Does Medicare Cover Genetic Testing? 

Clinical genetic testing may be ordered by your doctor for a variety of reasons. While not a substitute for regular checkups, genetic testing can identify risk factors for developing certain diseases like breast or colon cancer and Alzheimer’s disease. People who are over 65 years old can use genetic testing to find out more about their general health and future risk for disease, but Medicare may not cover every type of genetic test.

How does genetic testing work?

The process of genetic testing begins with a genetic consultation. After you give your informed consent for the testing, a health care provider takes a sample of your blood, hair, skin, amniotic fluid (if you’re pregnant), or other tissue. Technicians in a laboratory look for changes in DNA, chromosomes, or proteins – depending on the type of disorder they’re looking for. When the lab completes its testing, the written results are sent to your physician for evaluation.  

Does Medicare cover genetic testing? 

If you’re enrolled in Original Medicare Part B (medical insurance) or a Medicare Advantage (Part C) plan, you may have coverage for genetic testing in the following instances:

  • Your physician certifies that you have symptoms of a medical condition that can be diagnosed by a genetic test. 
  • Your physician certifies that the tests are medically necessary, orders the tests, and receives the results for evaluation. 
  • The genetic test required for the diagnosis has been FDA-approved and developed specifically for the diagnosis of the medical condition. 
  • Your physicians and testing laboratories accept Medicare assignment (for Original Medicare), or they are included in your Medicare Advantage plan’s network of health care providers. 

If your physician doesn’t consider your condition to be severe or doesn’t intend to provide treatment after diagnosis, Medicare may not cover it. Also, Medicare doesn’t cover genetic testing used solely for predicting your risk of a medical condition, or for detecting health conditions that haven’t been previously diagnosed. 

Types of genetic testing 

Medicare may cover the following types of genetic testing for those who qualify:

  • Next Generation Sequencing (NGS)
  • Molecular Diagnostic Genetic Tests (MDT) to analyze gene sequences and identify certain diseases.
  • Pharmacogenomic testing (PGx) to test how a person responds to certain medications.  
  • Diagnostic genetic testing for breast, prostate, ovarian, and pancreatic cancer (when the patient is at certain stages of the disease) 
  • Genetic testing for BRCA1 and BRCA 2 gene mutations for patients who have a history of breast or ovarian cancer, have a close relative with the gene mutations, are of Ashkenazi Jewish heritage, and have certain risk factors for hereditary cancers of these types 

If Medicare covers your genetic tests, Original Medicare Part B may help cover them. If they aren’t covered, you are responsible for the cost. 

If you have Medicare Advantage, your provider may require that you use in-network providers and laboratories for the testing. Your plan may also charge coinsurance or a copayment, depending on the type of coverage you have.  

Does Medicare cover genetic counseling sessions? 

Original Medicare Part B covers genetic counseling that’s provided by a cancer genetics professional. It doesn’t cover genetic counseling sessions that are provided by certified genetic counselors though, so you would be responsible for these expenses. 

If you have Medicare Part C, your coverage for genetic counseling may be different, so check with your plan provider for specific restrictions or allowances before making appointments.  

How much does genetic testing cost without Medicare insurance coverage? 

Your final cost for genetic testing depends on the type of test and where you have it done. According to the American Cancer Society, some labs charge $100 for some tests and thousands of dollars for others. Talk to your doctor to discuss your concerns and to determine if genetic testing is right for you.

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