Key takeaways

  • Medicare generally does not cover genetic screening tests unless they directly affect treatment or lead to a specific diagnosis, with exceptions for specific diseases like cancer.
  • A Medicare-approved doctor must confirm signs or symptoms of a condition or higher risk of developing one for genetic testing to be covered, and the results must be able to directly affect treatment recommendations.
  • Types of genetic tests that may be covered include molecular diagnostic genetic tests, next-generation sequencing for advanced cancer stages, and pharmacogenomics testing when there are known gene-drug interactions that could affect treatment.

Medicare may pay for genetic testing in certain cases, such as when it’s part of treatment for specific diseases, such as cancer.

But a Medicare-approved doctor must specify that you have signs or symptoms of a condition or you have a higher risk of developing one.

Read on to learn more about the cases in which Medicare might pay for genetic testing.

In most cases, a genetic test won’t be covered by Medicare if it’s intended to determine your risk of developing an inherited condition or disease.

However, Medicare may pay for a genetic test if the results could directly affect your doctor’s treatment recommendations or if the test is used to monitor the progress of an illness.

For example, Medicare Part A may cover laboratory testing if you’re in the hospital. This can include genetic testing related to a cancer diagnosis that’s performed in a hospital.

When it comes to outpatient testing, under Original Medicare’s Part B, you usually only qualify for coverage of one test per lifetime, but multiple tests may be approved on an as-needed basis if such testing may affect your treatment.

Fraud alert

The Department of Health and Human Services Office of the Inspector General (HHS OIG) warns about genetic testing fraud that’s targeting Medicare beneficiaries.

Scammers may offer you free screenings in order to get personal information for identity theft or false billing. If you undergo the screening and Medicare later denies this claim, you could be responsible for the full cost of the test.

Only accept tests ordered by your doctor, and be cautious of unsolicited requests for your Medicare number.

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

Medicare may cover genetic testing for the following conditions:

Cancer

Medicare may pay for genetic testing related to cancer if you have a diagnosis confirmed by a clinical evaluation and abnormal test results. In addition, your doctor must show that genetic testing results can directly affect the course of your condition.

Other factors that Medicare considers when deciding on coverage include the severity of your condition, the available evidence for a relationship between genes and the specific cancer type, and the likelihood of your treatment being effective.

With regard to breast or ovarian cancer, genetic testing for the BRCA1 and BRCA2 genes may be covered if:

  • you have a personal history of breast cancer before age 60 years
  • you have a personal history of other cancers, such as ovarian, male breast cancer, pancreatic, or prostate cancer
  • you have a close relative with one of these cancers
  • you’re adopted and have been diagnosed before age 60 years with a BRCA-associated cancer
  • you’re of Ashkenazi Jewish descent
  • you’ve been diagnosed with other conditions that put you at greater risk, such as Lynch syndrome, Li-Fraumeni syndrome, or Cowden syndrome

While Medicare doesn’t cover home genetic testing, there is one exception.

Medicare will cover a multi-target stool DNA test every 3 years. If you’re between the ages of 45 and 85 years, you don’t need to have proven symptoms of colorectal disease and you can have an average risk of developing cancer.

Heart disease

Family history can play a role in the development of heart disease. Heart diseases that may be inherited include cardiomyopathy, arrhythmia, cardiac amyloidosis, and more.

If you’ve received a diagnosis of one of these conditions or are showing symptoms, Medicare may cover genetic testing if it meets certain criteria and the results are likely to support your treatment.

Similar coverage criteria may apply to genetic testing for other conditions or diseases.

Types of genetic testing that may be covered by Medicare include:

  • Molecular diagnostic genetic tests: These tests detect specific molecules in your genetic material to help diagnose illnesses and predict health conditions. These may be covered for certain inherited conditions.
  • Next-generation sequencing: These tests check for a certain order of building blocks in a DNA sample that indicates a possible mutation. This may be approved for people with advanced stages of certain cancers who are looking for new treatments or for people with ovarian or breast cancer and a family history of these cancers.
  • Pharmacogenomics: These are tests that look at how your genes react to medications, which can affect your treatment. This testing may be covered if you have a condition requiring medication with known gene-drug interactions and the test meets certain criteria when evaluated by the Food and Drug Administration (FDA) or the Clinical Pharmacogenetics Implementation Consortium (CPIC).

How much does a full genetic test cost?

The cost of genetic testing varies based on the type of test. It can range between $100 and $2,000.

That said, if Medicare Part B covers your specific test, then you’ll pay a monthly premium of $174.70. Once you meet your deductible of $240, Medicare should pay for 80% of the cost.

Medicare may cover the cost of genetic testing in specific situations, such as when it’s needed for the treatment of diseases like cancer or to help track the progress of an illness.

But a Medicare-approved doctor will need to confirm that you have signs or symptoms of the condition or have an increased risk of developing it.