Reys Brian, Valentine Alyssa, Pan Vivian, Gaston Delaney, Harper Mardarius, Brouette Maya, Nuccio Regina
Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas, USA.
Cook County Health, Chicago, Illinois, USA.
J Genet Couns. 2025 Jun;34(3):e70057. doi: 10.1002/jgc4.70057.
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.
为遗传咨询师（GCs）争取医保覆盖对于该领域的长期可持续发展以及患者获得医疗服务至关重要。在获得联邦认可之前，加强医疗补助政策可能有助于解决现有的遗传咨询师覆盖差异问题。了解当前情况对于制定未来宣传工作的有效策略至关重要。本研究通过审查2024年美国50个州、华盛顿特区和5个美国属地的开放获取医疗补助网站，评估了美国医疗补助计划中遗传咨询师提供者注册情况及相关现行程序编码（CPT）。提取了CPT编码96040（仅遗传咨询师，30分钟）和S0265（有医生监督的遗传咨询师，15分钟编码）的医疗补助费用状态、费用表日期、遗传咨询师作为提供者注册类型的可获得性以及州许可状态。在美国各州和华盛顿特区的医疗补助提供者注册网站中，21.6%（11/51）包括遗传咨询师；49%（25/51）在费用表中列出了CPT编码96040，13.7%（7/51）列出了S0265且费率非零；美国属地均未列出这两个编码。在有遗传咨询师执照的34个地区中，32.4%（11/34）在其州医疗补助提供者网站中将遗传咨询师作为一种注册类型，而22个无执照地区均未这样做。这一评估凸显了州许可努力与州医保支付方对遗传咨询师注册之间的差距。直接针对州医疗补助计划的宣传和公共卫生政策为增加遗传咨询服务覆盖范围提供了另一条途径。通过这些努力使遗传咨询师获得认可的一个关键下游益处包括为服务不足的社区扩大遗传咨询服务的可及性。
