Will Medicare Pay for Genetic Testing?

• Medicare typically won’t cover genetic screening tests unless they directly influence treatment or result in a clear diagnosis, though exceptions exist for certain illnesses like cancer.
• A Medicare-authorized physician must document signs or symptoms of a condition—or an elevated risk of developing one—for genetic testing to be eligible for coverage, and the findings must be able to directly alter treatment guidance.
• Genetic tests that might be covered include molecular diagnostic genetic tests, next-generation sequencing for advanced cancer stages, and pharmacogenomic testing when known gene-drug interactions could change therapy.

Medicare may fund genetic testing in particular situations, for instance when it’s part of managing a specific disease such as cancer.

However, a Medicare-approved clinician must state that you display signs or symptoms of a condition or that you’re at higher risk of developing one.

Continue reading to understand the scenarios in which Medicare could cover genetic testing.

What makes you eligible for genetic testing under Medicare?

In general, Medicare won’t cover a genetic test if its purpose is solely to assess your risk of developing an inherited condition or disease.

That said, Medicare may cover a genetic test when results could have a direct impact on your physician’s treatment decisions or when the test is used to monitor the progression of a disease.

For instance, Medicare Part A may cover laboratory tests if you’re hospitalized. This coverage can include genetic tests tied to a cancer diagnosis performed in a hospital setting.

For outpatient services, under Original Medicare’s Part B, coverage generally is limited to one test per lifetime, although additional tests may be authorized as needed if they could affect treatment.

Fraud alert

The HHS Office of the Inspector General has warned beneficiaries about scams involving genetic testing.

Fraudsters might pitch free screenings to obtain personal information for identity theft or to submit fraudulent claims. If you undergo such screening and Medicare denies coverage later, you could be on the hook for the entire cost.

Only accept tests ordered by your healthcare provider, and be wary of unsolicited requests for your Medicare number.

If you suspect fraudulent activity, report it to the HHS OIG Hotline.

What conditions may qualify for genetic testing under Medicare?

Medicare may approve genetic testing for the following conditions:

Cancer

Medicare may cover genetic testing related to cancer if you have a clinical diagnosis with abnormal test findings. Additionally, your physician must show that genetic test results can directly influence your care plan.

Other elements Medicare takes into account when deciding coverage include how severe your condition is, the evidence linking particular genes to the cancer type, and the likelihood that a given treatment will be effective.

Regarding breast and ovarian cancer, BRCA1 and BRCA2 testing might be covered if any of the following apply:

• you have a personal history of breast cancer before age 60
• you have a personal history of other cancers, such as ovarian, male breast, pancreatic, or prostate cancer
• a close relative has had one of these cancers
• you’re adopted and were diagnosed with a BRCA-associated cancer before age 60
• you’re of Ashkenazi Jewish ancestry
• you’ve been diagnosed with other syndromes that increase risk, such as Lynch, Li-Fraumeni, or Cowden syndromes

While Medicare generally doesn’t reimburse at-home genetic tests, there is an exception.

Medicare will cover a multi-target stool DNA screening every three years. If you are between the ages of 45 and 85, you don’t need to show symptoms of colorectal disease and you may have an average risk for cancer.

Heart disease

Family history can influence risk for heart disease. Inherited heart conditions may include cardiomyopathy, arrhythmias, cardiac amyloidosis, and others.

If you’ve been diagnosed with one of these conditions or exhibit symptoms, Medicare may cover genetic testing if it satisfies certain criteria and the results are likely to inform your treatment.

Comparable coverage requirements can apply to genetic testing for other diseases.

What types of genetic tests are covered by Medicare?

Genetic tests that may be eligible for Medicare coverage include:

• Molecular diagnostic genetic tests: These tests identify specific molecular features in your genetic code to help diagnose illnesses and predict health outcomes. They may be covered for certain inherited disorders.
• Next-generation sequencing: These assays analyze the sequence of DNA building blocks to find possible mutations. They may be approved for patients with advanced stages of specified cancers seeking treatment options or for individuals with ovarian or breast cancer and a relevant family history.
• Pharmacogenomics:These tests examine how your genetic makeup influences medication response, which can alter therapy plans. Coverage may be available when you have a condition treated with drugs that have known gene-drug interactions and the test meets criteria set by the FDA or CPIC.

How much does a full genetic test cost?

Prices for genetic tests vary by type and can fall between $100 and $2,000.

If Medicare Part B covers your specific test, you’ll continue to pay the monthly premium (currently $174.70). After meeting your deductible of $240, Medicare generally pays 80% of the approved amount.

Takeaway

Medicare may cover genetic testing in defined circumstances, such as when testing is necessary for treating conditions like cancer or for monitoring disease progression.

However, a Medicare-approved provider must verify that you have symptoms of the condition or an increased risk of developing it for testing to be eligible for coverage.