Ohio
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
Maureen Corcoran, Director
614-466-4443
maureen.corcoran@medicaid.ohio.gov
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
Fee Schedule
BRCA Testing Coverage
Coverage is available.
Requirements for BRCA
Prior Authorization for genetic testing is required.
Prior Authorization for genetic counseling is not required.
CareSource will review for medical necessity and approve genetic testing based on all of the criteria below found under ONE of the following situations:
- A. Published MCG policy with endorsed inclusion criteria meeting all of the following:
- Documentation of an assessment based on the relevant MCG Guideline AND
- The quality, safety, statistical validity, and clinical validity is scientifically supported in medical literature as endorsed by inclusion criteria of the relevant MCG Guideline; AND
- Genetic counseling has been performed by a healthcare professional education and training in genetic issues relevant to the genetic tests under consideration; AND
- Counselor is free of commercial bias and discloses all (potential and real) financial and intellectual conflicts of interest, AND
- Process involves individual or family and is comprised of ALL of the following:
- Calculation and communication of genetic risks after obtaining 3- generation family history; AND
- Discussion of natural history of condition in question, including role of heredity AND iii. Discussion of possible impacts of testing (e.g., psychological, social, limitations of nondiscrimination statutes) AND
- Discussion of possible test outcomes (i.e., positive, negative, variant of uncertain significance) AND
- Explanation of potential benefits, risks, and limitations of testing AND 06. Explanation of purpose of evaluation (e.g., to confirm, diagnose, or exclude genetic condition) AND vi. Identification of medical management issues, including available prevention, surveillance, and treatment options and their implications; AND
- Written documentation that the patient has provided informed consent to the testing as evidenced by a statement detailing how the test results will affect the patient’s medical management.
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Coverage is available.
Lynch Syndrome Testing Coverage
Coverage is available.
Microarray Testing
Newborn Screening
Panel Testing
Pharmacogenetic Testing
Prenatal Testing Offered
Whole Exome Sequencing
Other Tests Covered
Preconception care means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies.
Medicaid covered preconception care services may include, but are not limited to:
- Laboratory tests and procedures including but not limited to:
- Screening, diagnostic, and counseling services for detection of genetic anomalies and/or hereditary metabolic disorders, including but not limited to:
- Chromosomal anomalies (in non-pregnant patients) that have neonatal implications;
- Sickle cell and other abnormal hemoglobin syndromes;
- Metabolic disorders such as phenylketonuria (PKU), galactosemia, or homocystinuria; and
- Cystic fibrosis (carrier status).
Other Information
The Ohio Department of Health (ODH) Genetics Services Program funds a network of genetic centers that provide comprehensive care and services to people affected with, or at risk for genetic disorders.
Resources
- 5101:3-10-26 Appendix A: JFS 01907, Certificate of Medical Necessity / Prescription Enteral Nutrition Services
- https://medicaid.ohio.gov/Portals/0/Resources/Publications/Guidance/Policy/DurableMedicalEquipment.pdf
- Physician Services ODM Guidance
- https://medicaid.ohio.gov/RESOURCES/Publications/ODM-Guidance#161540-emanuals-pre-july-2015
- Ohio Department of Health Genetic Services Program
- https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/genetic-services/welcome-to
- https://www.caresource.com/documents/medicaid-oh-policy-medical-mm-0003-20190718/
Newborn Screening Reimbursement
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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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