Does Medicare Cover Genetic Testing?

Medicare covers genetic tests when a patient has signs or symptoms that diagnostic testing can further clarify. Genetic tests determining 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 beneficiary.

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• Genetic testing can 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 B will cover medically necessary genetic testing a beneficiary’s doctor ordered.
• Medicare beneficiaries pay no costs for genetic testing unless they request one for something medically unnecessary.
• Medicare Advantage plans will cover genetic testing, but the beneficiary must use providers within the plan.

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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.[mfn referencenumber=1]mayoclinic.org, “Genetic testing“, Accessed November 9, 2021[/mfn]

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.[mfn referencenumber=1]mayoclinic.org, “Genetic testing“, Accessed November 9, 2021[/mfn]

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.[mfn referencenumber=1]mayoclinic.org, “Genetic testing“, Accessed November 9, 2021[/mfn]

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.[mfn referencenumber=2]Medicare.gov, “Diagnostic laboratory tests“, Accessed November 9, 2021[/mfn]

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.[mfn referencenumber=3]medlineplus.gov, “What is the cost of genetic testing, and how long does it take to get the results?“, Accessed November 9, 2021[/mfn]

Do Medicare Advantage Plans Cover Genetic Testing?

Medicare Advantage plans are required to cover the same services as Medicare Part A and Part B, in addition to any expanded services offered. That includes diagnostic lab tests such as genetic testing. However, your out-of-pocket costs with a Medicare Advantage plan may be different than those with Original Medicare. You will also be required to use the plan’s network providers for all services, supplies, and durable medical equipment.[mfn referencenumber=4]Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed November 9, 2021[/mfn]

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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.