A landscape assessment of Medicaid recognition for genetic counselors

Abstract

Payer enrollment for genetic counselors (GCs) is fundamental to long-term field sustainability and patient care access. Until federal recognition is obtained, enhancing Medicaid policies may help address existing GC coverage disparities. Understanding the current landscape is critical to mapping an effective strategy for future advocacy efforts. This study assessed GC provider enrollment and relevant CPT^® codes across Medicaid programs in the United States via a review of open-access Medicaid websites for 50 US states, Washington, DC, and 5 US territories in 2024. Medicaid fee status for CPT^® code 96040 (GC only, 30 min) and S0265 (GC with physician supervision, 15 min code), fee schedule dates, availability of GC as a provider enrollment type, and state licensure status were abstracted. Of Medicaid provider enrollment websites for US states and DC, 21.6% (11/51) included genetic counselors; 49% (25/51) listed CPT^® code 96040 and 13.7% (7/51) listed S0265 in the fee schedule with a non-zero rate; none of the US territories listed either. Of the 34 regions with GC licensure, 32.4% (11/34) included GCs as an enrollment type in their state Medicaid provider website, while none of the 22 unlicensed regions did. This assessment highlights a gap between state licensure efforts and enrollment of GCs by state payers. Advocacy and public health policy directly targeting state Medicaid programs provide another avenue to increase coverage for GC services. A key downstream benefit of GC recognition through these efforts includes expanding access to genetic counseling services for underserved communities.