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Committee approves Medicaid rule change requiring prior authorization for genetic tests
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Summary
The committee approved staff amendments to 907 KAR 3005 and 3010 that require prior authorization for all genetic testing in Kentucky Medicaid, remove a prior restriction on sleep disorder service coverage, and change several provider- and fee-schedule rules; Medicaid staff said prior-authorizations are generally completed within two to five days.
Frankfort — The regulatory review committee voted to approve staff-suggested amendments to two Medicaid administrative regulations that will require prior authorization for all genetic testing for Medicaid recipients and make several other changes to provider definitions and reimbursement rules.
Justin Derringer, director of health care policy for the Department for Medicaid Services, told the committee the change will require medical necessity review—prior authorization—before genetic testing is performed, citing rising costs for those tests. "So currently, different genetic tests have different authorization... So as you all know, prior authorization is inspecting the medical necessity of a procedure before given approval to have the procedure," Derringer said. He added the office aims to process prior authorizations within "2 to 5 days," and that delays typically result from incomplete provider submissions.
The amendments also remove a restriction on coverage for certain sleep disorder services and revise provider-group definitions (changing a group requirement from at least two licensed physicians to at least one), move physician fee-schedule updates from quarterly to annually, and add reimbursement for department-approved vaccines. Jonathan Scott, the department's legislative and regulatory officer, participated in the presentation and discussion.
Co-chair Lewis asked whether newer therapies reported to help sleep apnea—specifically GLP-1 drugs—would be covered under the revised sleep-disorder provisions. Derringer responded he was not aware of current diagnoses supporting GLP-1 use for sleep apnea and that the currently covered treatments remain CPAP machines and formal sleep studies: "Right now, that's mostly the CPAP machines, the sleep studies," he said.
Committee members made no changes to the staff amendments and approved them by unanimous consent. The committee recorded no roll-call vote; the chair ordered the regulation changes adopted by agreement.
The committee concluded its business and noted that the next meeting was tentatively scheduled for May 12 at 1 p.m.
