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
Office of Medical Assistant Programs
Pennsylvania Department of Human Services
625 Forster Street, Room 515
Harrisburg, PA 17120
Phone: (717) 787-2600
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 must be licensed. An applicant must hold a master’s degree or doctoral degree in human genetics or genetic counseling from an American Board of Genetic Counseling (ABGC)-accredited or American Board of Medical Genetics (ABMG)accredited educational program or has met the requirements for certification by the ABGC or the ABMG. An applicant must pass the examination for certification as a genetic counselor by the ABGC or the ABMG or has passed the examination for certification as a Ph.D. medical geneticist by the ABMG. Applicants must complete 3 hours of Board-approved continuing education in child abuse recognition and reporting for initial licensure.
Metabolic Formula Coverage Legislation
Pennsylvania Statutes Title 40 P.S. Insurance § 3904. Medical foods insurance coverage
Metabolic Formula Coverage & Criteria
- Nutritional supplements.–Except as provided in section 7, 1 any health insurance policy which is delivered, issued for delivery, renewed, extended or modified in this Commonwealth by any health care insurer shall provide that the health insurance benefits applicable under the policy include coverage for the cost of nutritional supplements (formulas) as medically necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria as administered under the direction of a physician.
- Amino acid-based elemental medical formula.–Except as provided in section 7, any health insurance policy which is delivered, issued for delivery, renewed, extended or modified in this Commonwealth by any health care insurer shall provide that the health insurance benefits applicable under the policy include coverage for infants and children for the usual and customary cost of amino acid-based elemental medical formula ordered by a physician as medically necessary and administered orally or enterally for food protein allergies, food protein-induced enterocolitis syndrome, eosinophilic disorders and short-bowel syndrome. An amino acid-based elemental formula covered under this section is a formula made of 100% free amino acids as the protein source.
Prior Authorization Requirements
Prior authorization is required for some genetic testing.
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Coverage is available, but criteria is unknown.
Requirements for BRCA
Cystic Fibrosis Screening
Coverage is available, but criteria is unknown.
Hereditary Cancer Testing Coverage
Coverage is available, but criteria is unknown.
Lynch Syndrome Testing Coverage
Coverage is available, but criteria is unknown.
Microarray Testing
Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores is covered.
Newborn Screening
Covered under Pennsylvania’s EPSDT program.
Panel Testing
Coverage is available, but criteria is unknown.
Pharmacogenetic Testing
Prenatal Testing Offered
Coverage is available for: fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21.
Whole Exome Sequencing
Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis is covered.
Other Tests Covered
For a full list of genetic tests covered, see the fee schedule.
Other Information
Resources
https://www.dhs.pa.gov/docs/Publications/Documents/FORMS%20AND%20PUBS%20OMAP/MAB2020052602.pdf
https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Medicine/Pages/Genetic-Counselor-Licensure-Requirements-Snapshot.aspx
https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-3904.html
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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