Does Medicare Cover Genetic Testing for Breast Cancer?

Medicare Benefits Solutions
Mar 12, 2021

Breast cancer remains one of the top health threats in the United States and across the world. But thankfully, recent medical innovations have made this disease more treatable than ever.

Even with advanced medical solutions available, testing and early detection remain vital to the success of any treatment regimen. Breast cancer screening tests are often utilized to find cancer. Genetic testing is also a valuable option that can provide insight into hereditary risk factors for developing breast cancer in the future.

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Medicare Coverage for Genetic Testing

In general, Medicare insurance does not cover genetic testing; however, there are some circumstances in which the program will cover genetic testing for breast cancer as long as you have met certain requirements, including having a personal or family history of breast cancer.

If covered under Original Medicare, genetic testing benefits will be provided by Medicare Part B for any services rendered through your doctor’s office or a lab. If testing is conducted while you are admitted to a hospital or skilled nursing facility, Medicare Part A would likely apply instead.

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How Does Genetic Testing for Breast Cancer Work?

Because the body relies on genetic instructions to tell it how to develop, certain mutations within specific genes can be monitored to assess the risk of developing the disease at some point in life. Even with these mutations, it is not definite that someone will develop a disease, but the odds do go up.

To test for breast cancer risk, the BRCA1, BRCA2 and PALB2 genes are examined to discern whether a mutation has occurred or not. If it has, precautionary measures may need to be enacted to reduce the risk of developing breast cancer in the future.

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Genetic Testing and Medicare Advantage

Medicare Advantage plan benefits may differ. Many Medicare Advantage plans offer additional benefits on top of those provided by Original Medicare coverage, but because each plan and provider are unique, you will need to consult with your plan manager for more details as to what services are covered.

Some Medicare Advantage plans may provide access to a wider range of genetic testing resources compared to Original Medicare coverage, and you may also face fewer restrictions or have to meet fewer obligations in order to receive coverage for testing.

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Medicare and Cancer Treatment Coverage

It should also be noted that both Original Medicare insurance and Medicare Advantage plans should cover cancer treatment care if you do end up being diagnosed with the disease. Medicare Part B would cover in-office care for your primary care visits as well as visits with specialists. In terms of hospital care or inpatient care, if needed after events like surgery, Medicare Part A would apply.

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

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