Medicare covers some genetic testing
January 1, 2022 | View PDF
Medicare may include coverage of diagnostic-level genetic testing for patients when the test is ordered by a physician, as long as certain requirements are met. Genetic tests of this sort are performed in order to help identify medical traits which may be cancer-related. The development and availability of genetic tests continues to evolve, especially in the diagnosis and early treatment of many diseases. Tests of this sort may be able to confirm or eliminate an appropriate diagnosis, far beyond just a written record of a patient’s family history of related diseases.
Most genetic testing procedures are as simple as swabbing the inside of the patient’s cheek, some tests do require a blood sample. These diagnostic tests do not catalog a person’s entire genome, nor do they quantify a patient’s entire medical history. The intended purpose of a genetic test is to identify the presence of specific markers associated with pre-selected diseases or hereditary conditions. Taken alone, the test does not provide exact answers. But the physician may be able to utilize the genetic testing results in order to treat the patient more holistically since early detection and treatment can avoid unneeded complications later.
Medicare only began covering laboratory diagnostic tests using next generation sequencing (NGS) a few years ago. Only certain patients with known cancers initially met the specific criteria required for Medicare to pay for this testing. Since then, additional coverage guidance has been approved by the Centers for Medicare and Medicaid Services (CMS), which sets the policies on how and when Medicare will pay for these prescribed procedures. Over-the-counter genetic tests are not covered by Medicare.
Unfortunately, situations have happened where scammers have offered genetic testing services to unsuspecting Medicare beneficiaries. Unscrupulous telemarketers, door-to-door salesmen, and even helpful-seeming people manning the booth at a local health fair often target senior citizens, claiming that Medicare will pay and that the test will be free. Don’t fall for it. Don’t hand over your Medicare card. And don’t agree to pay if the test is not prescribed by your doctor. Remember, if it sounds too good to be true, it probably is.
If you have been sent a kit or approached about genetic testing, contact the Alaska Medicare Information Office and report it.
For any Medicare related questions, please feel free to contact the State of Alaska Medicare Information Office at 800-478-6065 or 907-269-3680; our office is also known as the State Health Insurance Assistance Program (SHIP), the Senior Medicare Patrol (SMP), and the Medicare Improvements for Patients and Providers (MIPPA) program.
Sean McPhilamy is a volunteer and Certified Medicare Counselor at the Alaska Medicare Information Office.