventive services during AWV encounters supports comprehensive risk reduction.

Part 9: HCV Disease Burden in Georgia

Georgia HCV Epidemiology

Georgia has elevated HCV prevalence with particular impact in:

The 1945 to 1965 birth cohort.
Persons with current or past injection drug use.
Persons in correctional settings or with histories of incarceration.
Persons with HIV coinfection.
Persons in rural Georgia where treatment access has historically been limited.

The Georgia Department of Public Health Viral Hepatitis Surveillance program monitors HCV incidence and prevalence and coordinates statewide HCV prevention and treatment initiatives.

Rural Georgia Considerations

Rural Georgia counties may have:

Limited local hepatology capacity.
Historical or ongoing injection drug use prevalence linked to opioid epidemic.
Lower DAA treatment uptake reflecting access and awareness gaps.
Lower HCV screening rates.

Telemedicine, the Project ECHO model, and FQHC-based HCV treatment have expanded rural treatment capacity.

HIV/HCV Coinfection in Georgia

Georgia's HIV epidemic, particularly in Atlanta and other urban centers, creates substantial HIV/HCV coinfection populations. Coordinated care for HIV/HCV coinfection is provided through Ryan White-funded HIV clinics and infectious disease practices.

Part 10: The Georgia Hepatology and Infectious Disease Landscape

Emory Hepatology

Emory Healthcare operates a comprehensive hepatology program with the Emory Transplant Center providing liver transplant services for end-stage liver disease. Emory Hepatology provides DAA treatment, advanced liver disease management, and HCC surveillance.

Wellstar Hepatology

Wellstar Health System operates hepatology and gastroenterology programs across north and west Georgia providing DAA treatment and liver disease management.

Piedmont Hepatology

Piedmont Healthcare operates hepatology programs across metro Atlanta and the Piedmont network providing comprehensive HCV care.

Northside Hospital Hepatology

Northside Hospital operates hepatology and gastroenterology services across its north Atlanta network.

Augusta University Health Hepatology

Augusta University Health operates hepatology as an academic tertiary referral center in east Georgia.

Atrium Health Navicent

Atrium Health Navicent provides hepatology and gastroenterology services in central Georgia.

Memorial Health (Savannah)

Memorial Health University Medical Center provides hepatology and gastroenterology services in coastal Georgia.

Phoebe Putney

Phoebe Putney provides hepatology and gastroenterology services serving southwest Georgia.

FQHC-Based HCV Treatment Programs

Federally Qualified Health Centers across Georgia provide integrated HCV screening and treatment, particularly important for:

Medically underserved populations.
Uninsured and underinsured populations.
Patients connected to FQHC primary care.
Project ECHO model adoption.

FQHCs may use 340B drug pricing to reduce DAA cost barriers.

Ryan White HIV Programs and HCV Coinfection

Ryan White HIV/AIDS Program clinics across Georgia (including major Atlanta-based programs) provide coordinated HCV care for HIV/HCV coinfected patients.

Part 11: Best Practices for Beneficiaries and Clinicians

Screen all adults age 18 to 79 at least once: Per the 2020 NCD expansion, universal one-time screening is the standard of care. Document prior screening status for beneficiaries and order screening for those without documented prior testing.
Identify high-risk beneficiaries for annual screening: Past or current injection drug use, HIV coinfection, long-term hemodialysis, and other ongoing exposures support annual screening eligibility.
Use HCPCS G0472 for the screening test: The G0472 code is specific to Medicare HCV screening. Laboratory billing should ensure G0472 is used with appropriate diagnosis coding.
Order reflex HCV RNA testing for positive antibody screens: A positive HCV antibody is not diagnostic of current infection. Reflex HCV RNA testing in a single laboratory workflow expedites diagnostic clarity.
Coordinate workup for positive HCV RNA: Confirmed chronic HCV warrants fibrosis assessment, genotype testing, comprehensive labs, HIV testing, hepatitis A and B testing, and discussion of DAA treatment options.
Link to DAA treatment promptly: HCV is curable with DAA treatment, with cure rates above 95 percent. Linkage to treatment is the most important predictor of cure. Many primary care practices and FQHCs can manage DAA treatment directly with hepatology consultation as needed.
Use prior authorization workflows effectively: DAA treatment under Medicare Part D typically requires prior authorization. Practices treating HCV should have workflows in place to efficiently obtain authorization.
Counsel on cure expectations: Beneficiaries starting DAA treatment should understand that cure rates exceed 95 percent with appropriate regimen completion. SVR assessment occurs 12 weeks post-treatment.
Maintain HCC surveillance for cirrhotic patients post-SVR: Patients with pre-treatment cirrhosis remain at elevated HCC risk and require ongoing surveillance with semiannual ultrasound and alpha-fetoprotein testing.
Address reinfection prevention: Patients with continued risk factors (injection drug use, sexual transmission risk) can become reinfected. Annual rescreening of high-risk patients applies; harm reduction including syringe services may reduce reinfection risk.
Coordinate hepatitis A and B vaccination: Patients with HCV should be vaccinated against hepatitis A and B if not already immune.
Address alcohol use and liver disease risk factors: Liver disease management includes addressing alcohol use, metabolic dysfunction, and other contributors to liver disease progression.
Leverage GeorgiaCares SHIP for benefit navigation: GeorgiaCares (1-866-552-4464) provides free, unbiased Medicare counseling including HCV screening benefit and DAA treatment coverage questions.
Use telehealth and Project ECHO for rural access: Tele-hepatology and the Project ECHO model expand HCV treatment access in rural Georgia where local hepatology resources are limited.

Part 12: Common Issues and Resolutions

The HCV screening claim was denied as duplicate: The one-time-lifetime element of the universal age 18 to 79 screening applies to beneficiaries previously screened. If denied as duplicate, review whether a prior G0472 claim was processed or whether non-Medicare prior screening was documented. Annual screening eligibility for ongoing high-risk exposure may apply if relevant.
The beneficiary is older than 79: The current NCD 210.13 universal screening framework covers age 18 to 79. Beneficiaries older than 79 may still be screened under risk-based eligibility if they have ongoing high-risk exposures.
The screening was positive but the beneficiary cannot afford confirmatory testing cost-sharing: Confirmatory HCV RNA testing is subject to standard Part B cost-sharing. Beneficiaries with Medicare Supplement, Medicaid (dually eligible), or Low-Income Subsidy may have reduced cost-sharing. FQHCs may offer sliding fee scale.
The beneficiary has positive antibody but negative RNA: This pattern indicates prior HCV exposure with spontaneous clearance or prior successful treatment. The beneficiary does not have current chronic HCV and does not need DAA treatment. Documentation in the medical record is important to avoid repeated unnecessary testing.
The beneficiary's DAA prior authorization was denied: Part D plan prior authorization typically requires documentation of HCV diagnosis (positive RNA) and may require fibrosis assessment, alcohol use assessment, or other specific elements. Review denial reason and supplement documentation. Plan-specific appeal pathways apply.
The beneficiary is concerned about the high cost of DAAs: Medicare Part D coverage substantially reduces beneficiary cost compared to list price. Low-Income Subsidy (Extra Help) and the Inflation Reduction Act $2,000 Part D out-of-pocket cap (effective 2025) further reduce costs. Manufacturer patient assistance programs may provide additional support.
The beneficiary is in a rural area with no local hepatology: Telehepatology and Project ECHO model expand rural access. Some FQHC primary care providers offer DAA treatment directly with telephonic or video consultation.
The beneficiary has HCV/HIV coinfection: Coordinated care with infectious disease specialists is important. Many HIV-specific DAA regimens or considerations apply (e.g., drug-drug interactions with antiretrovirals).
The beneficiary completed DAA treatment but has detectable HCV RNA at follow-up: This is treatment failure, occurring in less than 5 percent of treated patients. Retreatment with a different DAA regimen (typically sofosbuvir/velpatasvir/voxilaprevir) achieves cure in most retreatment patients.
The beneficiary developed reinfection after SVR: Reinfection can occur in patients with continued exposure (injection drug use, sexual transmission risk). Reinfection should be treated; annual rescreening of high-risk patients identifies reinfection.
The beneficiary has cirrhosis and needs HCC surveillance: Semiannual liver ultrasound and alpha-fetoprotein testing constitute standard HCC surveillance for cirrhotic patients. This continues even after SVR.
The beneficiary is on hemodialysis: Long-term hemodialysis is a documented HCV risk factor warranting annual screening. DAA treatment for hemodialysis patients requires specific regimen selection (glecaprevir/pibrentasvir is generally preferred for severe renal impairment).
The Medicare Advantage plan denies HCV screening: Medicare Advantage plans must cover the HCV screening benefit at least as comprehensively as Original Medicare. Coverage denials should be addressed through plan appeals; pattern denials can be escalated to CMS and the Georgia Department of Insurance.
The beneficiary's primary care provider is not familiar with the 2020 NCD expansion: Practice education on the universal age 18 to 79 screening eligibility supports comprehensive screening. The 2020 expansion removed the prior requirement for documented risk factors or birth cohort membership; one-time screening is now the default for all adults in the age range.

Part 13: Worked Examples

Example 1: Fulton County Age 66 Male One-Time Screening Positive Linked to DAA Treatment

A 66-year-old man living in Fulton County (Atlanta), enrolled in Original Medicare Part B for one year, comes to his Emory primary care practice for his Annual Wellness Visit. He has never been screened for HCV. He reports no specific risk factors but acknowledges he received a blood transfusion in 1985 during gallbladder surgery (before universal blood supply HCV screening began in 1992). The primary care physician orders HCV antibody screening (G0472) as universal screening for adults 18 to 79 under the 2020 NCD expansion.

The HCV antibody test is positive. Reflex confirmatory HCV RNA testing returns positive at 1.2 million IU/mL, consistent with chronic HCV infection. The patient is referred to Emory Hepatology for evaluation. Workup includes FibroScan showing F2 fibrosis (moderate), HCV genotype 1a, normal renal function, negative HIV test, negative hepatitis A and B (vaccinated post-workup), and otherwise unremarkable comprehensive labs.

The hepatology team prescribes glecaprevir/pibrentasvir (Mavyret) 8 weeks. Medicare Part D prior authorization is obtained. The patient completes the 8-week course without significant side effects. SVR-12 assessment 12 weeks post-treatment shows undetectable HCV RNA — cure achieved. The patient continues annual primary care follow-up. The screening encounter cost-sharing was $0; the confirmatory RNA was subject to standard Part B cost-sharing (covered by his Medicare Supplement Plan G); DAA treatment was covered under his Part D plan with associated cost-sharing reduced by his Low-Income Subsidy eligibility.

Example 2: Worth County Age 70 Male Annual Screening for Continued IDU History at FQHC

A 70-year-old man living in Worth County (rural southwest Georgia), enrolled in Original Medicare Part B and Georgia Medicaid as dual eligible, has a history of injection drug use during the 1970s through early 1990s with continued non-injection substance use issues. He receives his primary care at a Federally Qualified Health Center in Worth County. He has been screened for HCV multiple times over the past decade, most recently 12 months ago with negative results.

The FQHC primary care provider orders annual HCV screening (G0472) based on his ongoing risk factor history (the prior injection drug use history, while remote, supports clinical judgment for continued annual screening per NCD 210.13 high-risk allowance). The HCV antibody screen is negative. The screening cost-sharing is $0 under the ACA Section 4104 waiver; as a dually eligible beneficiary, any cost-sharing would have been covered by Medicaid as secondary payer.

The encounter also includes brief alcohol use counseling, tobacco cessation discussion, and depression screening (G0444 for the year's depression screening) as part of comprehensive preventive care.

Example 3: Cobb County 1945-1965 Birth Cohort Age 69 Negative Screen

A 69-year-old woman living in Cobb County, enrolled in Medicare Advantage (Wellstar Total Care), comes to her Wellstar primary care practice for her Annual Wellness Visit. She was born in 1957, placing her squarely within the 1945 to 1965 birth cohort historically associated with elevated HCV prevalence. She has never been screened for HCV. She has no specific identified risk factors and reports never receiving blood transfusions, never using injection drugs, and no other identified exposures.

Under the 2020 NCD 210.13 expansion, the universal one-time screening for adults age 18 to 79 applies regardless of specific risk factors. The primary care provider orders HCV antibody screening (G0472). The test returns negative. The screening cost-sharing is $0 under the ACA Section 4104 waiver applied within the Medicare Advantage plan benefits.

Despite the negative screen, the case illustrates the importance of universal screening for the 1945 to 1965 birth cohort even when specific risk factors are not identifiable; many beneficiaries in this cohort acquired HCV through exposures they may not recall or recognize.

Example 4: DeKalb County HIV Coinfection Patient Annual HCV Screening With Hepatology Coordination

A 68-year-old man living in DeKalb County, enrolled in Original Medicare Part B, has chronic HIV infection diagnosed in 1996 and well-controlled on antiretroviral therapy with undetectable viral load and CD4 count over 700. He has annual coordinated care between his Emory infectious disease clinic and his Emory primary care practice. He has been previously screened for HCV with negative results annually for several years given his HIV coinfection risk.

The current annual HCV screening (G0472) under his ID clinic workflow returns a newly positive HCV antibody. Reflex HCV RNA confirms acute HCV with HCV RNA 5 million IU/mL. The patient is referred to Emory Hepatology for treatment evaluation. The hepatology team coordinates with ID for DAA selection, accounting for potential drug-drug interactions with his antiretroviral regimen. The selected regimen is sofosbuvir/velpatasvir (Epclusa) for 12 weeks given his pangenotypic indication and HIV coinfection.

The patient completes the 12-week course. SVR-12 assessment shows undetectable HCV RNA — cure achieved. Annual HCV screening continues going forward given his ongoing risk. The screening encounter cost-sharing was $0; downstream care was subject to standard Part A/B cost-sharing covered by his Medicare Supplement insurance and through 340B drug pricing through his Ryan White-funded ID clinic.

Example 5: Reflex Confirmatory Testing Pathway at Atrium Health Navicent Macon

A 64-year-old man living in Bibb County (Macon), enrolled in Original Medicare Part B, comes to his Atrium Health Navicent primary care practice. The practice has a standing reflex confirmatory laboratory protocol such that any positive HCV antibody test automatically triggers HCV RNA testing on the same blood sample without requiring a second blood draw or separate clinician order.

His routine universal HCV screening (G0472) returns positive at the antibody level. The reflex confirmatory HCV RNA test returns positive at 800,000 IU/mL. The primary care provider receives both results and contacts the patient to discuss findings and arrange hepatology referral. The reflex workflow shortens time to diagnosis from typically 2 to 3 weeks (separate appointment for confirmatory testing) to 5 to 7 business days (single laboratory workflow). The patient is referred to Atrium Health Navicent Gastroenterology with hepatology coordination for DAA treatment evaluation.

The screening test cost-sharing was $0; the confirmatory RNA test as a diagnostic test was subject to standard Part B cost-sharing, applied through his Medicare Supplement Plan G with no out-of-pocket cost.

Example 6: Successful DAA Treatment Cure With Sustained Virologic Response at Augusta University

A 71-year-old woman living in Richmond County (Augusta), enrolled in Original Medicare Part B and Medicare Part D, has chronic HCV diagnosed 18 months earlier through universal screening. She receives her care at Augusta University Hepatology. Her pre-treatment workup showed HCV genotype 3, FibroScan F3 (advanced fibrosis bordering on cirrhosis), normal renal function, negative HIV, and immune to hepatitis A and B from prior vaccination.

The hepatology team prescribes sofosbuvir/velpatasvir (Epclusa) 12 weeks. Part D prior authorization was obtained. The patient completes the 12-week course with mild fatigue but otherwise tolerable side effects. End-of-treatment HCV RNA is undetectable. SVR-12 assessment 12 weeks after end of treatment is also undetectable — cure achieved.

Because of her pre-treatment F3 fibrosis bordering on cirrhosis, the hepatology team continues semiannual HCC surveillance with liver ultrasound and alpha-fetoprotein, given persistent elevated HCC risk in patients with advanced fibrosis or cirrhosis even after SVR. She also has follow-up assessment of her fibrosis at 1 year post-SVR with FibroScan to track potential fibrosis regression. The case illustrates the durable benefit of DAA cure for HCV and the appropriate continued surveillance for patients with pre-treatment significant liver disease.

Part 14: Frequently Asked Questions

What is the Medicare HCV screening benefit?

Medicare covers Hepatitis C Virus (HCV) screening for eligible beneficiaries through National Coverage Determination (NCD) 210.13 under Section 1861(ddd) preventive services authority. The benefit became effective June 2, 2014 and was substantially expanded in March 2020 to align with the 2020 USPSTF Grade B recommendation update.

Who is eligible?

Under the current framework: (a) any adult age 18 to 79 not previously screened is eligible for one-time HCV antibody screening; (b) beneficiaries with ongoing high-risk exposure (such as continued injection drug use) are eligible for annual repeat screening.

What changed in the March 2020 NCD expansion?

The 2020 reconsideration aligned Medicare coverage with the 2020 USPSTF Grade B update. Before March 2020, screening was limited to specific risk factors and the 1945 to 1965 birth cohort. After March 2020, universal one-time screening for all adults age 18 to 79 became the standard.

What is the HCPCS code?

HCPCS G0472 (hepatitis C antibody screening, for individual at high risk and other covered indications).

What does the screening cost?

$0. ACA Section 4104 waives Part B cost-sharing for USPSTF Grade B aligned screening. HCV antibody screening (G0472) is free for eligible beneficiaries.

What if my antibody screen is positive?

A positive HCV antibody screen requires confirmatory HCV RNA testing to determine current chronic infection. Many laboratories perform reflex confirmatory testing as a single workflow. Confirmatory RNA testing is subject to standard Part B cost-sharing.

What does it mean to have positive antibody but negative RNA?

This pattern indicates prior HCV exposure with spontaneous clearance (approximately 20-30 percent of acutely infected individuals clear the virus naturally) or prior successful treatment. The beneficiary does not have current chronic HCV.

What is the 1945 to 1965 birth cohort and why is it relevant?

Adults born between 1945 and 1965 (currently age 61 to 81) have substantially elevated HCV prevalence due to historical exposures including injection drug use during the 1960s through 1970s, blood transfusions before 1992 screening, and other routes. While the 2020 NCD expansion removed birth cohort as a separate eligibility criterion, this cohort remains epidemiologically important.

Is HCV curable?

Yes. Modern direct-acting antiviral (DAA) treatment achieves sustained virologic response (SVR, considered cure) in over 95 percent of treated patients with 8 to 12 weeks of oral therapy. Cure rates exceed 95 percent for most patient populations.

What are DAAs?

Direct-acting antivirals are oral medications that directly target HCV viral replication. Common DAAs include glecaprevir/pibrentasvir (Mavyret), sofosbuvir/velpatasvir (Epclusa), and ledipasvir/sofosbuvir (Harvoni). Most current regimens are pangenotypic (effective across HCV genotypes).

Does Medicare cover DAA treatment?

Yes. DAAs are covered under Medicare Part D as outpatient prescription medications, typically with prior authorization. The Inflation Reduction Act $2,000 Part D out-of-pocket cap (effective 2025) substantially reduces beneficiary cost burden for high-cost specialty medications including DAAs.

How is HCV transmitted?

HCV is primarily transmitted through blood-to-blood contact including injection drug use, blood transfusion or organ transplant before 1992, healthcare-related exposures, mother-to-child transmission, and less commonly sexual transmission. It is not transmitted through casual contact, food, water, or sneezing/coughing.

What is the natural history of HCV?

After acute infection, approximately 20-30 percent of individuals spontaneously clear the virus, while approximately 70-80 percent develop chronic infection. Chronic HCV is typically clinically silent for decades but can progress to hepatic fibrosis, cirrhosis, hepatocellular carcinoma, and liver failure over 20 to 30 years.

How long does DAA treatment take?

Most current DAA regimens are 8 or 12 weeks of oral therapy. Glecaprevir/pibrentasvir is 8 weeks for most treatment-naive non-cirrhotic patients. Sofosbuvir/velpatasvir is 12 weeks pangenotypic.

What is sustained virologic response (SVR)?

SVR is undetectable HCV RNA 12 weeks after completion of treatment (SVR-12). SVR is considered functional cure. Late relapse after SVR-12 is rare.

What follow-up is needed after cure?

Patients with pre-treatment cirrhosis remain at elevated HCC risk and require ongoing HCC surveillance with semiannual liver ultrasound and alpha-fetoprotein. Patients with ongoing risk factors (injection drug use, sexual transmission) may need annual rescreening for reinfection.

Can I get HCV again after cure?

Yes. SVR clears the current infection but does not provide protective immunity against future HCV exposure. Patients with continued risk factors can become reinfected. Annual rescreening of high-risk patients identifies reinfection.

What if I'm in rural Georgia with limited hepatology access?

Telehepatology, the Project ECHO model, and FQHC-based HCV treatment have expanded rural access. Some primary care providers can manage DAA treatment directly with telephonic or video consultation. The Georgia Department of Public Health Viral Hepatitis program coordinates statewide HCV care.

Does Medicare Advantage cover HCV screening?

Yes. Medicare Advantage plans must cover the HCV screening benefit at least as comprehensively as Original Medicare. Cost-sharing for the screening itself is typically $0 in-network under the ACA Section 4104 framework.

What about HCV in nursing home residents?

Nursing home residents are not excluded from the NCD 210.13 framework, though the screening setting requirements may interact with the residential setting. Most screening occurs through visiting practitioners or during outpatient encounters.

How does HCV interact with HIV?

HIV/HCV coinfection accelerates HCV progression and complicates treatment. HIV/HCV coinfected patients warrant coordinated care with hepatology and infectious disease specialists. DAA regimen selection accounts for drug-drug interactions with antiretroviral therapy. Annual HCV screening applies for HIV-infected patients.

What about hepatitis A and B?

Hepatitis A and B are distinct viruses with separate screening, vaccination, and treatment considerations. Patients with HCV should also be tested for hepatitis A and B status; if not immune, vaccination is recommended. Medicare covers hepatitis B screening for certain at-risk populations and hepatitis B vaccination.

Does Medicaid coordinate with HCV screening and treatment?

For dually eligible beneficiaries, Medicaid covers Part B cost-sharing as secondary payer. Georgia Medicaid covers HCV screening and treatment for Medicaid-only beneficiaries with applicable Medicaid managed care plan utilization management.

What is Project ECHO?

Project ECHO (Extension for Community Healthcare Outcomes) is a model that connects rural and primary care providers with specialist consultation via video conferencing to support specialty-level care delivery in primary care settings. ECHO has been particularly important for expanding HCV treatment in rural communities.

Where can I get help understanding my Medicare HCV screening coverage?

Contact GeorgiaCares SHIP at 1-866-552-4464 for free, unbiased Medicare counseling. Call 1-800-MEDICARE or Palmetto GBA at 1-866-238-9650 for specific claim questions. The American Liver Foundation (1-800-465-4837) provides patient education and support.

Resources and Contacts

For questions about the Medicare HCV Screening benefit, DAA treatment, and hepatology resources in Georgia, the following resources can help:

Medicare: 1-800-MEDICARE (1-800-633-4227). General Medicare benefit questions, eligibility verification, claim status.
Palmetto GBA Medicare Administrative Contractor for Georgia: 1-866-238-9650. HCV screening claim adjudication, coverage clarifications.
Georgia DCH Medicaid Member Services: 1-866-211-0950. Medicaid eligibility for dually eligible beneficiaries, DAA Part D and Medicaid coordination.
GeorgiaCares SHIP: 1-866-552-4464. Free Medicare counseling including HCV screening benefit navigation.
Medicare Rights Center: 1-800-333-4114. Beneficiary advocacy and education.
Atlanta Legal Aid Society: 404-377-0701. Free legal assistance metro Atlanta.
Georgia Legal Services Program: 1-800-498-9469. Free legal assistance outside metro Atlanta.
211 Georgia: 211. Social service navigation.
Eldercare Locator: 1-800-677-1116. Local Area Agency on Aging services.
Georgia Department of Public Health: 404-657-2700. Viral hepatitis surveillance and program.
American Liver Foundation: 1-800-465-4837. HCV patient education and support.
CDC-INFO: 1-800-232-4636. Hepatitis information and resources.
Hepatitis C Association: 1-800-377-0026. Patient education and advocacy.
Emory Hepatology: Atlanta academic hepatology and liver transplant center.
Wellstar Hepatology: North and west Georgia network.
Piedmont Hepatology: Metro Atlanta and statewide network.
Augusta University Hepatology: East Georgia academic center.
Acentra Health Beneficiary and Family Centered Care Quality Improvement Organization: 1-844-455-8708. Quality concerns and appeals.

HCV screening under Medicare NCD 210.13 represents one of the most consequential preventive opportunities for the Medicare population. With universal one-time screening for adults age 18 to 79 under the 2020 expansion, plus annual screening for ongoing high-risk beneficiaries, every Medicare beneficiary has access to this potentially life-saving service. The clinical pathway from screening to cure through DAA treatment is well-established, with cure rates exceeding 95 percent in over 8 to 12 weeks of oral therapy. Georgia Medicare beneficiaries should ask their primary care providers about HCV screening status during their next Annual Wellness Visit if they have not previously been screened.