Delaware

Updated on October 12, 2023

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

Yes

State Contact Information

DIVISION OF MEDICAID & MEDICAL ASSISTANCE
Theodore Mermigos, Acting Director
Lisa Zimmerman, Deputy Director
(302) 255-9500
1901 N. Du Pont Highway, Lewis Bldg.
New Castle, Delaware 19720
FAX: (302) 255-4454

https://dhss.delaware.gov/dhss/main/contacts.htm

General Genetic Testing Criteria

Genetic Testing Not Covered

State Specific Definition

Genetic Services for Children

Genetic Counseling Requirement

You may apply for Genetic Counselor licensure by Original or Provisional methods. The documentation that you are required to submit depends on how you are applying.

Apply for an original license if you have certification from the American Board of Genetic Counselors (ABGC) or the American Board of Medical Genetics and Genomics (ABMGG).
Apply for a provisional license if ABGC has granted you Active Candidate Status.

In addition to submitting the application and fee in DELPROS, you must submit:

State of Delaware and Federal Bureau of Investigation criminal background checks (CBC). Follow the instructions on the Criminal History Record Check Authorization Open this document with ReadSpeaker docReader form to arrange to be fingerprinted. Submit the forms and payment to the State Bureau of Identification (SBI). Do not send these forms to the Board office.
Verification that you are certified as either a genetic counselor by the ABGC or ABMGG or a medical geneticist by the ABMG if you already hold one of these certifications. The certifying organization must send the verification directly to the Council office.
State/Jurisdiction Licensure Verification sent directly to the Board office from each state or jurisdiction in which you currently hold or have ever held a Genetic Counselor license.

Metabolic Formula Coverage Legislation

Delaware
DC §16‐201
DC §18‐3355
DC §18‐3571
DAC §16‐4103

Metabolic Formula Coverage & Criteria

Oral nutrition is considered reasonable and necessary for a patient who requires supplementation of their daily protein and caloric intake.
Patients who can adequately obtain nutrition orally will not be approved for nutrition therapy with the following exceptions:

Pregnant women with phenylketonuria (PKU)
Failure to thrive-documentation must be attached that details the diagnosis of
failure to thrive
Individuals with birth defects, cerebral palsy, cystic fibrosis, metabolic diseases,
or other medical conditions that prevent them from obtaining sufficient nutrition
from a normal diet.

When requesting authorization for oral nutrition, the DME provider must submit specific documentation and use modifier BO (Orally Administered Nutrition Not by Feeding Tube) which is available on the MMIS and in Appendix 2 of the Level
II HCPCS book.

When requesting authorization for oral nutrition for a patient with renal disease, the provider must obtain the following forms from the dialysis center: a Renal Supplement Application/Renewal Form (Appendix C), a Medicare Enteral Nutrition CMN (Appendix E), and a Medicare Denial for Medicare Part B enrollees. These forms must be submitted with a Medicaid Certificate of Medical Necessity (Appendix B).
When requesting authorization for oral nutrition for other patients, the provider must submit a Medicare Enteral Nutrition CMN (Appendix E) and a Medicaid Certificate of Medical Necessity (Appendix B) that are completed and signed by
the physician. In addition, a physician’s letter of medical necessity and prescription must be submitted. The letter must document the primary diagnosis and any other related medical conditions that prevent the individual from
obtaining sufficient nutrition from a normal diet and must include the following, as
appropriate:

Physical findings: Height, Weight and Ideal Body Weight or Body Mass Index.
Explanation of weight loss with specific dates and measurements. Other physical examination findings.
Significant laboratory data (for example, Serum Albumin)
Discussion of any risk factors found related to undernutrition in any of the following areas: clinical features, eating habits, living environment, functional status, mental/cognitive status.

Prior Authorization Requirements

PA required for:

Oncology (Breast);
MRNA;
Gene expression testing.

Prior Authorization Forms

https://eforms.com/prior-authorization/medicaid/delaware/

Fee Schedule

https://medicaidpublications.dhss.delaware.gov/docs/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download&EntryId=1306&language=en-US&PortalId=0&TabId=94