Payer Policy and Advocacy

CLINICAL SERVICES

Increasing Access

Rady Children’s Institute for Genomic Medicine is committed to supporting equitable patient access to rapid whole genome sequencing, and to helping enable our partners to adopt systems to support clinical ordering. We help advocate for public Medicaid and private insurance coverage of life-saving rWGS testing.

RCIGM collaborates with clinical partners to navigate systems and implement processes to seek reimbursement for testing and improve patient access to care.

Learn more about collaborating with RCIGM to impact and effectively utilize payer policy in your area by contacting Equitable Policy and Payer Engagement Manager Maddie Arenchild.

rWGS has demonstrated high clinical utility, downstream savings, and improves the experience of care for patients and health care providers. Providing rWGS as a first-line test is a cost-effective intervention and effective quadruple aim strategy for high quality care.

Learn about our research into rWGS.

RCIGM works with policy makers and payers advocating for better coverage policies for rapid whole genome sequencing. We know that favorable coverage positions help patients get the care they need when they need it.

Find out which states and private insurers cover rWGS.

Our advocacy work is supported by numerous peer-reviewed studies that we have published, showing that rapid Whole Genome Sequencing^TM (rWGS^®) can empower clinicians to make timely, precise diagnoses and treatment decisions for critically ill children with genetic diseases.

Demonstrated benefits of rWGS include:

Groundbreaking Study

Led by Rady Children’s and funded by the State of California, Project Baby Bear provided rapid Whole Genome Sequencing for infants hospitalized in intensive care while yielding life-changing benefits and saving $2.5 million in medical costs.

Learn more

Working with RCIGM has been like a ‘teaching other people to fish’ type of situation. And it is really nice to go into something that feels new and novel, and to come with a friend who’s done it and who’s willing to help you. That was certainly a key part of the success of Project Baby Deer.

— Caleb Bupp, Division Chief, Medical Genetics & Genomics, Helen DeVos Children's Hospital

Since RCIGM completed Project Baby Bear in 2021, several states have passed legislation covering rWGS for critically-ill infants, and a number of major insurance carriers have added it to their list of covered procedures.

This map indicates the latest coverage, as of July 2023. See the tables below for more details on the state Medicaid coverage and private payers.

Please visit this page on a desktop computer to view the map showing the latest coverage, as of July 2023.

See the tables below for more details on the state Medicaid coverage and private payers.

rWGS Coverage: Medicaid Blue Cross Blue Shield Association Medicaid + BCBSA Hover over a state for more information

State Medicaid Coverage for rWGS

State	Policy	Criteria
Arizona Medicaid*	S.1726 (2023-2024)	Less than 1 year of age and receiving inpatient hospital services in an intensive care unit or a high acuity pediatric care unit, subject to medical necessity criteria.
California Medi-Cal	AB133 and reflected in Provider Bulletin 573	≤ 1 year; ICU (NICU/PICU/CVICU)
Florida Medicaid*	SB2500 (2023-2024)	≤ 20 years of age and receiving inpatient treatment in a hospital ICU of high-acuity pediatric care unit, subject to medical necessity criteria.
Louisiana Medicaid*	SB 154	≤ 1 year; ICU (NICU/PICU/CVICU) or Pediatric Care Unit Louisiana Senate Bill 154 also requires that all private health plans cover rWGS subject to medical necessity criteria.
Maryland Medicaid	Lab Testing Policy	Approved for patients aged less than 1 year of life and currently admitted to or recently discharged from a Neonatal Intensive Care Unit (NICU), subject to medical necessity criteria and prior authorization.
Michigan Medicaid*	Lab Policy MSA 21-33	≤ 1 year; ICU (NICU/PICU/CVICU), subject to medical necessity criteria
Minnesota Medicaid	Lab & Pathology Services Provider Manual	No age restriction for pediatric critical care unit; ICU (NICU/PICU/CVICU), subject to medical necessity criteria
Oregon Medicaid	Prioritized Health Services List	≤ 1 year; ICU (NICU/PICU/CVICU)

*These are separately payable from DRG through Medicaid.

Blue Cross Blue Shield Coverage of rWGS

Plan	Policy No.	Criteria
BCBS Federal Employee Program	2.04.102	The patient should be critically ill and in the NICU or PICU when the test is ordered but may be discharged before results are delivered
Blue Shield of California	2.04.102	Critically ill infants or children less than 18 years of age
Florida Blue	05-82000-28	Critically ill infants and children in neonatal or pediatric intensive care with a suspected genetic disorder of unknown etiology
BCBS of HI – Hawaii Medical Service Association	MM.02.035	Critically ill infants in intensive care units with a suspected genetic disorder of unknown etiology
Blue Cross of Idaho	MP 2.04.102	Critically ill infants and children in neonatal or pediatric intensive care with a suspected genetic disorder of unknown etiology
BCBS of Louisiana	00389	The patient should be critically ill and in the NICU or PICU when the test is ordered but may be discharged before results are delivered
BCBS of Michigan	A.2.04.102	Critically ill infants and children in neonatal or pediatric intensive care with a suspected genetic disorder of unknown etiology
BCBS of Mississippi	>A.2.04.102	Critically ill infants and children in neonatal or pediatric intensive care with a suspected genetic disorder of unknown etiology
Horizon Blue New Jersey	094	Critically ill infants and children in neonatal or pediatric intensive care with a suspected genetic disorder of unknown etiology
BCBS of Western New York	204102	Critically ill infants with a suspected genetic disorder of unknown etiology following standard workup
Blue Shield of Northeastern New York	204102	Critically ill infants with a suspected genetic disorder of unknown etiology following standard workup

Other Private Insurers' Coverage of WGS

Plan	Policy No.	Criteria
Cigna	0519 Whole Exome and Whole Genome Sequencing for Non-Cancer Indications (cigna.com)	See policy for medical necessity criteria.
UnitedHealthcare Commercial and Individual Exchange Plans	2023T0589N Whole Exome and Whole Genome Sequencing – Commercial and Individual Exchange Medical Policy (uhcprovider.com)	See policy for medical necessity criteria.
UnitedHealthcare Community Plan	CS150.N Whole Exome and Whole Genome Sequencing – Community Plan Medical Policy (uhcprovider.com)	See policy for medical necessity criteria.

Payer information current as of July 2023.

Media Coverage

September 6, 2023

Key Largo Local10 News

Program leads way in diagnosing rare diseases

Key Largo's Local10 News covers the impact of Project Baby Manatee.

Up to Speed Blog

August 31, 2023

Florida and Arizona Medicaid Now Cover Rapid Whole Genome Sequencing

Earlier this summer, Florida and Arizona started offering Medicaid coverage for rapid whole genome sequencing. Find out more about the latest policies.

Media Coverage

February 28, 2023

Pediatric Meltdown Podcast