Does Medicare Cover Genetic Testing?
Yes, Medicare will cover genetic testing in some instances and for diagnostic purposes only. Medicare does not cover genetic testing for predictive purposes, meaning a test performed solely to predict if the genetic disease is cause for concern.
For Medicare to cover a genetic test, the insured must have a cancer diagnosis, and a physician must order the test. Genetic testing is covered under Medicare Part B, which covers doctors and other medical services.
Table of Contents
Why Genetic Testing Matters
Genetic testing looks for mutations or variations in your DNA to predict your likelihood of developing a specific condition or disease. Because these conditions can significantly affect your life and your need for medical care, understanding your risk can be a helpful step in maintaining your overall health.
Getting genetic testing done can empower you to take preventative actions. Sickle cell disease, epilepsy, and some types of cancers are just some diseases that genetic testing can reveal. For example, if you have a family history of epilepsy, getting a genetic test may help you not only with a diagnosis but also better grasp your health care needs.
Understanding Medicare Coverage for Genetic Testing
Keep in mind that Medicare will not cover genetic testing for predictive reasons. However, if you have symptoms of a disease and a cancer diagnosis, a genetic test may be ordered by your doctor to help form a better healthcare plan.
There are several genetic tests that your doctor can order that should be covered by Medicare including next generation sequencing, molecular diagnostics, PGx tests and colorectal cancer screening.
Next Generation Sequencing
One type of genetic testing is called next generation sequencing (NGS). Next generation sequencing is a fairly new form of genetic testing that allows multiple strands of DNA to be tested at one time rather than testing each strand individually.
NGS can test for variations of cancer, including breast and ovarian cancer. In 2020, Medicare expanded coverage to cover these tests. However, for Medicare to cover NGS, the test must be ordered by a doctor as part of a diagnosis, and the patient must meet the following eligibility requirements:
- The patient has advanced stage III or IV cancer, cancer that is recurrent, relapsed, metastatic, or refractory (treatment resistant).
- The patient has not had an NGS test already for the same type of cancer.
- The patient wants to receive further cancer treatment.
Molecular Diagnostic Genetic Tests
Molecular diagnostic genetic tests are another form of genetic testing that Medicare may cover. Molecular diagnostic genetic tests look for gene mutations associated with certain diseases, such as cancer, to help diagnose and treat a patient.
There are two eligibility requirements for Medicare to cover this test:
- The patient must have a cancer diagnosis.
- A physician must order the test.
PGx Genetic Testing
PGx genetic testing is a type of genetic test that studies the body’s DNA reaction to certain medications. This is helpful as it allows the treating physician to learn what medications the patient may better respond to.
In 2020, Medicare coverage was extended to cover tests for certain FDA-approved medications, such as Warfarin, a common drug used to treat blood clots. It is best to check with your Medicare provider to see if a specific medication is covered before getting a PGx test performed.
Colorectal Cancer Screening
Colorectal cancer screenings test individuals for conditions that may lead to colorectal cancer, which is cancer of the colon or rectum. Medicare will cover blood screenings and DNA tests for signs of colorectal cancer. A colonoscopy is also a standard test used to detect colorectal cancer. Colonoscopies are covered by Medicare every 10 years for people at low risk and every two years for high-risk individuals.
Unlike other genetic testing, you do not have to have a cancer diagnosis to receive colorectal cancer screenings under Medicare.
How Does Medicare Advantage Cover Genetic Testing?
At age 65, most individuals will become eligible for Medicare. However, they may decide to drop Medicare and pick up a Medicare Advantage (Part C) plan instead.
A Medicare Advantage plan offers the same coverage as Original Medicare but usually covers additional services such as prescription medications, dental services, and vision care.
Regarding genetic testing, Medicare Advantage plans must meet the same criteria as Original Medicare. Therefore, genetic testing is usually covered when Medicare coverage criteria are met. Medicare Advantage plans may offer additional coverages, and each plan should be looked over carefully.
How Much Do Genetic Tests Cost With Medicare?
Again, Medicare only covers genetic testing regarding cancer and cancer treatments. If Medicare covers the tests, they would be covered under Part B of Medicare. Any tests, screenings, and doctor’s fees would be subject to Medicare’s deductible and copay.
Out of pocket, a genetic test can cost anywhere from a few hundred dollars up to a few thousand dollars. While test costs vary widely, one source named the per-patient cost of an NGS test for Medicare beneficiaries as $2,099. Before having the testing, make sure to check with your Medicare provider to ensure the test is covered.
Medicare Part B Costs
While Medicare Part B may pay the majority of a covered test, there are still some out-of-pocket costs. In 2023, the annual deductible for Medicare Part B is $226. After that is met, there is a 20% copay on covered services. Medicare Part B also has a $164.90 per month premium.
Medicare Advantage Costs
The cost of genetic testing with a Medicare Advantage plan will vary greatly depending on the plan. While most plans do not have a monthly premium, they may have a much larger annual deductible and copay. Medicare Advantage plans may also require a patient to receive care within their network of providers.
Alternative Ways to Cover Genetic Testing
If Medicare does not cover your genetic testing, there may be other ways to cover the costs, such as private insurance and Medicaid.
Private Insurance
A private insurance plan may offer more coverage in regard to genetic testing. However, these plans may be costly and have higher out-of-pocket expenses. Each plan will have an annual deductible and copays that must be met. Depending on the plan type, the patient may need to see a doctor within the plan’s network to cover any services.
Medicaid
Medicaid is a government ran insurance program for low-income individuals. Genetic testing with Medicaid does not require a cancer diagnosis; rather, there must be a known history of the disease in the family. While this may be a good alternative for some, the income limits may exclude some individuals from Medicaid.
Does Medicare Cover At-Home Genetic Tests?
Medicare does not cover at-home genetic tests even if the individual has a known history of a disease or a diagnosis of a disease. The only at-home genetic test covered by Medicare is the Cologuard, an at-home stool sample test for colorectal cancer. Medicare will pay for one Cologard test every three years for eligible patients.
Does Medicare Cover Genetic Counseling?
Genetic counseling may be covered under Medicare when the counseling is deemed to be a medical necessity only. Genetic counseling is counseling from a doctor or other healthcare professional on how genetics may affect your health. The counseling can include an in-depth look at your family history and your symptoms to see if you need a genetic test.
Putting It All Together
If you or someone you care for are recipients of Medicare, it is essential to know what coverages and services are available to you in regard to genetic testing.
Medicare will cover some genetic tests, including next generation sequencing, molecular diagnostic genetic tests, and PGx tests when there is a cancer diagnosis and a physician orders the test. Other tests, such as colorectal screenings, do not need a cancer diagnosis to be covered.
If Medicare does not cover genetic testing, you may look into other options, such as a private insurance plan or Medicaid. It is important to know what your plan covers to ensure you are receiving the best care possible.