Colorado
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
Adela Flores-Brennan
Medicaid Director
Colorado Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO 80203-1818
Phone: (303) 866-5929
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
Genetic Testing Not Covered
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
The “Genetic Counselor Licensure Act”makes it so that on and after June 1, 2020, a person cannot practice genetic counseling without being licensed by the director of the division of professions and occupations in the department of regulatory agencies. To be licensed, a person must have been certified by a national body, except that the director may issue a provisional license to a candidate for certification pursuant to requirements established by rule.
BRCA screening is covered and must be conducted prior to any BRCA-related genetic testing.
Metabolic Formula Coverage Legislation
CRS §10‐16‐104
10 CCR 2505‐3
Metabolic Formula Coverage & Criteria
Enteral nutrition (EN) refers to medical formula/solutions when ordered by a physician, physician assistant, or nurse practitioner and provided according to standards of practice. The allowance for all items includes delivery to a member’s residence. Equipment, supplies, and nutrients for enteral feeding or food supplements are a benefit when prior authorized.
Durable Medical Equipment providers should request that members participate in the Women, Infants & Children (WIC) program as a primary resource for medically necessary enteral nutrition products. Enteral nutrition products are a covered benefit when a member has been prescribed over the WIC limit and or WIC is unable to fulfill the prescription due to supply. Providers have the option of requesting a three (3) month PAR for members in the process of applying for WIC. After WIC determination is completed, provider may then submit a new PAR for one (1) year less one (1) day.
Prior Authorization Requirements
Prior authorization is required for some tests. See the fee schedule for a list of tests that require PA.
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Yes
Requirements for BRCA
Per the Women’s Health Services rule found at 10 CCR 2505-10 8.731, the following are requirements for BRCA screening and testing:
BRCA screening, genetic counseling, and testing is only covered for clients over the age of 18.
BRCA screening is covered and must be conducted prior to any BRCA-related genetic testing.
The provider shall make genetic counseling available to clients with a positive screening both before and after genetic testing, if the provider is able, and genetic counseling is within the provider’s scope of practice. If the provider is unable to provide genetic counseling, the provider shall refer the client to a genetic counselor*.
Genetic testing for breast cancer susceptibility genes BRCA1 and BRCA2 is covered for clients with a positive screening
Cystic Fibrosis Screening
Coverage is available, but criteria is unknown.
Hereditary Cancer Testing Coverage
Coverage is available, but criteria is unknown.
Lynch Syndrome Testing Coverage
Coverage is available, but criteria is unknown.
Microarray Testing
Coverage is available, but criteria is unknown.
Newborn Screening
Costs associated with Newborn Metabolic Screening (NMS) are included in the inpatient hospital diagnosis-related grouper (DRG) calculation and the birthing center facility payment and may not be billed separately by the hospital or birth center. This service is covered.
Panel Testing
Pharmacogenetic Testing
Prenatal Testing Offered
Effective July 1, 2022, Genetic Screening, including but not limited to Non-Invasive Prenatal Testing (NIPT), and Genetic Counseling are covered in accordance with nationally recognized standards of care per the American College of Obstetricians and Gynecologists. Screening coverage is available for women carrying a singleton gestation who meet national standard guidelines.
Access the following link to learn the nationally recognized standards of care per the ACOG: https://www.acog.org/advocacy/policy-priorities/non-invasive-prenatal-testing/current-acog-guidance
Coverage of this service was available under more specific criteria prior to June 30, 2022.
Whole Exome Sequencing
No coverage.
Other Tests Covered
Other Information
Resources
Newborn Screening Reimbursement
On this Page
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.
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