Does Medicare Cover BRCA Cancer Tests?

Cancer impacts millions of people each year. In fact, it’s estimated that one in three people in the United States will develop cancer at some point in their life.

Of these, about 10% of cancers occur in someone who has inherited gene mutations. To date, researchers have found mutations in more than 50 hereditary cancer syndromes.

Drilling down even further, women who have either the BRCA1 or BRCA2 mutation are at a 5x higher risk of getting breast cancer, and an even higher risk of getting ovarian cancer compared to women who do not have the BRCA mutations.

As part of the fight against cancer, genetic testing can help spot issues early so that appropriate treatments can be implemented. Genetic testing for cancer is covered by Medicare in some cases, but not always.

Here’s what you need to know.

How does Genetic Testing Work?

Your body relies on genetic instructions that tell it how to develop and function. In some cases, genes mutate, causing the body to function improperly or develop diseases. Genetic testing identifies specific genes that can be monitored to assess the risk for developing a disease later in life. Mutations do not make it definite that someone will develop a disease, but the odds do go up.

Healthcare providers test for breast cancer risk by examining the BRCA1, BRCA2 and PALB2 genes to see if a mutation has occurred.

Testing is simple and worth the small inconvenience to provide you with your medical history and the possibility of passing mutated genes on to your loved ones.

A genetic test for cancer involves a risk assessment by looking at your personal and family medical history. Before your test, you must give informed consent, which means that you’re aware of and that you agree to:

The genetic test’s purpose
The type and nature of the genetic condition being tested
The test’s accuracy
The pros and cons of testing (including thelimits of the results and what your provider might tell you)
Other testing options
Potential screening or treatment options depending on the test results
Further decisions you might need to make once the results are back
The possible consent to use the results for research purposes
Availability of counseling and support services
Your right to refuse testing

After you give informed consent, you will provide saliva, blood, hair, cheek cells, urine, or a stool sample. The sample is sent to a lab where it is analyzed. After the results return, a genetic counselor or healthcare provider will tell you about your test results and the next steps you should take.

If you prefer, the test can be mailed to you and completed at home.

Hereditary Cancer Risk Factors

When cancers are linked to an inherited gene mutation, that’s called a family cancer syndrome.

Some genetic factors may make it more likely that you and your family members can pass cancer on to other family members. These factors include:

Many cases of the same kind of cancer such as ovarian cancer caused by BRCA1 and BRCA2 gene mutations
Cancers that occur much sooner than usual (i.e., breast cancer in a teenager).
One person who has multiple types of cancer (i.e., a man who has both colon and prostate cancer)
Cancers that occur in pairs of organs such as both kidneys or both breasts.
Siblings who have childhood cancers
Cancer that occurs in the opposite sex of the one usually affected (i.e., breast cancer in a man)
Cancer that occurs in multiple generations

Medicare Coverage and Genetic Cancer Testing

Medicare covers certain genetic cancer tests if they’re medically necessary. Currently, Medicare will cover genetic testing if:

You have recurring, relapsed, refractory, metastatic, or advanced stage III or IV cancer
You have not used the same genetic test for the same cancer diagnosis previously
You have decided to seek further cancer treatment such as chemotherapy and radiation
You have signs or symptoms of a cancer like colorectal cancer that can be clarified or verified with diagnostic testing
You have a first-degree relative who has a known mutation such as Lynch syndrome
You have a close relative with a BRCA (1 or 2) mutation.

Medicare may cover BRCA testing for people with ovarian, fallopian tube or primary peritoneal cancer. Coverage is provided for the following groups:

breast cancer diagnosed in women at age 45-50 or younger
women diagnosed with triple-negative breast cancer before age 60
Your ethnicity has a higher rate of BRCA mutation frequency such as people of Ashkenazi Jewish heritage
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
two primary breast cancers before the age of 50.
a history of epithelial ovarian, fallopian tube, or primary peritoneal cancer.

Some Medicare Administrative Contractors 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.

In addition, your health care provider must certify that by undergoing genetic testing for BRCA mutations to determine your risk for developing breast or ovarian cancer, you have definite medical benefits. The genetic testing must be ordered by a health care provider who accepts Medicare assignment, and the laboratory doing the testing must also be Medicare approved.

For example, Medicare currently covers the Myriad Genetics myPath and Castle Biosciences DecisionDx genetic tests for melanoma.

Medicare also covers screenings for lung, breast, prostate, and cervical cancer. Screenings are used to detect potential disease and a diagnostic test establishes the presence or absence of the disease.

Medicare also covers prostate cancer screening every 12 months for men over 50. If cancer is detected, Medicare Part B coverage includes a variety of options, including genetic testing to help physicians distinguish between an aggressive and a non-aggressive tumor.

Testing for Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, or EPCAM genes) is covered only for people with signs and symptoms of a Lynch-associated cancer AND a blood relative with a known Lynch syndrome mutation.

Multigene panel testing for inherited genetic mutations looks at more than one gene at the same time. It might include testing for BRCA1 and BRCA2 mutations and 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
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.

Medicare beneficiaries who need genetic counseling can get it covered under Medicare Part A and Part B only if it has been ordered by a physician before starting medication covered under Part D or if it is medically necessary in a skilled nursing facility.

Genetic Testing Costs with Medicare

If you meet the criteria for genetic testing, Medicare Part B pays for 80 percent of the Medicare-approved cost of the testing. You are responsible for the remaining 20 percent and the Part B deductible which is $233 in 2022.

If you have a Medicare Advantage policy, the amount you pay out-of-pocket depends on your policy. You may have a copayment, coinsurance, or deductible fee to pay. However, in many cases, Medicare Advantage policies cover 100% of the genetic testing costs.

If you’re diagnosed with cancer, Original Medicare and Medicare Advantage plans should cover cancer treatment care. Medicare Part B covers in-office care for your primary care visits and specialist visits. Part A applies for hospital or inpatient care.

Medications are covered under Medicare Part D, but only for medications that can be purchased from retail pharmacies. If you have medications administered in a clinical setting, Medicare Part B covers these, or in the case of medications administered while hospitalized, Medicare Part A provides coverage.

Does Medicaid Cover BRCA Counseling and Testing?

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 a specific personal or family cancer history.

Coverage varies depending on the state. Some provide coverage only for those diagnosed with cancer and others only cover testing for women.

Most 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 or family cancer history.

Multigene panel testing or testing for specific inherited mutations in genes beyond BRCA1, BRCA2 and the Lynch syndrome genes is not covered by most Medicaid programs.

Testing eligibility criteria differ by state, so it’s best to contact your state Medicaid office to learn more about access to genetic counseling.