Medicare Part B covers various genetic tests, such as those to assess certain cancer risks or diagnose genetic conditions, if a healthcare professional deems them medically necessary and the claims meet certain criteria.

Healthcare professionals can use genetic tests to identify genetic changes that people inherit from their parents through DNA. The results of genetic tests can inform diagnoses or provide information about someone’s risk of developing certain conditions.

Before undergoing genetic testing, a person needs to check with their insurer to determine the costs involved and the coverage provided.

This article explains whether Medicare covers genetic testing, the criteria for screening, the potential costs, and when to contact a doctor about genetic testing.

Glossary of Medicare terms

We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:

  • Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
  • Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
  • Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
  • Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
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Medicare Part B covers medical services and supplies to help diagnose and treat medical conditions. It also covers some preventive services.

Part B coverage can include specific types of genetic testing, such as tests for:

Medicare resources

For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.

Medicare may cover genetic testing if a person meets certain criteria, which include the following:

  • A healthcare professional recommends genetic testing.
  • The test is reasonable and medically necessary for diagnosis, treatment, or risk evaluation.
  • Specific indications are present for genetic testing, such as a personal or family history of certain heritable conditions.
  • The Food & Drug Administration (FDA) approves the test.
  • In some cases, Medicare may require testing within a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory.

Additionally, further criteria may apply to each type of genetic test.

Limitations

Medicare may refuse to cover genetic testing if a person does not meet the necessary criteria or falls under certain limitations.

Limitations include once-in-a-lifetime testing for certain genetic mutations, such as those in the BRCA1 and BRCA2 genes. This means Medicare will not cover repeat tests, as the results of genetic tests do not change over a person’s lifetime.

Medicare may also not cover BRCA1 and BRCA2 testing for people under 18 years of age.

Additionally, it will not cover repeat germline testing, which involves testing noncancerous cells.

Regional requirements

Medicare Administrative Contractors (MACs) are private healthcare insurers responsible for administering Medicare claims. They can provide coverage according to National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs).

  • NCDs: These are nationally applicable rules that guide coverage decisions for medical services. MACs must adhere to NCDs regardless of their region.
  • LCDs: If NCDs are unavailable for a specific medical service, such as genetic testing, local MACs may provide coverage under LCDs. Coverage requirements may differ between LCDs in different regions.

Before undergoing genetic testing, a person can check with their insurance provider to determine whether they meet the coverage criteria.

What conditions does Medicare cover?

Medicare may cover genetic testing for various conditions, provided a person meets certain criteria. These include:

  • Breast and ovarian cancers: Medicare may cover genetic testing to determine if a person has a mutation in the BRCA1 and BRCA2 genes, which can help identify their risk of breast and ovarian cancers.
  • Acquired and inherited cancer: Medicare may cover next generation sequencing, a type of genetic test that can diagnose or assess a person’s level of risk for various cancers.
  • Sickle cell disease: Medicare may cover molecular diagnostic testing, which looks for variations in chromosomes, proteins, and other molecules to help diagnose various genetic conditions. These include conditions such as sickle cell disease, which affects red blood cells.
  • Chromosomal conditions: Genetic testing can help identify extra, missing, or changed chromosomes, which indicate chromosomal conditions, such as Williams syndrome and Down syndrome.
  • Adverse drug effects: If a person has a condition that requires them to take medication known to have a specific gene interaction, Medicare may cover genetic testing if they consider the test to be medically necessary.

The costs of genetic testing vary depending on the type and complexity of the test.

According to health experts, genetic test costs range from $100 to more than $2,000 without coverage. Some tests may require multiple family members to undergo testing, which can increase the cost.

If a person meets the criteria for Medicare coverage, they may not have to pay out-of-pocket costs.

However, Medicare may not cover certain types of genetic testing, or a person’s claim may be unsuccessful. Individuals should check with their insurer before undergoing genetic testing.

People can discuss genetic testing with a healthcare professional to see if it is necessary. A doctor may suggest genetic testing for someone who:

  • has a personal history of a genetic condition
  • has a family history of a genetic condition
  • is part of a high risk group for a genetic condition
  • has signs and symptoms of a genetic condition
  • requires a genetic test as part of their diagnosis or treatment

A healthcare professional can also help a person determine whether Medicare will cover testing costs. Individuals can also contact Medicare directly to find out if they meet the criteria for coverage:

  • Phone: 800-MEDICARE (800-633-4227)
  • Medicare account: Log in to or create a Medicare account to access information.

Does Medicare cover genetic testing while pregnant?

According to the American College of Obstetricians and Gynecologists, Medicaid may cover some genetic tests during pregnancy. A person’s coverage can depend on certain risk factors, their medical history, and whether they meet the coverage criteria.

Individuals should discuss the specifics of their policy with their insurance provider.

How much does a full genetic test cost?

The costs of genetic tests can vary and may be between $100 and $2,000 without insurance coverage.

Does Medicare cover genetic testing for cancer?

Medicare covers genetic testing for various types of cancer, including breast and ovarian cancer, as long as a person meets specific criteria.

Medicare provides coverage for various genetic tests if a person meets certain criteria. It may cover genetic tests when a healthcare professional orders them and when the screenings are medically necessary and adhere to certain clinical standards.

The cost of genetic testing can vary depending on the type of test necessary and other factors.

People can check with their insurance provider before undergoing genetic testing to see if they qualify for coverage.