Does Medicare Cover DNA Testing?
Key Takeaways
- Medicare covers limited types of genetic testing, including next generation sequencing, molecular diagnostic genetic tests, and pharmacogenetic (PGx) testing.
- Medicare covers specific cancer genetic tests for acquired cancer (caused by genetic mutations) or inherited cancer (i.e., advanced Stage III or IV cancer, inherited breast or ovarian cancer).
- To be covered, all tests must be ordered and received by a physician, approved by the Food and Drug Administration (FDA), and medically necessary.
- It’s important to check whether your genetic test is covered by your insurance and what costs you’ll pay out of pocket.
Genetic testing gives us a window into the building blocks we receive from our parents and that help shape who we are. Advances in medical technology have enabled us to gather an amazing amount of information about people’s heritage from their DNA. In addition, doctors have learned a great deal about both the inherited traits and mutations (changes in a DNA sequence) that could lead to health concerns.
If you’ve seen the kinds of insights that our DNA can reveal, you may wonder whether your health insurance coverage through Medicare offers coverage for genetic testing. Medicare does help with the costs of a few types of genetic testing, including some genetic cancer diagnostic tests. However, for your testing to be covered by insurance, you must meet certain eligibility criteria.
In this article, we’ll take a closer look at the genetic tests that are covered by Medicare.
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Does Medicare Pay for Genetic Testing?
Medicare typically covers genetic testing that’s used to screen, diagnose, or guide treatment for a specific health problem. That does not include genetic tests to predict your risk for a condition or to detect an undiagnosed health condition.
Medicare Part B is the part of Original Medicare that provides medical insurance, including coverage for diagnostic testing. Part B helps pay for a few different types of genetic testing for specific conditions. If you’re enrolled in a Medicare Advantage (Part C) plan, it’s required to match Original Medicare’s coverage. However, you may need to see doctors and specialists who are in your plan’s provider network to get the most out of your benefits.
Your doctor may recommend genetic testing in certain situations. For example, your DNA could affect your risks for certain conditions and how effectively drugs will work to treat you. Genetic testing can guide treatment to better outcomes.
Some types of genetic testing that Medicare may cover include:
- Molecular diagnostic genetic tests (MDT), which involve analyzing gene sequences for mutations that result in specific diseases.
- Next Generation Sequencing (NGS) genetic testing, also called multigene panel testing, which examines multiple human DNA sequences at one time. It helps doctors understand how mutations in your DNA may predict risk factors and help diagnose conditions.
- Pharmacogenomics (PGx), which show how your body responds to certain types of medications. PGx helps improve drug therapy with targeted, effective treatment.
Medicare does cover other forms of screening and diagnostic tests for health conditions like cancer, diabetes, and depression.
Beware of scams when it comes to genetic testing, especially if you hear from a person or company offering “free” testing or an immunodeficiency genetic test under Medicare. This is often a trick that can leave you stuck with a big bill. Always check with your doctor before taking a genetic test.
Does Medicare Cover Genetic Testing for Cancer?
Medicare covers some diagnostic genetic tests for cancer. These tests help identify abnormal cell activities in your body (biomarkers). For example, Medicare covers the breast cancer gene (BRCA) test, looking for gene changes that heighten risks for not only breast cancer, but also prostate cancer, ovarian cancer, and pancreatic cancer.
In addition, Medicare covers NGS genetic testing for both acquired (cancer from gene mutations) and germline (inherited) cancer if you:
- Have advanced stage III or IV cancer, cancer that is recurrent, relapsed, metastatic or refractory (treatment resistant).
- Haven’t had an NGS test already for the same germline (inherited) type cancer.
- Want to receive further cancer treatment.
Coverage can vary depending on where you live. It’s important to check on the availability of specific genetic testing coverage.
How Much Does a Genetics Test Cost?
Your cost for a genetic test depends on the specific test being done, how it’s done (using saliva, a blood sample, etc.), and whether you meet Medicare coverage criteria.
If your test is covered, you’ll pay nothing as long as your provider accepts assignment. This means they agree to perform services for the amount set by Medicare. Genetic testing costs can run anywhere from several hundred to several thousand dollars, so it’s worthwhile to make sure Medicare covers the test.
You must meet certain eligibility rules set by Medicare, and the testing must be ordered by your physician. You may also have to meet local eligibility requirements.
It’s always a good idea to check with your doctor before genetic testing. This is your chance to ask questions like:
- How will genetic testing benefit me?
- Should I worry about confidentiality?
- Will Medicare cover my test?
- What costs do I need to pay?
- Does the lab accept assignment?
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When Does Medicare Cover Genetic Testing?
Medicare covers genetic testing for certain conditions and PGx for medications if it is ordered by your physician and done in a lab that’s certified under regulations set by the federal government (the Clinical Laboratory Improvement Amendments of 1988, or CLIA). Coverage details may vary depending on where you live and whether you’re on a Medicare Advantage plan from a private insurance carrier.
Medicare covers genetic diagnostic testing for specific gene mutations, and NGS multi-gene panel testing if you have a cancer diagnosis. NGS testing is also covered for other inherited conditions like heart problems (such as cardiomyopathy or arrhythmia) if you meet Medicare requirements.
PGx testing is also covered for specific medications. Certain enzymes like CYP2C19, CYP2D6, and CYP2C9 found in the liver help break down many medications. Genetic testing for these enzymes allows doctors and pharmacists to target your medication therapy.
Medicare covers PGx testing for some medications (including warfarin, clopidogrel, and amitriptyline) if you meet testing criteria. Your doctor can provide more information about PGx testing benefits for you.
Does Medicare Cover BRCA Genetic Testing?
Medicare covers genetic testing for BRCA 1 and BRCA 2 gene mutations. There are several types of diagnostic genetic tests for BRCA covered by Medicare.
Medicare also covers NGS testing for breast cancer and ovarian cancer. Research shows people with the BRCA 1 or BRCA 2 gene mutations (male and female) are at much higher risk for breast and ovarian cancer compared to people who do not have these gene mutations.
A multigene panel test like NGS can help identify BRCA 1, BRCA 2 and other gene mutations in one test to help with a cancer diagnosis.
Some criteria that could qualify your for BRCA 1 and BRCA 2 testing are:
- A history of ovarian, breast, fallopian tube, primary peritoneal, pancreatic, or prostate cancer
- A breast cancer diagnosis with other age and hereditary risk-specific criteria
- A close relation with BRCA1 or BRCA2 gene mutation
- Ashkenazi Jewish heritage
- Risk factors for hereditary breast or ovarian cancer
- You haven’t been tested with NGS previously for the same hereditary cancers.
- You must receive pre testing genetic counseling.
- Multi-gene testing must be relevant based on your family history of cancer
- You must meet eligibility criteria to test for breast cancer or other cancer and one other type of hereditary cancer based on National Comprehensive Cancer Network guidelines (e.g. Lynch Syndrome, Cowden Syndrome)
Does Medicare Cover Counseling with Genetic Testing?
Medicare covers genetic counseling provided by a cancer genetics professional such as a physician. However, you must be a patient of that physician.
Certified genetic counselors have special training and experience to help you understand your hereditary risks for certain diseases such as cancer, but Medicare does not currently recognize these counselors as healthcare providers. So, if you go to a certified genetic counselor, your visit may not be covered.
Medicare also does not currently cover genetic counseling for any screening or prevention testing.
Your Medicare plan provider can provide more information on genetic counseling coverage requirements.
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Does Medicaid Cover DNA Testing?
Medicaid provides health insurance for U.S. adults with low incomes and limited financial resources. Since this program is administered by individual states, separate from Medicare, coverage details for genetic testing differ based on where you live.
Most state Medicaid programs cover testing for a Lynch syndrome mutation — the most common cause of hereditary colorectal cancer — for people who have a known genetic mutation in their family or either a personal or family history of cancer.
However, the majority of Medicaid programs don’t cover testing for many other specific mutations or for multigene panel testing, which checks for inherited mutations in multiple genes at once.
Does Medicaid Cover BRCA Testing?
The Medicaid programs in nearly every state do cover BRCA genetic testing and counseling for people who meet certain criteria, such as a known mutation in their family or a personal or family history of cancer. Eligibility and coverage details depend on the state; certain states only cover people who have already been diagnosed with cancer, and others only cover testing for women.
Sources
- Genetic Testing in Clinical Settings. PubMed.
- What is next generation sequencing? PubMed.
- The Genetics of Cancer. Cancer.net.
- What is Pharmacogenomics. Medline Plus.
- Decision Memo for Screening for Colorectal Cancer – Stool DNA Testing (CAG-00440N). CMS.gov.
- Medicare Preventive Services. CMS.gov.
- National Coverage Determination (NCD) for Next Generation Sequencing (NGS) (90.2). CMS.gov.
- Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450R). CMS.gov.
- What is a MAC? CMS.gov.
- What is the cost of genetic testing, and how long does it take to get the results? MedlinePlus.gov.
- Clinical Laboratory Improvement Amendments (CLIA). CMS.gov.
- Pharmacogenetic prediction of individual variability in drug response based on CYP2D6, CYP2C9 and CYP2C19 genetic polymorphisms. PubMed.
- Local Coverage Determination (LCD): CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing (L35698). CMS.gov.
- Local Coverage Article: Billing and Coding: MolDX: Myriad’s BRACAnalysis CDx® (A54689). CMS.gov.
- Local Coverage Determination (LCD): BRCA1 and BRCA2 GENETIC TESTING (L36499). CMS.gov.
- BRCA1- and BRCA2-Associated Hereditary Breast and Ovarian Cancer. PubMed.
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