Rhode Island
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
Kristin Sousa
Medicaid Director
Executive Office of Health and Human Services
3 West Road Virks Building Cranston, RI 02920
Phone: (401) 462-1965
https://medicaiddirectors.org/wp-content/uploads/2023/06/Public_DirectorsList_June2023-1.pdf
General Genetic Testing Criteria
The Medicaid Program covers the clinical laboratory services listed on the fee schedule. This list is reviewed and updated periodically. New procedures are added and old procedures removed based on criteria determining the validity and medical necessity of each procedure.
Genetic Testing Not Covered
Generally, procedures not listed in the fee schedule are not covered services.
State Specific Definition
Genetic Services for Children
Genetic Counseling Requirement
https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/pa_form_0.pdf
Licensure is required. The following is the link for the genetic counselor license application: https://health.ri.gov/applications/GeneticsCounselor.pdf
Metabolic Formula Coverage Legislation
§ 27-41-74. Enteral nutrition products.
Metabolic Formula Coverage & Criteria
Every individual or group health insurance contract, or every individual or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state on or after January 1, 2009, shall provide coverage for nonprescription enteral formulas for home use for which a physician has issued a written order and that are medically necessary for the treatment of malabsorption caused by Crohn’s disease, ulcerative colitis, gastroespphageal reflux, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein and shall extend to all recipients regardless of age.
Prior Authorization Requirements
Prior Authorization Forms
Fee Schedule
BRCA Testing Coverage
Coverage is available.
Requirements for BRCA
Cystic Fibrosis Screening
Coverage is available.
Hereditary Cancer Testing Coverage
Coverage is available.
Lynch Syndrome Testing Coverage
Coverage is available.
Microarray Testing
Coverage is available.
Newborn Screening
The program shall be a covered benefit and be reimbursable by all health insurers, as defined in § 27-38.2-2.
Panel Testing
Coverage is available.
Pharmacogenetic Testing
Coverage is available.
Prenatal Testing Offered
Coverage is availabe.
Whole Exome Sequencing
Other Tests Covered
Other Information
Resources
https://eohhs.ri.gov/sites/g/files/xkgbur226/files/Portals/0/Uploads/Documents/MA-Providers/MA-Reference-Guides/Clinical-Lab/clinical_laboratory_manual.pdf
http://webserver.rilin.state.ri.us/Statutes/TITLE23/23-13/23-13-14.HTM
https://law.justia.com/codes/rhode-island/2018/title-27/chapter-27-41/section-27-41-74/
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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