New Mexico
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
Lorelei Kellogg
Acting Director
Medical Assistance Division
New Mexico Department of Human Services
PO Box 2348
Santa Fe, NM 87504-2348
Phone: (505) 827-3100
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
Genetic Testing Not Covered
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Genetic counselors are required to be licensed. For a full list of licensure requirements see below:
https://www.srca.nm.gov/parts/title16/16.010.0021.html
Metabolic Formula Coverage Legislation
Metabolic Formula Coverage & Criteria
The New Mexico medical assistance division (MAD) covers the following benefits with prior authorization for a
non-institutionalized MAP eligible recipient:
- enteral nutritional supplements and products for a MAP eligible recipient who must be tube
fed oral nutritional supplements; - oral nutritional support products prescribed by the MAP eligible recipient’s PCP:
- on the basis of a specific medical indication for a MAP eligible recipient who has a
defined need for which nutritional support is considered therapeutic, and for which regular food, blenderized food,
or commercially available retail consumer nutritional supplements would not meet his or her medical needs; - when medically necessary due to inborn errors of metabolism;
- medically necessary to correct or ameliorate physical illnesses or conditions in a MAP eligible recipient under 21 years of age; or
- coverage does not include commercially available food alternatives, such as low or sodium-free foods, low or fat-free foods, low or cholesterol-free foods, low or sugar-free foods, low or high calorie foods for weight loss or weight gain, or alternative foods due to food allergies or intolerance;
- on the basis of a specific medical indication for a MAP eligible recipient who has a
Prior Authorization Requirements
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Medicaid covers BRCA screening and counseling. Criteria is unknown.
Requirements for BRCA
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Lynch Syndrome Testing Coverage
Microarray Testing
Newborn Screening
Panel Testing
Pharmacogenetic Testing
Prenatal Testing Offered
The New Mexico Human Services Department, Medical Assistance Division (HSD/MAD) is issuing this Supplement toimplement reimbursement for prenatal genetic screening for cystic fibrosis (CF), spinal muscular atrophy (SMA) and fetal chromosomal aneuploidy for Medicaid eligible recipients. Currently, New Mexico Medicaid covers prenatal diagnostic tests through amniocentesis or chorionic villis sampling (CVS). Effective July 1, 2022, HSD/MAD will allow and reimburse specific prenatal genetic screening tests for all Medicaid eligible pregnant women to determine if the fetus has a possibility to be born with a genetic condition or birth defect. These screenings will: 1) help determine different options for the pregnancy; 2) determine whether special management of the pregnancy and delivery are needed; and 3) improve the outcome for the baby.
All options should be discussed and offered to all pregnant Medicaid eligible recipients regardless of maternal age or risk of chromosomal abnormality. After review and discussion, every recipient has the right to pursue or decline prenatal genetic screening and diagnostic testing.
If screening is accepted by the pregnant Medicaid eligible recipient, they should have one prenatal screening approach, and should not have multiple screening tests performed simultaneously.
Prenatal Maternal Genetic Screening
Eligibility requirements for prenatal genetic screening tests:
- All pregnant individuals
- Once in a lifetime
- Gestation between 10 and 22 weeks of pregnancy
- Underwent pretest counseling
Prior authorization is not required.
Whole Exome Sequencing
Other Tests Covered
Other Information
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.
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