Massachusetts

Updated on February 15, 2023

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

Yes

State Contact Information

Amanda Cassel Kraft
Assistant Secretary for MassHealth
(617)-573-1770

General Genetic Testing Criteria

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

https://www.mass.gov/prior-authorization-for-masshealth-providers

Fee Schedule

https://www.mass.gov/regulations/101-CMR-32000-clinical-laboratory-services

BRCA Testing Coverage

Coverage is available.

Requirements for BRCA

MassHealth considers genetic testing for BRCA-related cancer medically necessary once per lifetime in any of the following categories of high risk adults. MassHealth bases its determination of medical necessity for genetic testing for BRCA-related cancer on clinical data including, but not limited to, indicators that would affect the relative risks and benefits of genetic testing for BRCA-related cancer. These criteria include the following.

The member is 18 years of age or older; AND
The results of genetic testing will be clinically useful (i.e., will provide added value compared with not using the test) in the clinical management of the member; AND
The member has given prior written consent for genetic testing in accordance with Massachusetts General Laws Chapter 111, Section 70G; AND
The member’s personal and/or family cancer history suggests that an inherited pathogenic/likely pathogenic variant in BRCA1 or BRCA2 may exist by meeting criteria for one of the following categories of genetic test (I, II, III, or IV) for BRCA-related cancer ” https://www.mass.gov/doc/genetic-testing-for-hereditary-breast-andor-ovarian-cancer-0/download

Cystic Fibrosis Screening

Hereditary Cancer Testing Coverage

Some hereditary cancers are covered.

Lynch Syndrome Testing Coverage

Yes

Microarray Testing

Newborn Screening

<ol> <li>To be paid for an EPSDT periodic visit of a newborn, the provider must have visited the newborn at least twice before the newborn leaves the hospital.</li> <li>The first visit, for an initial history and physical examination, is payable as newborn care and not as an EPSDT periodic visit.</li> <li>The second visit, for a discharge history, physical examination, and all other screens required for the newborn, is payable as an EPSDT periodic visit.</li> </ol>

Panel Testing

Pharmacogenetic Testing

Prenatal Testing Offered

Whole Exome Sequencing

Other Tests Covered

MassHealth bases its determination of medical necessity for Oncotype DXTM on a combination of clinical data and the presence of indicators that would affect the relative risks and benefits of the procedure.

Other Information

Resources

MassHealth Guidelines for Medical Necessity Determination for Gene Expression Profiling Tests for Breast Cancer
- https://www.mass.gov/guides/masshealth-guidelines-for-medical-necessity-determination-for-gene-expression-profiling
MassHealth Guidelines for Medical Necessity Determination for Enteral Nutrition Products
- https://www.mass.gov/guides/masshealth-guidelines-for-medical-necessity-determination-for-enteral-nutrition-products
MassHealth Guidelines for Medical Neccesity determination for Genetic Testing for Hereditary Breast and/or Ovarian Cancer
- https://www.mass.gov/doc/genetic-testing-for-hereditary-breast-andor-ovarian-cancer-0/download

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.

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