Idaho
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
Dave Jeppesen, Director of Health and Welfare
208-334-5500
General Genetic Testing Criteria
Idaho Medicaid coverage includes genetic testing or molecular pathology services performed in a credentialed lab, but only when such testing is considered under current standards to be reasonable and necessary for the diagnosis and potential treatment of an illness, disease, or condition.
Genetic Testing Not Covered
The following types of genetic testing are NOT covered by Idaho Medicaid:
- Tests performed for screening purposes only, in the absence of signs, symptoms, or personal history of disease or injury;
- Tests that are done solely to diagnose a patient, and will not impact medical decision-making for the patient or the patient’s treatment plan;
- Tests for conditions and diseases which are symptomatically treated;
- Tests done to confirm a diagnosis;
- Tests done for informational purposes only;
- Tests on people other than the participant;
- Tests for paternity;
- Tests for legal reasons; or
- Tests performed for the purposes of genetic counseling or family planning.
Genetic Testing for mental health conditions is considered experimental and investigational Testing is non-covered for all situations.
Idaho Medicaid considers genotyping of SLCO1B1 and UGT1A1 experimental and investigational for assessing risk of neonatal hyperbilirubinemia because the clinical value of this approach has not been established.
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Genetic counseling is a required component of genetic testing. It provides participants with the ability to make informed decisions about their healthcare. Genetic Testing must be provided to the participant before and after testing.
Genetic counseling must be provided by one of the following:
- A genetic counselor with a master’s degree specifically in genetic counseling or related field, who is certified by the American Board of Genetic Counseling (ABGC) or American Board of Medical Genetics (ABMG).
- A physician or physician assistant with the appropriate expertise and training about inherited conditions, risks for disease, testing implications for health management, and interpreting findings of genetic tests.
Metabolic Formula Coverage Legislation
Nutrional services are covered by medicaid when medically necessary as outlined by IDAPA §16.03.09 as seen https://adminrules.idaho.gov/rules/current/16/160309.pdf
Metabolic Formula Coverage & Criteria
Nutrional services are covered by medicaid when medically necessary as outlined by IDAPA §16.03.09 as seen https://adminrules.idaho.gov/rules/current/16/160309.pdf
Prior Authorization Requirements
The Medicaid Fee Schedule shows which labs always require a prior authorization.
Some genetic tests require prior authorization through Telligen. That list can be found at: http://idmedicaid.telligen.com/document-library under “Idaho Prior Authorization Codes”
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
No coverage is available.
Requirements for BRCA
No coverage is available.
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
The following types of genetic testing are NOT covered by Idaho Medicaid:
- Tests performed for screening purposes only, in the absence of signs, symptoms, or personal history of disease or injury;
- Tests that are done solely to diagnose a patient, and will not impact medical decision-making for the patient or the patient’s treatment plan;
- Tests for conditions and diseases which are symptomatically treated;
- Tests done to confirm a diagnosis;
- Tests done for informational purposes only;
- Tests on people other than the participant;
- Tests for paternity;
- Tests for legal reasons; or
- Tests performed for the purposes of genetic counseling or family planning.
Genetic Testing for mental health conditions is considered experimental and investigational Testing is non-covered for all situations.
Idaho Medicaid considers genotyping of SLCO1B1 and UGT1A1 experimental and investigational for assessing risk of neonatal hyperbilirubinemia because the clinical value of this approach has not been established.
Lynch Syndrome Testing Coverage
The following types of genetic testing are NOT covered by Idaho Medicaid:
- Tests performed for screening purposes only, in the absence of signs, symptoms, or personal history of disease or injury;
- Tests that are done solely to diagnose a patient, and will not impact medical decision-making for the patient or the patient’s treatment plan;
- Tests for conditions and diseases which are symptomatically treated;
- Tests done to confirm a diagnosis;
- Tests done for informational purposes only;
- Tests on people other than the participant;
- Tests for paternity;
- Tests for legal reasons; or
- Tests performed for the purposes of genetic counseling or family planning.
Genetic Testing for mental health conditions is considered experimental and investigational Testing is non-covered for all situations.
Idaho Medicaid considers genotyping of SLCO1B1 and UGT1A1 experimental and investigational for assessing risk of neonatal hyperbilirubinemia because the clinical value of this approach has not been established.
Microarray Testing
Newborn Screening
Panel Testing
Pharmacogenetic Testing
The drug must be covered for the participant for the pharmacogenetic testing to be a covered service, and, in addition the general genetic testing requirements, one of the following conditions must be met:
- Testing is required or recommended by the drug prescribing information; or
- A drug trial would be contra-indicated without genetic testing results known ahead of time.
Prenatal Testing Offered
Idaho Medicaid is implementing temporary coverage of noninvasive prenatal testing (NIPT) for fetal aneuploidy screening, effective 5/01/2020.
Whole Exome Sequencing
Other Tests Covered
Other Information
Resources
- Genetic Laboratory Testing https://www.idmedicaid.com/Provider%20Guidelines/Laboratory%20Services.pdf Idaho Medicaid Provider Handbook: Suppliers
- https://www.idmedicaid.com/Provider%20Guide/Provider%20Handbook.aspx Updated genetic information June 2021
- https://www.idmedicaid.com/MedicAide%20Newsletters/June%202021%20MedicAide.pdf
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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