Medicare covers genetic tests when a patient has signs or symptoms that can be further clarified by diagnostic testing. Some genetic tests that determine a patient’s ability to metabolize certain drugs may also qualify for coverage. Federal Regulation 42 CFR § 410.32(a) requires genetic tests to be ordered by a medical doctor treating the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs..
Key Takeaways
- Genetic testing can be used to check a person’s DNA for susceptibility to an illness or disease.
- Genetic testing results are not a guarantee that a person will or will not have that condition.
- Most genetic tests use a blood or saliva sample to analyze a person’s DNA.
- Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. will cover medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. genetic testing ordered by a beneficiary’s doctor.
- Medicare beneficiaries pay no costs for genetic testing unless they request one for something medically unnecessary.
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover genetic testing, but the beneficiary will have to use providers within the plan.
Key Takeaways
What Is Genetic Testing?
Genetic testing refers to analyzing your DNA samples, the chemical data that guides your body’s functions. Genetic testing can detect mutations in your DNA that can make you prone to certain illnesses or diseases. Doctors will order a genetic test if you are showing signs or symptoms that can be further clarified by analyzing your DNA.1mayoclinic.org, “Genetic testing“, Accessed November 9, 2021
Genetic testing can provide valuable information to diagnose, treat, and prevent a possible illness. However, the results are not a guaranteed prediction. A positive test result from a genetic test does not mean someone is doomed to have that condition. Likewise, and negative test result does not guarantee you will never have that condition.1mayoclinic.org, “Genetic testing“, Accessed November 9, 2021
How Is Genetic Testing Administered?
Your doctor will talk with you about your family’s medical history to better understand what they are looking for when performing genetic testing. The doctor will then gather a blood or saliva sample from you to be tested in a diagnostic lab. If your doctor orders a genetic test for your unborn child, they will either take an amniotic fluid or placenta tissue sample.1mayoclinic.org, “Genetic testing“, Accessed November 9, 2021
How Does Medicare Cover Genetic Testing?
Medicare will cover genetic testing if you have signs or symptoms that your doctor can properly diagnose with a diagnostic lab testing. Medicare Part B fully covers all medically necessary diagnostic laboratory tests ordered by your doctor, including genetic testing. Part B beneficiaries pay nothing for medically necessary genetic testing because it is a preventative care method.2Medicare.gov, “Diagnostic laboratory tests“, Accessed November 9, 2021
How Much Does Genetic Testing Cost?
Genetic testing costs without coverage can vary between $100 to over $2,000 depending on its nature and complexity. Genetic testing costs can increase if more tests are needed or multiple family members need to be tested for significant results. Medicare Part B beneficiaries do not pay any costs for genetic testing unless they request it for something that is not medically necessary for their condition.3medlineplus.gov, “What is the cost of genetic testing, and how long does it take to get the results?“, Accessed November 9, 2021
Do Medicare Advantage Plans Cover Genetic Testing?
Medicare Advantage plans are required to cover the same services as Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part B, in addition to any expanded services offered. That includes diagnostic lab tests such as genetic testing. However, your out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. with a Medicare Advantage plan may be different than those with Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.. You will also be required to use the plan’s network providers for all services, supplies, and durable medical equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds..4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 9, 2021
Summary
If you are concerned with potentially being vulnerable to a disease within your family history, Medicare will fully cover the costs for your genetic tests. The results of your test may be able to ease your concerns or allow you to take preventative care actions for your health. However, there are no guarantees with genetic testing, so do not interpret them as a death sentence or a get-out-of-jail-free card for the conditions you tested for.
Citations
- 1mayoclinic.org, “Genetic testing“, Accessed November 9, 2021
- 2Medicare.gov, “Diagnostic laboratory tests“, Accessed November 9, 2021
- 3medlineplus.gov, “What is the cost of genetic testing, and how long does it take to get the results?“, Accessed November 9, 2021
- 4Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 9, 2021