California

Yes

Jacey Cooper
Chief Deputy Director, Health Care Programs
California Department of Health Care Services
1501 Capitol Avenue, 6th Floor, MS 0000
Sacramento, CA 95814
Phone: (916) 440-7418

https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf

HTT (huntingtin) gene analysis; evaluation to detect abnormal alleles is covered for children if TAR for CPT code 81271 documents the following criteria:

1. The patient has a family history of HD and develops symptoms that raise the suspicion for juvenileonset HD as exemplified by two or more of the following:
   1. Declining school performance
   2. Seizures
   3. Oral motor dysfunction
   4. Rigidity
   5. Gait disturbance

Any person employed as or practicing as a Genetic Counselor in California, or providing genetic counseling to residents of California, is required to have a valid Genetic Counselor License or a Temporary Genetic Counselor License issued by the State of California.

Genetic counseling is necessary for certain genetic testing to be approved. Physicians who are board-certified in clinical genetics may apply for and receive a separate category of service (COS) and reimbursement code for genetic services. Providers cannot use code HCPCS S0265 (genetic counseling, under physician supervision, each 15 minutes) for genetic services unless they have been approved by Medi-Cal through the genetic provider credentialing process. Each clinical geneticist (physician) in the practice may obtain this approval. The physician must bill using an individual National Provider Identifier (NPI), not a billing NPI number issued to a group practice. No other person or facility (for example, hospital or clinic) may bill for genetic counseling services provided by the approved physician. However, a physician may submit claims for the services of a genetic counselor who is working under his/her supervision. Medi-Cal coverage of genetic counseling and consultation services is as follows:

1. Billing code S0265 may be billed for the first two hours (eight 15-minute units) without submission of additional documentation. The first eight units are reimbursed at $15 per unit, for a total reimbursement of $120 for two hours.
2. Any subsequent time is reimbursed at $5 per unit, up to a maximum of 24 units and requires submission of the consultation note as a claim attachment for payment of time beyond two hours. Reimbursement for three hours would be $140, four hours – $160, five hours – $180 and six hours – $200.
3. Code S0265 cannot be billed with another Evaluation and Management (E&M) code on the same day, whether by the same or another provider, unless the other visit is for a different medical indication. The reason for the second visit should be entered in the Remarks field (Box 80)/Additional Claim Information field (Box 19) of the claim.
4. Services may include review of pertinent medical records, pre-clinic visit and consultation as required; complete examination of the patient or affected child (complete physical examination may not be required for counseling services [for example, infant deaths due to congenital anomalies or family with cystic fibrosis or muscular dystrophy]); examination of siblings, parents and/or other relatives, if indicated; complete pedigree and complete history; determination of likely diagnosis, confirmation of the diagnosis by interpretation of laboratory tests, documentation of natural history of the disease and evaluation of prognosis and recurrence risks;
   conveyance of information to patient or family and written report to the referring physician.

Note: Services are no longer limited to once-in-a-lifetime. Code S0265 may be billed up to four times per year, per recipient

California Health and Safety
§1374.56
17 CCR §2932
22 CCR §40675
22 CCR §40715
22 CCR §41848,
41849
22 CCR §51313.3

Authorization of metabolic products on the List of Enteral Nutrition Products administered orally or through a feeding tube is restricted to beneficiaries with a diagnosis of inborn errors of metabolism (genetic, metabolic condition). Refer to the List of Enteral Nutrition Products for product-specific criteria that may also apply.
Exception: For metabolic ketogenic formulas, authorization may also be considered when documentation confirms the beneficiary meets one of the criteria below:

1. Have seizures that are refractory to standard anti-seizure medications
2. Have a chronic medical diagnosis where a ketogenic diet is medical necessary and a history of use with a product in another enteral nutrition category that failed to provide adequate nutrition unless such products are medically contraindicated.
   Note: For adult beneficiaries 21 years of age and older, authorization is restricted to the ICD-10-CM diagnosis codes on the tables below. The ICD-10-CM code and diagnosis name must be clearly supplied on the authorization request as documented in the beneficiary’s medical record.

To see the ICD-10-CM code table use the following link: https://www.cahealthwellness.com/content/dam/centene/cahealthwellness/pdfs/provider/pharmacy/medi-cal-enteral-policy.pdf

Some, but not all genetic tests require a Treatment Authorization Request (TAR) and claim documentation requirements.

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/7EF8E5B3-10EE-433E-AA79-ABBDBA0D0F65/formsreo.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/rates

Yes

A Treatment Authorization Request (TAR) for CPT code 81162 (BRCA1, BRCA2 gene analysis; full sequence analysis and full duplication/deletion analysis) requires documentation of one or more of the following numbered criteria. Based on 2019 U.S. Preventive Services Task Force (USPSTF) recommendation:

1. The patient has personal or family history that suggests an inherited cancer susceptibility based on any one of the following familial risk assessment tools:
   1. The Ontario Family History Assessment Tool
   2.  Manchester Scoring System
   3. Referral Screening Tool
   4.  Pedigree Assessment Tool
   5. 7-Question Family History Screening Tool
   6. International Breast Cancer Intervention Study instrument
   7.  Brief versions of BRCAPRO; and
2. The patient is willing to talk with a health professional who is suitably trained to and interpret test results; and provide genetic counseling
3. The test results will aid in the decision-making; or

An individual from a family member with a known deleterious BRCA mutation; or Personal history of breast cancer (invasive or ductal carcinoma in situ) plus one or more of the following:

1. Diagnosed at ≤45 years of age; or
2.  Diagnosed at 46 to 50 years of age with:
   1. An additional breast cancer primary at any age
   2. One or more close blood relatives with breast cancer at any age
   3.  One or more close blood relatives with prostate cancer (Gleason score ≥7)
   4.  An unknown or limited amily history; or
3.  Diagnosed at ≤60 years of age with a triple negative breast cancer; or
4. Diagnosed at any age with:
   1. One or more close blood relatives with:
      1. Breast cancer diagnosed at ≤50 years of age; or
      2. Ovarian carcinoma; or
      3. Male breast cancer; or
      4. Metastatic prostate cancer; or
      5. Pancreatic cancer
   2. Two or more additional diagnosis of breast cancer at any age in patient and/or in close blood relatives; or
5. Ashkenazi Jewish ancestry; or

Personal history of ovarian carcinoma (includes fallopian tube and primary peritoneal cancers); or

Personal history of male breast cancer; or Personal history of pancreatic cancer; or

Personal history of metastatic prostate cancer (biopsy-proven and/or with radiographic evidence; includes distant metastasis and regional bed or nodes; not biochemical recurrence); or

Personal history of high-grade prostate cancer (Gleason score ≥7) at any age with:

1. One or more close blood relatives (first-, second- or third-degree) with ovarian carcinoma, pancreatic cancer or metastatic prostate cancer at any age or breast cancer under 50 years of age; or
2. Two or more close blood relatives (first-, second- or third-degree relatives on the same side of family) with breast or prostate cancer (any grade) at any age; or
3.  Ashkenazi Jewish ancestry; or

BRCA1/2 pathogenic/likely pathogenic variant detected by tumor profiling on any tumor type in the absence of germline pathogenic/likely pathogenic variant analysis; or

For an individual without history of breast or ovarian cancer, but with one or more first- or second-degree blood relative meeting any of the above criteria; or

For BRACAnalysis CDx testing for breast cancer, all of the following TAR criteria must be met:

1. Patient has metastatic breast cancer.
2. Patient is human epidermal growth factor receptor 2 (HER2)-negative.
3.  Patient has previously been treated with chemotherapy in the neoadjuvant, adjuvant or metastatic setting.
4.  Patient’s additional treatment is contingent on the test results.

CFTR (cystic fibrosis transmembrane conductance regulator) gene analysis; common variants. Requirements include:

1. When used to bill for cystic-fibrosis screening requires ICD-10-CM diagnosis code O09.00 thru O09.93, Z31.430, Z31.440, Z34.00 thru Z34.03, Z34.80 thru Z34.83, Z34.90 thru Z34.93
2.  Not reimbursable with code 81224 for same date of service, recipient and provider
3. May be billed separately with an appropriate National Correct Coding Initiative (NCCI) associated modifier

CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; known familial variants. TAR requires documentation of the following criteria:

1. The Patient has a strong clinical presentation suspicious of CF, and
2. Family with known variant not included in the test for common variants

CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; duplication/deletion variants. TAR requires a documentation of the following criteria:

1. The patient has a strong clinical presentation suspicious of CF, and
2. Gene test for common variants did not result in two disease-causing variants in CFTR

CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; full gene sequence. TAR requires documentation of the following criteria:

1. Patient has intermediate sweat chloride result, or
2. Patient with confirmed or suspected CF, with unknown genotype, and additional treatment or assessment of prognosis is contingent on the result of the test, or
3. Patient with normal sweat chloride results despite a strong clinical suspicion of CF

CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; intron 8 poly-T analysis (e.g., male infertility). Requirements include:

1. When used to bill for cystic-fibrosis testing requires ICD-10-CM diagnosis code N46.9

Yes, coverage is available. Aside from Lynch Syndrome and Hereditary Breast and Ovarian Cancer coverage, the following hereditary cancer testings are also covered.

Hereditary colon cancer disorders; genomic sequence analysis panel, must include sequencing of at least 10 genes. Reimbursable only when billed in conjunction with one of the following ICD-10-CM diagnosis codes: C17.0 thru C20, C24.0 thru C25.9, C54.0 thru C54.9, C65.1 thru C66.9, C71.0 thru C71.9, D23.0 thru D23.9, Z80.0, Z80.49, Z85.030 thru Z85.038, Z85.040 thru Z85.048, Z85.42 or Z86.010

FH (fumarate hydratase) (e.g., fumarate hydratase deficiency, hereditary leiomyomatosis with renal cell cancer), full gene sequence:

1. The patient presents with clinical symptoms and history suspicious for Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC), which may include one of the criteria below:
   1. Multiple cutaneous leiomyomas, with at least one histologically confirmed lesion
   2. Solitary cutaneous leiomyoma and family history of HLRCC
   3. Presentation of severely symptomatic uterine fibroids before age 40
   4.  Presentation of Type II papillary renal cell cancer before age 40
   5. Family history of first-degree family member meeting one of the above-mentioned criteria; and
2. The patient requires the service as a confirmatory test for HLRCC

CDH1 (hereditary diffuse gastric cancer):

1. Two gastric cancer cases in family, one confirmed diffuse gastric cancer younger than 50 years of age, or
2. Three confirmed diffuse gastric cancer cases in first or second degree relatives, regardless of age, or
3. Diffuse gastric cancer diagnosed younger than 40 years of age, or
4. Personal or family history of diffuse gastric cancer and lobular breast cancer, one diagnosed younger than 50 years of age

1. Microsatellite instability analysis of markers for mismatch repair deficiency, includes comparison of neoplastic and normal tissue, if performed. This is reimbursable for patients who meet one of the following criteria:
   1. the patient is diagnosed with one of the Lynch syndrome-associated cancers; or,
   2. the patient is diagnosed with an unresectable or metastatic solid tumor and the treatment will be contingent on the test result.
2. PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) gene analysis; known familial variants. Requirements include:
   1. Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious PMS2 mutation
3. MLH1 gene analysis; promoter methylation analysis Document the following criteria on the TAR:
   1. Patient with cancer(s) associated with Lynch Syndrome, and
   2. The tumor demonstrates microsatellite instability or immunohistochemistry results indicating loss of MLH1 protein expression
4. MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) gene analysis; known familial variants. Requirments include:
   1. Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MLH1 mutation
5. MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) gene analysis; known familial variants. Requirements include:
   1. Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MSH2 mutation
6. MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) gene analysis; duplication/deletion variants. Requirements include:
   1. One of the following ICD-10-CM codes is required on the claim: C17.0 thru C20, C24.0 thru C25.9, C54.0 thru C54.9, C65.1 thru C66.9, C71.0 thru C71.9, D23.0 thru D23.9, Z80.0, Z80.49. Z85.030, Z85.038, Z85.040, Z85.048, Z85.42
7. MSH6 (mutS homolog 6 [E. coli]) gene analysis; full sequence analysis. Requirements include:
   1. One of the following ICD-10-CM codes is required on the claim: C17.0 thru C20, C24.0 thru C25.9, C54.0 thru C54.9, C65.1 thru C66.9, C71.0 thru C71.9, D23.0 thru D23.9, Z80.0, Z80.49, Z85.030, Z85.038,Z85.040, Z85.048, Z85.42
8. MSH6 (mutS homolog 6 [E. coli]) gene analysis; known familial variants. Requirements include:
   1. Document on the TAR family history of Lynch Syndrome that includes a relative with a known deleterious MSH6 mutation
9. MSH6 (mutS homolog 6 [E. coli]) gene analysis; duplication/deletion variants. Requirments include:
10. One of the following ICD-10-CM codes is required on the claim: C17.0 thru C20, C24.0 thru C25.9, C54.0 thru C54.9, C65.1 thru C66.9, C71.0 thru C71.9, D23.0 thru D23.9, Z80.0, Z80.49. Z85.030, Z85.038, Z85.040, Z85.048, Z85.42

Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes is covered. Requires a TAR with documentation of the following criteria:

1. The recipient has high clinical risk per MINDACT categorization.
2. The recipient is estrogen and progesterone receptor (ER/PgR)-positive.
3. The recipient is HER2-receptor negative.
4. The recipient is lymph node negative or lymph node positive.
5. The recipient is a candidate for chemotherapy.
6. The assay is used within six months of diagnosis.
7. The recipient is under consideration for adjuvant systemic therapy.
   Use CPT code 81521 when billing for MammaPrint.

Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score. The following criteria must be documented on the TAR:

1. For identification of patients with Prostate Cancer who are most likely to benefit from active surveillance or treatment.
   1. Coverage is limited to Decipher®, Prolaris® and ProMark. Gene expression profiling for prostate cancer may be billed as follows:
      1. Decipher® Prostate – Use CPT code 81542
      2. Prolaris® – Use CPT code 81541
      3. ProMark – Use CPT code 81599
   2. The patient must have one of the following:
      1. Higher volume Grade Group 1
      2. Favorable intermediate risk (e.g., Grade Group 2, percentage of positive biopsy scores, 50 percent and no more than on NCCN intermediate-risk factor)
      3. Discordant features in their risk stratification (e.g., palpable mass with Grade Group 1)
      4. Other features associated with progression while on active surveillance (e.g., high PSA density and certain germline or somatic mutations)
      5. Unfavorable intermediaterisk when considering decisions to proceed with treatment (i.e. add androgen deprivation therapy to radiation)
      6. Result of the test, when considered as a whole with routine clinical factors, is likely to influence the decision to proceed with surveillance or treatment
2. For post-prostatectomy patients who seek guidance on adjuvant vs. salvage radiation:
   1. Coverage is limited to Decipher Genomic Classifier
   2. Result of the test, when considered as a whole with routine clinical factors, is likely to affect treatment

Cardiac ion channelopathies; genomic sequence analysis panel, must include sequencing of at least 10 genes. The required TAR must document a copy of the report of the physician interpreted 12-lead electrocardiogram (ECG) with pattern consistent with or suspicious for prolonged QT interval. The TAR must also have clinical documentation of one or more of the following:

1. Torsade de pointes in the absence of drugs known to prolong QT interval
2. T-wave alternans
3. Notched T-wave in three leads
4.  Syncope
5. Family members with long QT syndrome
6. Sudden death in family members less than 30 years of age without defined cause

Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9AG, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, and ZEB2. The required TAR must document the following:

1.  Patient has specific epilepsy syndrome of unknown cause for which a number of genetic etiologies exist.
2. The test is needed for identifying the underlying diagnosis
3. The diagnostic or treatment strategy will be contingent on test results

Hereditary retinal disorders (e.g., retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR and USH2A. A TAR is required with the following documentation:

1. Patient has a clinical diagnosis of retinal dystrophy (retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy) and
2. The decision for gene therapy is contingent on the test results

CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19), gene analysis, common variant is billable with any valid ICD-10-CM diagnosis code.

Information about the California Prenatal Screening Program must be offered to patients seen before the 20th completed week of gestation. Prenatal screening tests are used to
detect Down Syndrome (trisomy 21), trisomy 18, trisomy 13, neural tube defects and other specified birth defects. The Prenatal Screening Program consists of cell-free DNA (cfDNA) to screen for autosomal trisomies after 10 weeks of gestation, and maternal serum alpha-fetoprotein (MSAFP) in the second trimester.

Prenatal screening, which includes CPT® codes 81420 (fetal chromosomal aneuploidy [e.g., trisomy 21, monosomy X] genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21) or PLA Code 0327U (fetal aneuploidy [trisomy 13, 18, and 21], DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy, includes
sex reporting, if performed), and CPT code 82105 (alpha fetoprotein [AFP]; serum), is reimbursable only once for women in the first and/or second trimester of pregnancy, including women with Presumptive Eligibility for Pregnant Women (PE4PW) benefits. Women with positive screen results also may receive specialized follow-up services and diagnostic tests that are authorized only through GDSP.

If the prenatal screening results are negative and the recipient then requires follow-up services and diagnostic tests, claims submitted for the following procedures must include a statement of medical necessity in the Remarks field (Box 80)/Additional Claim Information field (Box 19) or on an attachment (if billed up to 12 weeks after a negative prenatal screening test, for the same recipient).

The statement of medical necessity should indicate one of the following:

1. Patient failed to understand the prenatal screening consent form.
2. Patient’s risk on her prenatal screening result is higher than her chronologic age.
3. Patient has an abnormal ultrasound and is offered an amniocentesis or chorionic villus sampling procedure.
4. Patient is discovered to have a risk for a prenatally detectable genetic or chromosomal abnormality, metabolic disease, or neural tube defect not known at the time of the prenatal screen.
5.  Patient has significant anxiety regarding her risk of a genetic defect despite a negative prenatal screen.
6. Patient will be 35 years old at the time of delivery and remains concerned regarding her risk of a genetic defect.

CPT code 81220 (CTFR [cystic fibrosis transmembrane conductance regulator] gene analysis; common variants [eg, ACMG/ACOG guidelines]) is reimbursable for cystic fibrosis prenatal testing when billed as follows:

1. When CPT code 81220 is used to bill for the purpose of cystic fibrosis screening, providers must document in the diagnosis field of the claim one of the ICD-10-CM diagnosis codes:
   1. Z31.430
   2. Z31.440
   3. Z34.00 thru Z34.03
   4. Z34.80 thru Z34.83
   5.  Z34.90 thru Z34.93
   6. ‹‹O09.00 thru O09.93››
2. CPT code 81220 is not reimbursable when billed with code 81224, for the same date of service, recipient and provider, but may be billed separately with the appropriate National Correct Coding Initiative (NCCI) associated modifier.
3. Fetal testing is reimbursable using the recipient’s Medi-Cal identification number if “fetal specimen” and medical justification is documented in the Remarks field (Box 80)/Additional Claim Information field (Box 19) or on a claim attachment. Failure to document these tests will result in claim denial.
4. Cystic fibrosis screening is reimbursable for the father only if he is a Medi-Cal recipient. Providers must document in the Remarks field (Box 80)/Additional Claim Information field (Box 19) or on a claim attachment, “patient screen positive/partner sample his recipient number” and ICD-10-CM code Z31.440, or the claim will be denied.
5. Cystic fibrosis screening is a once-in-a-lifetime procedure, which cannot be overridden with a Treatment Authorization Request (TAR).
6. CPT code 81220 is reimbursable for PE recipients with aid code 7G.

CPT code 59015 (Chorionic Villus Sampling [CVS], any method) is reimbursable when billed with the following provisions:

1. CVS should be performed only by a physician experienced in this procedure. The physician performing a CVS procedure should be able to provide to prospective patients the rate of miscarriage that the physician has experienced for this procedure.
2. Genetic counseling should include:
   1. A full comparison of the risks and benefits of amniocentesis versus CVS.
   2. That the overall risk for transverse limb deficiencies from CVS is 0.03 percent – 0.10 percent (1/3000 – 1/1000) and that the current data indicates no increased risk for limb deficiencies after amniocentesis performed at 15 – 18 weeks gestation.
   3. That CVS cannot detect most neural tube defects. Therefore, a maternal serum alpha-Fetoprotein (AFP) to screen for neural tube defects should be offered at 15 – 20 weeks gestation and if positive (approximately 1.5 percent of cases) would need to be followed up by amniocentesis to rule out this genetic abnormality. This second procedure would have risks separate from the previous CVS.

For amniocentesis performed within 10 weeks after a CVS, providers must include medical documentation in the Remarks field (Box 80)/Additional Claim Information field (Box 19) on the claim about the previous results of the CVS including but not limited to one of the following:

1. Placental mosaicism
2. Tissue culture failure
3. Maternal cell contamination
4. An elevated maternal serum AFP level

Effective January 1, 2022, rapid whole genome sequencing (rWGS) is a covered benefit for clinically eligible Medi-Cal beneficiaries. Only patients 1 year of age or younger admitted to an intensive care unit in the hospital (NICU, PICU, CVICU) are eligible.

For a full list of genetic tests covered their criteria, see the following: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/D56B6486-27C2-40E5-ACDF-E5E4AA599CA5/pathmolec.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

GHPP provides health care services for adults with genetic diseases specified in the California Code of Regulations (CCR), Title 17, Section 2932. GHPP eligibility determination, case management and authorization of services are conducted on a statewide basis by the GHPP state office. Applicants must meet age, residence, income and medical eligibility requirements to participate in GHPP. Applicants must submit completed Genetically Handicapped Persons Program (GHPP) Application to Determine Eligibility and Genetically Handicapped Persons Program (GHPP) Initial/Annual Income Verification forms. Eligibility requirements are as
follows. Applicants must be 21 years of age or older. Persons younger than 21 years of age with GHPP-covered genetic diseases may be eligible for GHPP if they have been determined to be financially ineligible to receive services from the California Children’s Services (CCS) program.
There is no income limit for GHPP. However, GHPP clients may be required to pay an annual enrollment fee. The amount of the enrollment fee is based on the client’s adjusted gross income. For adjusted gross income between 200 and 299 percent of the federal poverty level, the annual enrollment fee shall be 1.5 percent of adjusted gross income. For adjusted gross income equal to or greater than 300 percent of the federal poverty level, the
annual enrollment fee shall be 3 percent of adjusted gross income.

Medical Eligibility
GHPP covers genetic disease conditions specified in the California Code of Regulations (CCR), Title 17, Section 2932. The following is a summary of GHPP-eligible medical conditions. This summary is solely to assist providers in understanding the medical eligibility criteria of the GHPP program. It is not an authoritative statement of, and should not be cited as, authority for any decisions, determinations or interpretations of the GHPP program.
Providers should refer to the CCR section cited above for a definitive description of GHPP medical eligibility requirements.

• Hemophilia and other genetic bleeding disorders
• Cystic fibrosis
• Hemoglobinopathies with anemia, including sickle-cell disease and thalassemia
• Huntington’s disease, Joseph’s disease, Friedreich’s ataxia and other neurologic
  diseases
• Phenylketonuria, Wilson’s disease, galactosemia and other metabolic diseases
• Von Hippel-Lindau syndrome

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/6D5F956F-8D4E-4A67-BEC9-27D047EC3F68/genecoun.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/523A5E95-1E30-49FA-B42D-48D4AC95C160/genetic.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/D56B6486-27C2-40E5-ACDF-E5E4AA599CA5/pathmolec.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

https://radygenomics.org/clinical-genome-services/payer-policy-advocacy/california-medi-cal-rapid-wgs/

https://www.cdph.ca.gov/Programs/CFH/DGDS/Pages/psqa/gclp.aspx#

https://www.cahealthwellness.com/content/dam/centene/cahealthwellness/pdfs/provider/pharmacy/medi-cal-enteral-policy.pdf

https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/heritable-disorders/reports-recommendations/state-laws-medical-foods-tab.pdf