Is Genetic Testing Covered by Medicaid Insurance?

Genetic testing can be a powerful tool for health care providers. It’s used to confirm diagnoses, identify the possibility of future illness, detect if someone carries a gene that they may pass on and predict a response to therapy.

If a condition is identified through genetic testing, doctors may be able to intervene early to reduce severity or prevent the condition developing altogether. However, the costs involved may be daunting, so it’s important to know whether Medicaid covers genetic testing.

Does Medicaid Cover Genetic Testing?

When talking about Medicaid coverage, it’s always important to understand that the program is administered by states. As such, rules differ depending on where you live and what type of Medicaid program you’re enrolled in. 

The most common types of tests are screenings during pregnancy and for infants and tests to detect cancer risk. Genetic prescreening during pregnancy is covered in the majority of states. These include amniocentesis and chorionic villus sampling (CVS) tests. Typically, the tests are only covered when medically necessary. 

Infant genetic screening is mandatory throughout the country and is usually conducted around 48 hours after birth. A small blood sample is taken and is tested for up to 50 genetic conditions, including sickle cell disease and hypothyroidism. This screening does cost money, but in most states, eligible infants will have the test covered by Medicaid or the Child Health Insurance Program (CHIP). 

Genetic testing in adulthood is usually used to diagnose a disease or determine if a person is at risk for developing a condition or passing it on to children. Whether the testing is covered depends on the condition and your location. For example, all but two states cover BRCA genetic counseling and testing to determine risk for breast cancer, but testing for Lynch syndrome mutation, which is linked to colorectal cancer, is not as universal.

Multigene panel testing, which looks for mutations in more than one gene at the same time, is not covered by most Medicaid programs. It’s also important to remember that testing is only available to qualified individuals, and eligibility criteria can differ by state.

When Is Genetic Testing Covered by Medicaid?

Common criteria to determine if you’re eligible for genetic testing include:

• Is there an impact on medical management of the condition? A test may only be conducted if the results will impact your treatment.
  
  
• Is there a potentially significant disability? Testing is normally only conducted if the condition being tested for can cause a significant disability and this disability can be prevented by a genetic diagnosis.
  
  
• Can it be diagnosed in another way? If the condition can be diagnosed through other tests, genetic testing is not generally covered.

Typically, prior authorization from Medicaid is also needed. Tests won’t be covered if you already have a firm diagnosis or if it’s just for your convenience. Genetic testing to establish paternity is also not covered by Medicaid. 

During pregnancy, genetic prescreening is only covered if other prenatal tests indicate a concern. Your local Medicaid office can provide you with more information about what’s covered in your state. 

What Does Medicaid Cover for Pregnancy?

In addition to genetic testing, Medicaid provides a range of other benefits to pregnant women. There are three different types of Medicaid programs available during pregnancy, each with slightly different eligibility criteria and coverage. 

Full-Scope Medicaid

This is normal Medicaid available to anyone who is financially and functionally eligible. This provides comprehensive coverage, including prenatal care, labor and delivery and other services that are medically necessary. 

Pregnancy-Related Medicaid

This has higher income limits than normal Medicaid, so it is accessible to more families. It covers pregnancy-related services and any conditions that may complicate a pregnancy. Pregnancy-related services are defined as “necessary for the health of a pregnant woman and fetus or that have become necessary as a result of the woman having been pregnant. 

According to federal rules, pregnancy-related Medicaid must cover prenatal care, postpartum care, delivery, family planning and conditions that may threaten pregnancy or a safe delivery. As it’s impossible to separate the health of the mother and the fetus, comprehensive coverage is usually provided.

Children’s Health Insurance Program

Some states cover pregnancy through CHIP. This can cover the pregnant woman directly or provide coverage to the fetus. The coverage is generally comprehensive, but in states where the fetus is covered, the pregnant woman may not be able to access all health services. 

Pregnancy-related Medicaid and CHIP for pregnancy both provide postpartum coverage for 60 days. Benefits finish at the end of this period, regardless of income. At this point, states can reevaluate families to determine if they’re eligible for any other Medicaid programs. 

When Does Medicaid End for a Child?

Children’s Medicaid provides health care to low-income children. Similarly, CHIP provides insurance to children whose families earn too much to enroll in Medicaid but who can’t afford health insurance. The programs cover a wide range of benefits, including dental care, mental health services and doctor visits. 

Coverage through both programs continues as long as your family meets the eligibility criteria and you renew coverage each year. Children stop being eligible on their 19th birthday. In some states, foster children can continue to get coverage through Medicaid after they age out of foster care. This typically continues until the 20th or 25th birthday.