Maine
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
Michelle Probert
Director, Office of MaineCare Services
Maine Department of Health and Human Services
221 State Street
Augusta, ME 04333
Phone: (207) 287-2674
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
The following are listed as medically necessary reasons for a molecular pathology test:
- Diagnostic testing if a member is experiencing symptoms of or demonstrating findings consistent with a disease that may be caused by genetic alterations.
- Pre-symptomatic and pre-dispositional predictive testing for members with a documented family history of a genetic disorder.
- Pharmacogenetic testing for medical conditions if the results will help inform clinical therapeutic decision-making.
- Genetic carrier screening/testing if a member or member’s partner has a family history of a genetic disorder, including risk based on belonging to certain ethnic groups who are at increased risk of having children with certain genetic disorder (e.g. cystic fibrosis, Ashkenazi disease screen, sickle cell disease and other hemoglobinopathies).
- Prenatal screening and diagnostic molecular pathology to detect some types of abnormalities in a fetus’ genetic and/or genomic make-up.
- Genomic assay to predict recurrence risk and chemotherapy benefit in hormone-receptorpositive (HR+) invasive breast cancer.
Genetic Testing Not Covered
Genetic tests listed as non-covered under the fee schedule include:
- Ugt1a1 gene analysis common variants
- Vkorc1 gene analysis common variant(s)
- Autoimmune rheumatoid arthrts analys 12 biomrkrs
- Coronary artery disease mrna gene expression 23 genes
- Growth stimulation expressed gene 2
- Genetic test susceptability to oral disease
- Caries susceptibility tests
- Genetic test for susceptibility to diseases
- Warfarin respons genetic test, any methd, any nm
- Genetic counseling
- DNA analysis RET-oncogene to multiple endocrn
- Genetic testing for retinoblastoma
- Genetic testing for von Hippel-Lindau disease
- DNA analys of connexin 26 gene for congenital deafness
- Genetic testing for alpha-thalassemia
- Genetic testing hemoglobin E beta-thalassemia
- Genetic testing for Niemann-Pick disease
- Genetic testing for sickle cell anemia
- Genetic test for myotonic muscular dystrophy
- DNA analysis APOE eps for Alzheimer’s disease
- Gene testing for presenilin-1 gene
- Genetic testing Brugada syndrome
- Comprehensive gene test hyp cardiomyopathy
- Spec gene test hypertrophic cardiomyopathy
- Cyp2c9 gene analysis common variants
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
No licensure requirement.
Metabolic Formula Coverage Legislation
§2745-D. Medical food coverage for inborn error of metabolism
Metabolic Formula Coverage & Criteria
All individual insurance policies and contracts, except accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care and other limited benefit health insurance policies and contracts, must provide coverage for metabolic formula and special modified low-protein food products that have been prescribed by a licensed physician for a person with an inborn error of metabolism. The policies and contracts must reimburse:
- For metabolic formula; and
- Up to $3,000 per year for special modified low-protein food products.
Prior Authorization Requirements
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Coverage is available.
Requirements for BRCA
The BRCA test should be ordered in accordance with recommendations from the United States Preventive Services Task Force:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing.
Cystic Fibrosis Screening
Coverage is available.
Hereditary Cancer Testing Coverage
Coverage is available.
Lynch Syndrome Testing Coverage
Coverage is available.
Microarray Testing
Newborn Screening
The newborn metabolic screening panel is a covered benefit.
Panel Testing
“Gene profile panel breast cancer treatment” is listed as a covered benefit.
The 21-gene Recurrence Score assay to predict recurrence risk and chemotherapy benefits in hormone-receptor-positive (HR+) invasive breast cancer test should be ordered in accordance with recommendations from the National Comprehensive Cancer Network or the American Society of Clinical Oncology
(https://www.asco.org/; https://www.nccn.org/)
Pharmacogenetic Testing
Coverage is available.
Prenatal Testing Offered
Coverage is availabe.
Whole Exome Sequencing
No coverage.
Other Tests Covered
For a full list of genetic tests covered, see the following link:
https://mainecare.maine.gov/Provider%20Fee%20Schedules/MaineCare%20UCR/2-MaineCare%20UCR%20(pdf).pdf
Other Information
Tests for a carrier screening for cystic fibrosis, spinal muscular atrophy, or Fragile X Syndrome should be ordered in accordance with the recommendations from The American College of Obstetricians and Gynecologists
http://www.acog.org/
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.
The database contains links to third-party websites. These links are provided solely as a convenience to users and not as a guarantee, warrantee, or recommendation by NCC of the content on such third-party websites or as an indication of any affiliation, sponsorship or endorsement of such third party websites. NCC is not responsible for the content of linked third-party sites and does not make any representations regarding the privacy practices of, or the content or accuracy of materials on, such third-party websites. If you decide to access linked third-party websites, you do so at your own risk. Your use of third-party websites is subject to the terms of use for such sites.