Paying for Genetic Services

Insurance coverage of genetic testing depends on several factors. If you are interested in genetic testing or if you think cancer runs in your family, it is important to speak with a qualified healthcare professional with training in genetics. Often, they can advise you on the right genetic test, coverage of testing, and offer guidance if you need to appeal an insurance decision or obtain financial assistance. If your health plan does not cover the full cost of testing, or you do not have health insurance, you may be able to receive testing from a reputable lab for $300 or less. 

Out-of-pocket costs for genetic counseling and testing vary based on several factors, including:

• your gender
• the type of insurance and your specific health plan
• which laboratory performs the test
• whether a previously identified mutation exists in your family
• which gene mutations are included in the test

Read below for more details regarding paying for genetic services.

Private insurance

Most private health insurers cover genetic counseling and testing with low or no out-of-pocket costs for people who have a personal history of cancer or a family history of cancer that meets certain criteria; deductibles, coinsurance or copays may apply. This includes the following tests:

• Testing for BRCA1, BRCA2 and other genes (i.e. ATM, CHEK2, PALB2, Lynch Syndrome, etc.) and multigene panel testing for people who meet testing guidelines.
• Testing for people with cancer, for whom test results may change treatment options. 

In limited situations, the Affordable Care Act requires most private insurance companies to cover genetic counseling and testing for BRCA1 and BRCA2 mutations with no out-of-pocket costs ONLY for eligible women.

Complete coverage (100 percent) for BRCA1 and BRCA2 testing applies only to women who:

• use an in-network provider.
• have a personal or family history of breast, ovarian, fallopian tube or primary peritoneal cancer.
• are not currently undergoing cancer treatment.

Note that some health insurers require genetic counseling before genetic testing.

Medicare

Medicare covers genetic testing only for people with a cancer diagnosis and a specific personal or family cancer history.   Different Medicare Administrative Contractors (MACs) provide health insurance to people with Medicare in their region. Their rules about who qualifies for genetic testing and what tests are covered may vary slightly. 

Genetic testing for BRCA mutations

Medicare may cover BRCA testing for people with:

• ovarian, fallopian tube or primary peritoneal cancer.
• breast cancer, in women at ages 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.

Medicare may also cover BRCA testing for individuals who are adopted, know little about their family health history, are from a small family or have few female relatives AND meet 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 suspected of being a BRCA-related cancer

Genetic testing for Lynch syndrome

Medicare covers Lynch syndrome testing in people diagnosed with cancer, including:

• colorectal or endometrial cancer before age 50.
• more than one type of Lynch syndrome-related cancer.
• Lynch syndrome cancers in one or more relatives with at least one diagnosis before age 50.

In families 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. For patients who meet these criteria, testing begins with tumor testing for indications of Lynch syndrome. If the results are suspicious for Lynch syndrome, Medicare will cover the cost of genetic testing.

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

Multigene panel testing for inherited genetic mutations

A multigene panel is a genetic test that looks for inherited mutations in multiple genes. It might include testing for mutations in BRCA1, BRCA2 and 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.
• posttest genetic counseling with a genetics professional who does not work for a testing laboratory.
• a cancer diagnosis that meets the BRCA testing criteria listed above, and all of the following conditions:
  • The genetic test will affect their cancer treatment options.
  • All genes included in the test panel are relevant based on their personal and family history.
  • The patient meets the criteria for at least ONE other hereditary cancer syndrome for which NCCN guidelines provide clear genetic testing criteria and management recommendations (e.g., Li Fraumeni syndrome, Cowden syndrome or Lynch syndrome).

Medicare coverage of multigene panel testing is available in all Medicare regions, although eligibility varies by Medicare Administrative Contractor (MAC). Some MACs have more narrow testing policies than others.

Medicaid

Every state Medicaid program EXCEPT Alabama covers BRCA genetic testing for qualifying individuals, including those with a known mutation in the family or a specific personal and/or family history of cancer. Coverage policies and eligibility vary; some states 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 a personal and/or family history of cancer.

Most Medicaid programs do not cover multigene panel testing.

Testing eligibility criteria differ by state. A genetic counselor can help determine whether you meet Medicaid guidelines for genetic testing coverage in your state. 

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