Pennsylvania
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
Sally Kozak, Deputy Secretary
(717)-787-2600
sakozak@pa.gov
General Genetic Testing Criteria
Genetic Testing Not Covered
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
Metabolic Formula Coverage Legislation
MEDICAL FOODS INSURANCE COVERAGE ACT – MEDICAL FOODS INSURANCE COVERAGE, COST-SHARING PROVISIONS, REGULATIONS AND APPLICABILITY 2014 Act 158
Metabolic Formula Coverage & Criteria
MEDICAL FOODS INSURANCE COVERAGE ACT – MEDICAL FOODS INSURANCE COVERAGE, COST-SHARING PROVISIONS, REGULATIONS AND APPLICABILITY 2014 Act 158
Prior Authorization Requirements
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Coverage is available.
Requirements for BRCA
Cystic Fibrosis Screening
Hereditary Cancer Testing Coverage
Coverage for some hereditary cancers is available.
Lynch Syndrome Testing Coverage
Coverage is available.
Microarray Testing
Newborn Screening
Panel Testing
Pharmacogenetic Testing
Prenatal Testing Offered
The Department will review and evaluate the PA request for NiPS and determine whether the screening is medically necessary by taking into account the following:
- Whether the beneficiary is at least ten weeks pregnant at time of testing and is carrying a single gestation;
- Whether there is documentation of pretest genetic counseling;
- Whether there is documentation of a scheduled appointment for posttest counseling; and
- Whether there is documentation of how the results of the test will change, influence, or be considered in the care of the mother.
Whole Exome Sequencing
Other Tests Covered
Other Information
Cystic Fibrosis (CF), Spina Bifida (SB), and Metabolic Formula Program application
Family Planning Services program: “provides for family planning and certain family planning-related services, pharmaceuticals and supplies to men and women, who are not otherwise eligible for MA and meet both of the following:
- Income at or below 215% of the Federal Poverty Limit;
- Who are not pregnant.”
Covered services include genetic counseling and testing
Resources
- Medical Assistance Bulletin Updates to Laboratory Services on the Medical Medical Handbook:
- http://www.dhs.pa.gov/publications/forproviders/promiseproviderhandbooksandbillingguides/index.htm
- Assistance Program Fee Schedule; Prior Authorization for Noninvasive Prenatal Screening (NiPS) No. 01-19-01
- https://www.dhs.pa.gov/docs/Publications/Documents/FORMS%20AND%20PUBS%20OMAP/c_284582.pdf
- Cystic Fibrosis (CF), Spina Bifida (SB), and Metabolic Formula Program application
- https://www.health.pa.gov/topics/Documents/Programs/Infant%20and%20Children%20Health/2018_Cystic%20Fibrosis,%20Spina%20Bifida,%20and%20Metabolic%20Formula%20Program%20Application%20Combined%20Files_BFH_NBS.pdf
- Family Planning Service
- http://www.dhs.pa.gov/provider/familyplanningsrvcs/
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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