Rhode Island

Updated on March 28, 2023

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

Yes

State Contact Information

Kristin Sousa, Interim Medicaid Director
401-462-2121
kristin.sousa@ohhs.ri.gov

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

Metabolic Formula Coverage Legislation

Every infant who is born in this state shall be tested for phenylketonuria and such other metabolic or genetic diseases as are prescribed by the department.  The test used by the department shall be dictated by accepted medical practice and such tests shall be of the types approved by the department.  All newborn screening tests required by the department shall be performed by the department of health and senior services laboratories.  The attending physician, certified nurse midwife, public health facility, ambulatory surgical center or hospital shall assure that appropriate specimens are collected and submitted to the department of health and senior services laboratories.

Metabolic Formula Coverage & Criteria

Every infant who is born in this state shall be tested for phenylketonuria and such other metabolic or genetic diseases as are prescribed by the department.  The test used by the department shall be dictated by accepted medical practice and such tests shall be of the types approved by the department.  All newborn screening tests required by the department shall be performed by the department of health and senior services laboratories.  The attending physician, certified nurse midwife, public health facility, ambulatory surgical center or hospital shall assure that appropriate specimens are collected and submitted to the department of health and senior services laboratories.

Prior Authorization Requirements

Prior Authorization Forms

https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/pa_form_0.pdf

Fee Schedule

http://www.eohhs.ri.gov/ProvidersPartners/FeeSchedule.aspx

BRCA Testing Coverage

Requirements for BRCA

Cystic Fibrosis Screening

Hereditary Cancer Testing Coverage

Lynch Syndrome Testing Coverage

Microarray Testing

Newborn Screening

<p>Coverage is available for initial evaluation and management of a healthy individual requiring a comprehensive history, a comprehensive examination, the identification of risk factors, and the ordering of appropriate laboratory/diagnostic procedures.</p>

Panel Testing

Pharmacogenetic Testing

Prenatal Testing Offered

Whole Exome Sequencing

Other Tests Covered

Other Information

Resources

  • Coverage Guidelines for Durable Medical Equipment
    • http://www.eohhs.ri.gov/ProvidersPartners/ProviderManualsGuidelines/MedicaidProviderManual/DME/CoverageGuidelinesforDurableMedicalEquipment.aspx
  • RI Medicaid Provider Reference Manual: Independent Clinical Laboratory
    • http://www.eohhs.ri.gov/ProvidersPartners/ProviderManualsGuidelines/MedicaidProviderManual/ClinicalLab.aspx https://eohhs.ri.gov/providers-partners/provider-manuals-guidelines/medicaid-provider-manual
Newborn Screening Reimbursement

TwitterFacebookMessengerRedditLinkedInPinterestWhatsAppEmail

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.

The database contains links to third-party websites. These links are provided solely as a convenience to users and not as a guarantee, warrantee, or recommendation by NCC of the content on such third-party websites or as an indication of any affiliation, sponsorship or endorsement of such third party websites. NCC is not responsible for the content of linked third-party sites and does not make any representations regarding the privacy practices of, or the content or accuracy of materials on, such third-party websites. If you decide to access linked third-party websites, you do so at your own risk. Your use of third-party websites is subject to the terms of use for such sites.