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
Director, Office of MaineCare Services
General Genetic Testing Criteria
Laboratory Services which are medically necessary for diagnosis and control of a medical condition, are covered services. These services must be ordered by a physician or other licensed practitioner of the healing arts authorized to order lab services within the scope of his or her license and be consistent with good medical practice.
Genetic Testing Not Covered
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Metabolic Formula Coverage Legislation
Metabolic Formula Coverage & Criteria
Prior Authorization Requirements
Prior Authorization Forms
BRCA Testing Coverage
Coverage is available.
Requirements for BRCA
A molecular pathology service is medically necessary if for the following reasons:
- 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.
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Some known familial variants are covered.
Lynch Syndrome Testing Coverage
No coverage is available.
Most panels are listed under non covered services.
Prenatal Testing Offered
Whole Exome Sequencing
Other Tests Covered
Maine Medical Center – Genetics Program: “The Division of Genetics at the Barbara Bush Children’s Hospital provides Genetics services for individuals from primarily southern Maine and New Hampshire.”
- Department of Health and Human Services Chapter 101: MaineCare Benefits Manual Ch. II – Section 60: Medical Supplies and Durable Medical Equipment
- Non Covered Codes
- Legislation about genetics
- Maine Medical Center
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.