Illinois
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
Division of Medical Programs
Illinois Department of Healthcare and Family Services
201 South Grand Avenue East, 3rd Floor
Springfield, IL 62763-0001
Phone: (217) 782-2570
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
Licensure is required. For a full list of requirements and to view the application, use the following link: https://idfpr.illinois.gov/content/dam/soi/en/web/idfpr/renewals/apply/forms/1985GC.pdf
Metabolic Formula Coverage Legislation
PUBLIC HEALTH (410 ILCS 240/) Newborn Metabolic Screening Act.
Metabolic Formula Coverage & Criteria
The Department of Public Health shall administer the provisions of this Act and shall: Supply the necessary metabolic treatment formulas where practicable for diagnosed cases of amino acid metabolism disorders, including phenylketonuria, organic acid disorders, and fatty acid oxidation disorders for as long as medically indicated, when the product is not available through other State agencies.
Prior Authorization Requirements
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Coverage is available, but criteria is unknown.
Requirements for BRCA
Cystic Fibrosis Screening
Coverage is available, but criteria is unknown.
Hereditary Cancer Testing Coverage
Lynch Syndrome Testing Coverage
Coverage is available, but criteria is unknown.
Microarray Testing
Coverage is available, but criteria is unknown.
Newborn Screening
The NBS fee is $128.00 per screen, which covers testing and follow-up. The fee also covers the cost of metabolic formula. The Illinois Department of Public Health bills birthing hospitals or other entities that submit a sample for newborn screening. The Department does not bill private insurance or Medicaid. In the case of home births, or other out of hospital births, the state newborn screening program does bill parents directly. Then the screen is usually paid for out of pocket.
Panel Testing
Coverage is available, but criteria is unknown.
Pharmacogenetic Testing
Coverage is available, but criteria is unknown.
Prenatal Testing Offered
Coverage is available, but criteria is unknown.
Whole Exome Sequencing
Coverage is available, but criteria is unknown.
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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