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
Amanda Cassel Kraft
Assistant Secretary for MassHealth
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
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
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.
- MassHealth Guidelines for Medical Necessity Determination for Gene Expression Profiling Tests for Breast Cancer
- 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
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.