Although Medicare covers a yearly mammogram for women aged 40 and above, genetic testing for breast cancer isn’t as widely covered.

In this article, we aim to alleviate some of your concerns by providing a clear and comprehensive guide as to whether Medicare covers genetic testing for breast cancer, the associated costs, and the extent to which different parts of Medicare might be of assistance. 

Will Medicare cover genetic testing for breast cancer?

Medicare’s stance on covering genetic testing for breast cancer is geared towards supporting individuals with a high risk due to family history or other factors. Original Medicare Part B and Medicare Advantage (Part C) may offer coverage for genetic testing if you meet certain criteria outlined by Medicare. 

Medicare covers genetic testing for breast cancer in the following situations:

• Diagnosed Early: Medicare covers genetic testing if you were diagnosed with breast cancer at age 45 or earlier. This is because early diagnosis might indicate a genetic predisposition.
• Multiple Diagnoses: If you have had two primary diagnoses of breast cancer before the age of 50, Medicare covers genetic testing as this suggests a higher genetic risk.
• Specific Cancer History: Medicare provides coverage if you have a history of epithelial ovarian, fallopian tube, or primary peritoneal cancer, as these cancers can be associated with breast cancer gene mutations.
• Ethnicity with Higher Mutation Frequency: Certain ethnic groups such as Ashkenazi Jews have a higher frequency of BRCA mutations. Medicare covers genetic testing for individuals belonging to such ethnicities.
• Close Relative with BRCA Mutation: Having a close relative with a BRCA1 or BRCA2 mutation increases your risk. Medicare covers genetic testing if this is your case to determine if you have inherited the mutation.
• Male Blood Relative with Breast Cancer: If you have a close male blood relative diagnosed with breast cancer, Medicare covers genetic testing, since male breast cancer is often linked to genetic mutations.

In all cases, your healthcare provider must certify that undergoing genetic testing for BRCA mutations has definite medical benefits for you, and the genetic testing must be ordered by a healthcare provider who accepts Medicare assignment, with the laboratory doing the testing also being Medicare approved.

How much will you need to pay in case of Medicare-covered genetic testing?

Understanding the financial implications of genetic testing for breast cancer is crucial. If your genetic testing is covered by Original Medicare Part B, you will need to pay the Part B deductible, which stands at $240 for the year 2024. 

If you have a Medicare Advantage Plan (Part C), your out-of-pocket expenses might vary. The costs depend on the specifics of your plan; you may face a copayment, coinsurance, or deductible. It is advisable to consult with your insurance provider and the laboratory conducting the testing to understand the expected expenses. Some Medicare Advantage plans may even cover 100% of the genetic testing costs.

For individuals without Medicare coverage, the average cost of BRCA mutation testing is around $300, though this may vary depending on the laboratory. There are also several laboratories in the United States that offer free testing for BRCA mutations, which can be an invaluable resource for those concerned about the financial burden.

Coverage Type	Deductible	Copayment/Coinsurance	Notes
Original Medicare Part B	$240 (for 2024	20% of the approved amount after paying deductible	Co-payment kicks in after the annual deductible is met. Learn more here.
Medicare Advantage	Varies	Varies	May cover up to 100% of the testing
No Insurance	N/A	N/A	Approx. $300 or free in some labs

In what instances does Medicare not cover BRCA testing?

Medicare has specific conditions under which it does not cover BRCA testing, as it might be deemed not medically reasonable or necessary. These instances include:

• Repeat Testing: BRCA testing under Medicare is limited to once in a lifetime. If a patient has undergone BRCA1 and BRCA2 testing previously, Medicare will not cover repeat testing before certain therapies, such as olaparib.
• Genetic Screening in the General Population: Medicare does not cover BRCA1 and BRCA2 testing for individuals without signs and symptoms of breast, ovarian, or other hereditary cancer syndromes. Such testing is considered screening, and an Advance Beneficiary Notice (ABN) must be obtained.
• Testing of Individuals with No Personal Cancer History: Medicare does not cover BRCA testing for individuals who have no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. This is also considered screening and requires an ABN.

It’s essential to understand Medicare’s coverage limitations and work closely with healthcare providers to ensure the appropriateness of testing within the Medicare guidelines.

Article updated on January 19, 2024.