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
Kelly Cunningham, Medicaid Administrator
General Genetic Testing Criteria
Genetic Testing Not Covered
State Specific Definition
Genetic Services for Children
Every infant with confirmed hearing loss should be evaluated by an otolaryngologist with knowledge of pediatric hearing loss and have at least one examination to assess visual acuity by an ophthalmologist experienced in evaluating infants. A genetics consultation should be offered to families of children with congenital hearing or vision deficits.
Genetic Counseling Requirement
A physician may submit a bill for services rendered by an Advanced Practice Nurse (APN), a Physician Assistant (PA) or a Genetic Counselor, as long as such practice is in accordance with the policy outlined in this handbook or not in conflict with the following rules and regulations:
- Physician Assistant Practice Act (225 ILCS 95)
- Genetic Counselor Licensing Act (225 ILCS 135)
- Department of Professional Regulations rules for administration of Physician Assistant Practice Act (68 Ill. Adm. Code 1350)
Metabolic Formula Coverage Legislation
Metabolic Formula Coverage & Criteria
Prior Authorization Requirements
Prior Authorization Forms
BRCA Testing Coverage
Coverage is available.
Requirements for BRCA
Under the Meridian care plan, which applies to Illinois Medicaid:
Criteria for Coverage (To be used for requests not listed under specific diagnoses):
- There must be evidence that the requested test is clinically appropriate. Detailed documentation is provided that
supports test results will be used to significantly alter the management or treatment of the member (e.g. surgery,
the extent of surgery, a change in surveillance, hormonal manipulation, choice of medication, or a change from
standard therapeutic or adjuvant chemotherapy.
- Clinical documentation should be submitted that suggests a key genetic disorder is present, which can be
indicated by the following:
- Clinical features indicative of a condition or disease with suspected genetic etiology; OR
- High risk of inheriting the disease based upon personal history, family history, documentation of a
genetic mutation and/or ethnic background; OR
- Following history, physical examination, pedigree analysis and completion of conventional
diagnostic testing, a definitive diagnosis remains uncertain and a hereditary diagnosis is suspected,
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Under Meridian Medicaid, certain cancers are covered.
Lynch Syndrome Testing Coverage
hMLH1, hMSH2, hMSH6 and PMS2 gene tests are covered to diagnose Lynch syndrome.
Criteria for Lynch syndrome genetic testing includes:
- At least two close relatives of the affected beneficiary must have or have had a cancer associated with Lynch syndrome; and all of the following criteria must be present:
- One must be a first-degree relative of the other two;
- At least two successive generations must be affected;
- At least one of the relatives or the beneficiary with cancer associated with hereditary nonpolyposis colorectal cancer should be diagnosed before the age 50 years;
- Familial adenomatous polyposis (FAP) should be excluded in the colorectal cancer case(s) (if any);
- Histologic diagnosis of tumors should be verified whenever possible.
Prenatal Testing Offered
Whole Exome Sequencing
Other Tests Covered
The llinois Department of Public Health (IDPH) offers a Genetics Program “to provide access to appropriate genetic services for any family with concerns about an inherited condition, and to increase awareness of services provided by the program among health care providers and consumers. Genetic services are available to families or persons of any age residing in Illinois, who may have a family history of, or concern about a medical condition with a genetic basis.
- Medical Provider Handbook: Chapter 200 , Durable Medical Equipment
- Medical Provider Handbook: Chapter 200, Healthy Kids manual
Medical Provider Handbook: Chapter 200, Practitioners Handbook
- Family Planning and Reproductive Health Services Provider Notice (6/26/14) Meridian Health Plan BRCA/Lynch/Hereditary Cancer:
- Newborn Screening:
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.