Montana

Updated on October 12, 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

Charlie Brereton, Director of Department of Health and Human Services
charles.brereton@mt.gov, (406) 444-5623

Mike Randol, Medicaid and Health Services Executive Director
michael.randol@mt.gov, (406) 444-5622

Office of the Director
111 North Sanders, Room 301, Helena MT 59620
PO Box 4210, Helena MT 59604-4210
Main: (406) 444-5622
Fax: (406) 444-1970

https://dphhs.mt.gov/directorsoffice

General Genetic Testing Criteria

Genetic Testing Not Covered

State Specific Definition

Genetic Services for Children

Genetic testing for Children’s Mental Health is covered. Youth must meet the SED criteria as described in this manual and additional criteria below:

Youth displays clinical feature or is at direct risk of inheriting a gene that testing is necessary to improve clinical outcomes of neuropsychiatric medication.
Documented previous medication failures and intent to alter medication course consistent with test results. Youth must have failed or currently be failing on at least one neuropsychiatric medication.
Results of test will directly impact treatment being delivered to the patient.
Documentation of risk and clinical need must include a comprehensive history, physical examination and completion of conventional diagnostic studies.

Genetic Counseling Requirement

37-49-201. Representation or practice as genetic counselor — license required. (1) On issuance of a license under this chapter, a licensee may use the title “licensed genetic counselor”.
Except as otherwise provided in this chapter, a person may not represent that the person is a licensed genetic counselor by using the title “genetic counselor”, “licensed genetic counselor”, “gene counselor”, “genetic consultant”, “genetic associate”, or any words, letters, abbreviations, or insignia indicating or implying a person holds a genetic counseling license unless the person is licensed under this chapter.

37-49-202. Licensure requirements — examination — fees — temporary practice. (1) The department shall license as a genetic counselor an applicant who:

submits an application and pays the fee required by the department;
provides satisfactory evidence of having received certification from the American board of genetic counseling as a genetic counselor; and
complies with other requirements established by the department by rule.

The department may issue:

a temporary license to an applicant to whom the American board of genetic counseling has granted active candidate status; and
a license to an applicant who satisfactorily demonstrates that the applicant is licensed or registered under the laws of another state, territory, or jurisdiction of the United States that in the department’s opinion imposes substantially the same requirements for licensure as are required under this chapter.
A temporary license expires automatically on the earliest of the following:
1. issuance of a full license to a person who successfully passes the American board of genetic counseling certification exam; or
2. at the time a person loses active candidate status for failure to complete or pass the American board of genetic counseling certification exam.
Licenses issued under this section are valid for the period established by the department by rule and may be renewed only on the filing of a renewal application and payment of the license renewal fee.
An applicant shall submit an application fee in the amount established by the department by rule and a written application on a form provided by the department that demonstrates the applicant has completed the eligibility requirements and competency standards required under this chapter and by the department by rule.
The department may not license an applicant who has:
1. committed any act that if committed by a licensee would be grounds for license suspension or revocation; or
2. misrepresented any material fact on the application.

Metabolic Formula Coverage Legislation

MCA §32‐22‐131 ARM 37.57.110

Metabolic Formula Coverage & Criteria

33-22-131.Coverage for treatment of inborn errors of metabolism.

Each group or individual medical expense disability policy, certificate of insurance, and membership contract that is delivered, issued for delivery, renewed, extended, or modified in this state must provide coverage for the treatment of inborn errors of metabolism that involve amino acid, carbohydrate, and fat metabolism and for which medically standard methods of diagnosis, treatment, and monitoring exist.
Coverage must include expenses of diagnosing, monitoring, and controlling the disorders by nutritional and medical assessment, including but not limited to clinical services, biochemical analysis, medical supplies, prescription drugs, corrective lenses for conditions related to the inborn error of metabolism, nutritional management, and medical foods used in treatment to compensate for the metabolic abnormality and to maintain adequate nutritional status.
For purposes of this section:
1. “medical foods” means nutritional substances in any form that are:
  1. formulated to be consumed or administered enterally under supervision of a physician;
  2. specifically processed or formulated to be distinct in one or more nutrients present in natural food;
  3. intended for the medical and nutritional management of patients with limited capacity to metabolize ordinary foodstuffs or certain nutrients contained in ordinary foodstuffs or who have other specific nutrient requirements as established by medical evaluation; and
  4. essential to optimize growth, health, and metabolic homeostasis;
2. “treatment” means licensed professional medical services under the supervision of a physician.
These services are subject to the terms of the applicable group or individual disability policy, certificate, or membership contract that establishes durational limits, dollar limits, deductibles, and copayment provisions as long as the terms are not less favorable than for physical illness generally.
This section does not apply to disability income, hospital indemnity, medicare supplement, accident-only, vision, dental, or specified disease policies

Prior Authorization Requirements

Required for genetic tests.

Prior Authorization Forms

https://medicaidprovider.mt.gov/formshttps://medicaidprovider.mt.gov/docs/forms/PAmedicalsurgicalform11142018.pdf

Fee Schedule

https://medicaidprovider.mt.gov/docs/feeschedules/2023/January2023/January2023LabServicesFeeSchedule.pdf

BRCA Testing Coverage

Yes

Requirements for BRCA

BRCA screening is allowed in the following instances:
Members is over the age of 18; and
Have at least one of the following criteria:

Personal history of any of the following:

Breast cancer diagnosis at or before age 45.
Breast cancer diagnosis at or before age 50 with any of the following:
An additional breast cancer primary;
1. 1 or more close blood relative with breast cancer at any age;
2. 1 or more close blood relative with pancreatic cancer;
3. 1 or more close blood relative with prostate cancer with a Gleason score ≥7.
Breast cancer diagnosis at or before age 60 with:
1. Triple negative breast cancer.
Breast cancer diagnosis at any age with any of the following:
1. 1 or more close relatives with breast cancer diagnosed before age 50;
2. 2 or more close blood relatives with breast cancer diagnosis at any age;
3. 1 or more close blood relative with ovarian cancer diagnosis;
4. 2 or more close blood relatives with pancreatic cancer diagnosis or prostate cancer diagnosis with a Gleason score ≥7;
5. 1 or more close blood relative diagnosed with male breast cancer.
Male breast cancer diagnosis at any age.
Ovarian cancer diagnosis at any age.
Fallopian tube cancer diagnosis at any age.
Primary peritoneal cancer diagnosis at any age.
Prostate cancer diagnosis with a Gleason score 7 at any age with any of the following:
1. 1 or more close blood relative with ovarian cancer at any age;
2. 1 or more close blood relative with breast cancer before age 50;
3. 2 or more close blood relatives with breast,pancreatic, or prostate cancer (Gleason score ≥7) at any age.
Pancreatic cancer diagnosis at any age with any of the following:
1. Ashkenazi Jewish ancestry;
2. 1 or more close blood relative with ovarian cancer at any age;
3. 1 or more close blood relative with breast cancer before age SO;
4. 2 or more close blood relatives with breast,pancreatic,or prostate cancer (Gleason score ≥7) at any age.

Family history of any of the following:

First or second degree blood relative who meet any of the above criteria.
Third degree blood relative who has breast cancer and/or ovarian cancer and who has 2 or more close blood relatives with breast cancer (at least one with breast cancer before age SO) and/or ovarian cancer.
1 or more family member with a known potentially harmful mutation In the BRCAl or BRCA2 gene.

*Close blood relative includes first, second,and third degree relatives on the same side of the family.

**Breast cancer diagnosis includes invasive and ductal carcinoma in situ.