This data is meant to be used for educational purposes to inform providers, patients, insurers, and state Medicaid agencies what genetic services may or may not be written into each state’s Medicaid policy. The database is not meant to indicate or imply whether a certain program will cover a specific service, since many decisions are made on a case by case basis. If you have specific questions about whether a service is covered, you should reach out to your plan administrator. Please see this disclaimer below for more information.
Medicaid Coverage Information Published
State Contact Information
Jacey Cooper, Chief Deputy Director, Health Care Programs
General Genetic Testing Criteria
Genetic Testing Not Covered
State Specific Definition
Genetic testing involves taking a sample of blood, cheek swab, or tissue in order to analyze a person’s genes. Genetic testing can be used to determine if someone has a change in his or her genes (mutation) that makes him or her more likely to develop certain diseases such as cancer.
Genetic Services for Children
Genetic Counseling Requirement
Medi-Cal provides coverages of genetic counseling and consultation services. Services may include:
- Review of pertinent medical records, pre-clinic visit and consultation as required;
- Complete examination of the patient or affected child 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; and
- Conveyance of information to patient or family and written report to the referring physician.
Services are no longer limited to once-in-a-lifetime.
Metabolic Formula Coverage Legislation
AB-30 Health care coverage: phenylketonuria: inborn errors of metabolism.
Metabolic Formula Coverage & Criteria
AB-30 Health care coverage: phenylketonuria: inborn errors of metabolism.
Prior Authorization Requirements
Please contact the Provider Helpline at 1-800-552-8627 (in-state long distance) or (804) 786-6273 (local and out of state customers) for services that are currently authorized by DMAS Medical Support Unit.
Prior Authorization Forms
BRCA Testing Coverage
Requirements for BRCA
- The patient has personal or family history that suggests an inherited cancer susceptibility based on any one of the following familial risk assessment tools;
- The patient is willing to talk with a health professional who is suitably trained to provide genetic counseling and interpret test results; and
- 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:
- Diagnosed at ≤45 years of age; or
- Diagnosed at 46 to 50 years of age with:
- An additional breast cancer primary at any age;
- One or more close blood relatives with breast cancer at any age
- One or more close blood relatives with prostate cancer (Gleason score ≥7);
- An unknown or limited family history; or
- Diagnosed at ≤60 years of age with a triple negative breast cancer; or
- Diagnosed at any age with one or more close blood relatives with:
- Breast cancer diagnosed at ≤50 years of age; or
- Ovarian carcinoma; or
- Male breast cancer; or
- Metastatic prostate cancer; or
- Pancreatic cancer
- Two or more additional diagnosis of breast cancer at any age in patient and/or in close blood relatives; or
- 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:
- 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
- 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
- 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:
- Patient has metastatic breast cancer.
- Patient is human epidermal growth factor receptor 2 (HER2)-negative.
- Patient has previously been treated with chemotherapy in the neoadjuvant, adjuvant or metastatic setting.
- Patient’s additional treatment is contingent on the test results.
Cystic Fibrosis Screening
Coverage is available.
Hereditary Cancer Testing Coverage
Lynch Syndrome Testing Coverage
Yes. Criteria includes a patient with a relative with a known deleterious mutation.
Prenatal Testing Offered
Prenatal screening, which includes fetal congenital abnormalities, fetal congenital abnormalities, are reimbursable only once for women in the first and/or second trimester of pregnancy, including women with Presumptive Eligibility for Pregnant Women (PE4PW) benefits and can include any combination of the five analytes. 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.
Whole Exome Sequencing
Other Tests Covered
Genetically Handicapped Persons Program
The Genetically Handicapped Persons Program (GHPP) is a health care program for adults with specific genetic diseases. GHPP helps beneficiaries with their health care costs. GHPP works with doctors, nurses, pharmacists, and other members of the health care team in providing many types of health services. “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
- Medi-Cal: Provider Manuals: General Medicine (GM), Genetic Counseling and Screening Medi-Cal: Provider Manuals: Durable Medical Equipment and Medical Supplies (DME), Genetically Handicapped Persons Program (GHPP) (genetic)
- Medi-Cal: Provider Manuals: Durable Medical Equipment and Medical Supplies (DME), Enteral Nutrition Products (enteral)
http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp Lynch Syndrome: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/pathmolec.pdf Metabolic
- Legislation Coverage https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=200720080AB30 Genetically Handicapped Persons Programs: https://www.dhcs.ca.gov/services/ghpp/Pages/MedicalEligibility.aspx https://files.medi-cal.ca.gov/pubsdoco/chdp_manual.aspx
Newborn Screening Reimbursement
Disclaimer: The information contained in the database has been obtained from sources believed to be reliable but NCC has not attempted to validate or confirm the information. The database may be updated periodically. However, the accuracy and completeness of the information contained in the database cannot be, and is not, guaranteed. NCC makes no warranty of the accuracy, completeness or timeliness of this information, and shall not be liable for any decision made in reliance on this information. It is the user’s responsibility to verify this information by contacting the state Medicaid agency directly.