Hawaii
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
Judy Mohr Peterson
Medicaid Director, Administrator for Med-QUEST
General Genetic Testing Criteria
Genetic Testing Not Covered
Procedures that are considered experimental, investigational or generally of unproven benefit are not covered. In addition, laboratory procedures related to a non-covered service are not covered.
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Metabolic Formula Coverage Legislation
Public assistance recipients in this State who receive medical assistance pursuant to this chapter shall be allowed coverage for medical foods and low-protein modified food products for the treatment of an inborn error of metabolism; provided that the medical food or low-protein modified food product is:
- Prescribed as medically necessary for the therapeutic treatment of an inborn error of metabolism; and
- Consumed or administered enterally under the supervision of a physician or osteopathic physician licensed under chapter 453.
Metabolic Formula Coverage & Criteria
Public assistance recipients in this State who receive medical assistance pursuant to this chapter shall be allowed coverage for medical foods and low-protein modified food products for the treatment of an inborn error of metabolism; provided that the medical food or low-protein modified food product is:
- Prescribed as medically necessary for the therapeutic treatment of an inborn error of metabolism; and
- Consumed or administered enterally under the supervision of a physician or osteopathic physician licensed under chapter 453.
Prior Authorization Requirements
As a general statement, most tests that are necessary for a diagnosis do not require prior approval (PA). Those that are confirmatory or are more costly may require PA utilizing the Medical Authorization Form 1144.
Testing that require authorizations include but are not limited to:
- Chromosome analysis.
Approval is given when medically necessary such as in the following:
- Myelogenous leukemia, acute or exacerbation;
- Ambiguous genitalia;
- Malformations consistent with a chromosome disorder;
- Primary amenorrhea not attributable to other causes;
- Other cytogenetic studies such as tissue culture, cryopreservation of cell lines, molecular cytogenetics, DNA probe;
- On fetal cells by amniocentesis between the 16th and 20th week of gestation (confirmed by ultrasound) when:
- The mother is 35 or older;
- A parent has a previous child with a known or strongly suspected chromosome abnormality;
- Either parent has a known chromosome disorder; or
- There is a family history of a hereditary disorder diagnosable by chromosome analysis. 6
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Coverage is available.
Requirements for BRCA
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Coverage is available.
Lynch Syndrome Testing Coverage
Microarray Testing
Newborn Screening
Panel Testing
Pharmacogenetic Testing
Prenatal Testing Offered
Prior authorization is not required for amniocentesis.
Amniocentesis alone is covered when:
- An assessment of fetal lung maturity is necessary because pre-term delivery is either imminent or necessary.
- The determination of amniotic fluid bilirubin levels is necessary to assess fetal involvement in hemolytic diseases of the newborn.
Whole Exome Sequencing
Other Tests Covered
Other Information
Resources
- Provider Manual Chapter 7: Laboratory, Pathology & Radiology Services
- Provider Manual Chapter 10: DMEPOS, 10.5.2 Prepared Foods
- https://medquest.hawaii.gov/en/plans-providers/fee-for-service/provider-manual.html Hawaii legislation https://law.onecle.com/hawaii/title-20/chapter-346/index.html
Newborn Screening Reimbursement
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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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