Medicare and Medicaid cover genetic testing for some people

In this section, we provide information on coverage of genetic counseling and/or genetic testing under:

Medicare

Medicare has limited coverage of genetic testing for an inherited genetic mutation.

• Medicare covers genetic testing for people with a cancer diagnosis who meet certain criteria; you must have a cancer diagnosis to qualify for coverage of genetic testing for an inherited mutation under Medicare.
• For people with a cancer diagnosis, Medicare policies for coverage of genetic testing for an inherited mutation vary based on where you live. Different Medicare Administrative Contractors (MACs) provide health insurance to people with Medicare in their region and their rules about who qualifies and what tests are offered.

Genetic testing for a BRCA mutation

Medicare may cover BRCA testing for people with:

• ovarian, fallopian tube or primary peritoneal cancer
• breast cancer diagnosed in women at age 45-50 or younger
• women diagnosed with triple-negative breast cancer before age 60
• Ashkenazi Jewish heritage with breast cancer
• male breast cancer
• pancreatic cancer
• metastatic prostate cancer or prostate cancer with a Gleason score >7
• a cancer associated with a BRCA mutation when there is a known BRCA mutation in the family

Some MACs require one of the above combined with a family history of specific cancers and/or Ashkenazi Jewish ancestry.

Medicare may also cover BRCA testing for an adopted person or someone with little known family health history, who comes from a small family, or who has few female relatives and meets the following criteria:

• breast or ovarian cancer diagnosed at or before the age of 45
• triple-negative breast cancer diagnosed at or before the age of 60
• a personal history of another cancer that is suspicious of being a BRCA-related cancer.

Multigene panel testing for inherited genetic mutations

A multigene panel is a type of genetic test that looks for inherited mutations in more than one gene at the same time. It might include testing for BRCA1 and BRCA2 mutations in addition to mutations in other genes such as ATM, PALB2, CHEK2, etc. Medicare covers panel testing when:

• the patient has pretest genetic counseling with a genetics professional who does not work for a testing laboratory
• the patient has a post-test genetic counseling appointment with a genetics professional who does not work for a testing laboratory
• the patient has a cancer diagnosis and meets the BRCA testing criteria listed above; and
• the genetic test will affect their cancer treatment options; and
• all of the genes included in the test panel are relevant based on their personal and family history; and
• the patient also meets criteria for at least ONE other hereditary cancer syndrome for which NCCN guidelines provide clear genetic testing criteria and management recommendations (e.g., LiFraumeni syndrome, Cowden syndrome, or Lynch syndrome)

Medicare coverage of multigene panel testing is available in all Medicare regions, although eligibility for this testing varies by Medicare Administrative Contractor (MAC). First Coast Service Options and Novitas Solutions MACs have more narrow testing policies. Broader coverage is available under Noridian Healthcare Solutions, Palmetto, Wisconsin Physicians Service Insurance, and CGS Administrators.

Genetic testing for Lynch syndrome

Testing for Lynch syndrome in people diagnosed with cancer begins with tumor biomarker testing. See our section on Treatment for more information. In a family with a known Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, or EPCAM), genetic testing is covered only for people with signs and symptoms of a Lynch-associated cancer AND a blood relative with a known Lynch syndrome mutation.

Visit the Medicare website or call 1-800-MEDICARE (1-800-633-4227) to learn more about covered genetic services.

Medicaid

All but two state Medicaid programs cover BRCA genetic counseling and testing for qualifying individuals, including those with a known mutation in the family, or specific personal and/or family history of cancer. There is variability in coverage policies and eligibility; some states provide coverage only for those diagnosed with cancer and others only cover testing for women. Alabama currently does not cover genetic testing for hereditary cancer risk. Rhode Island's Medicaid program covers BRCA testing for people in its managed care programs, leaving about 10% without access to these services.

The majority of states cover testing for a Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, or EPCAM) for qualifying individuals, including people with a known genetic mutation in the family, or specific personal and/or family history of cancer. As of 2020, the following Medicaid programs did not cover genetic counseling or testing for Lynch syndrome: Alabama, Delaware, North Carolina, Nevada, Rhode Island and South Carolina. There is limited or questionable coverage in New Hampshire, South Dakota, Tennessee and Utah.

Multigene panel testing—a type of genetic test that looks for inherited mutations in more than one gene at the same time—or testing for specific inherited mutations in genes beyond BRCA1, BRCA2 and the Lynch syndrome genes (MLH1, MSH2, MSH6, PMS2, or EPCAM) is not covered by most Medicaid programs.

Contact your state Medicaid office to learn more about access to genetic counseling and/or testing in your state.