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Does Medicare Cover Genetic Testing?

Does Medicare Cover Genetic Testing? text overlaying image of a dna strand The Centers for Medicare and Medicaid (CMS) has begun covering genetic sequencing in 2018. It began when the FDA approved FoundationOne CDx, a test that can detect over 300 types of gene mutations. While Medicare does cover genetic testing to help detect possible health conditions it only covers a few types of genetic testing, and you have to meet certain criteria. Typically, genetic testing is used to screen, identify, or plan a specific treatment. That means without having certain symptoms or being at risk for certain health conditions Medicare won’t cover genetic testing. In most cases your doctor will be the one who advises you to get genetic testing done. For example, if you have a hereditary risk for a certain disorder. Along with testing to check the effectiveness of a new medication, this would help your doctor determine a better treatment plan.

Types Of Genetic Testing

Mainstream adult genetic testing covers several conditions. These are usually categorized by function:

Diagnostic, Predictive, or Presymptomatic – These tests are for patients who may have symptoms or know a certain medical condition runs in their family. A genetic test can show indicators for various cancers, polycystic kidney disease, and hemochromatosis. However, having indicators does not mean you will develop the disease. It just means you have the genes that can trigger it.
Carrier – Even if a person never gets sick or shows signs of a disease, they may be a genetic carrier for that disease. A test that looks for DNA markers that show a person is a carrier of an inherited disease can tell them if they could pass this gene on to a child or if they already have. If the other parent is also a carrier, this test can also tell them if they have already passed this gene onto a child.
Pharmacogenomic – The study of genetics is a big part of learning how the body breaks down drugs or responds to them. In some cases, a person’s genes can show whether or not a certain treatment will work or cause a bad response. This can help doctors tailor their treatment plan to the patient’s needs. Which can improve the chances of the patient’s health and healing going well.

Are There Risks To Genetic Testing?

Most genetic tests have very few risks and may be as easy as swabbing the inside of a patient’s cheek. Other tests may need a sample of blood. Which can cause some of the usual side effects of having blood taken. This could lead to redness or soreness in the place where the injection was given. Genetic testing, like any test, can also lead to changes in your mental health. Depending on how bad the scenario is, genetic testing can take an emotional toll. This could happen while deciding if a genetic test is needed, while waiting for the results, or after a genetic problem has been confirmed. This is natural since the possibility of serious medical conditions can be scary.

Keep in mind, genetic tests might be able to find out if a person has genetic markers linked to hereditary conditions. But they don’t tell us how likely it is that a person will get the disease. Or how signs might change or get worse over time. The health care worker who does the genetic test can tell you if there are any limits to the test and what it is usually used for.

Genetic Testing With Medicare

As we noted before, Medicare will pay for only a few types of genetic testing if you meet Medicare’s standards. If your doctor suggests that you get a genetic test it will most likely be covered because it will stem from a set of symptoms you’ve been showing. These are the genetic tests Medicare will cover:

Molecular Diagnostic Genetic Test (MDT) – Involves looking at gene sequences for changes that could cause certain illnesses.
Next Generation Sequencing (NGS) – NGS is a type of genetic testing that looks at many different parts of a person’s DNA at once. It helps doctors figure out how changes (mutations) in your DNA can show risk factors. And help them figure out what’s wrong with you.
Pharmacogenomics (PGx) – As we noted above, this is a type of test designed to learn how your body will react to certain types of medication.

Medicare also pays for NGS genetic tests for both acquired cancer (caused by gene mutations) and germline cancer (which is passed down from parent to child). Medicare will also cover some types of genetic tests that are used to diagnose cancer. These tests help find biomarkers, which are signs of abnormal cell activity in your body. For example, Medicare pays diagnostic tests for breast cancer, prostate cancer, ovarian cancer, and pancreatic cancer for people who have never been tested for specific mutations (BRCA).

BRCA Testing

Medicare pays for genetic tests that look for changes in the BRCA 1 and BRCA 2 genes. Which are the breast and ovarian cancer genes. Medicare also pays for other genetic tests that can tell if someone has a BRCA gene. Research shows that both men and women with the BRCA 1 or BRCA 2 gene mutations are much more likely to get breast and ovarian cancer than people who don’t have these gene mutations. A test like NGS that looks at many genes at once can find changes in BRCA 1, BRCA 2, and other genes. This can help doctors figure out if someone has cancer or not. There is criteria to get testing for BRCA 1 and BRCA 2:

You have to have pre-testing genetic counseling
Testing must be relevant to your family history of cancer
National Comprehensive Cancer Network rules say that you must meet certain standards to be eligible for testing for breast cancer or another type of cancer and one other type of inherited cancer.

When Does Medicare Cover Genetic Testing?

Medicare will pay for genetic testing for certain conditions and PGx for medications. As long as your doctor orders it and it is done in a lab that is approved by the Clinical Laboratory Improvement Amendments (CLIA).

Medicare covers genetic diagnostic testing for specific gene changes and NGS multi-gene panel testing if you have been diagnosed with cancer. If you meet Medicare’s requirements, NGS testing is also covered for other inherited diseases. Such as heart problems (cardiomyopathy, which is a problem with the heart muscle) and arrhythmia. Coverage for the Individual Plan may change based on where you live. For some medicines, PGx testing is also covered. Many medicines are broken down in the liver by enzymes like CYP2C19, CYP2D6, and CYP2C9. Doctors and pharmacists can better focus your medication therapy by testing your genes for these enzymes.

Medicare will pay for PGx testing for certain drugs like warfarin, clopidogrel, amitriptyline, and others if certain conditions are met. Your doctor can tell you more about the perks of PGx testing for you. The company that gives you your Medicare plan can tell you which PGx tests are covered by your plan. Medicare also lets MACs decide if they will cover NGS genetic tests that are not FDA-approved and other types of NGS genetic tests. For instance, for other types of cancer and other health problems.

Cost Of Genetic Testing

How much a genetic test will cost you varies based on the type of test, how it’s done (saliva or blood sample), and whether or not you meet the requirements for Medicare coverage. If your test is covered, you won’t have to pay anything as long as your provider accepts Medicare assignment. This means they agree to the payment terms set by Medicare. Costs for genetic tests can range from a few hundred to a few thousand dollars. So, it is important to make sure that Medicare pays for the test. Medicare has rules about who can get testing, and your doctor must give you an order for it. Medicare Administrative Contractors (MACs) may also have eligibility standards based on where you live.

Counseling With Genetic Testing

Medicare rules say that a “cancer genetics professional” like a doctor can give genetic advice. Which is covered, but you have to be a patient of that doctor. Certified genetic counselors are not yet seen as health care experts by Medicare. So, if you see a genetic counselor who is certified, your visit may not be paid. Certified genetic counselors have special training in genetics and therapy, so they can help you understand how your genes affect your chances of getting diseases like cancer. Based on the rules in place, Medicare doesn’t pay for genetic advice for any screening or prevention tests. Your Medicare plan provider can tell you more about the coverage standards for genetic counseling.

Get Covered With EZ

Medicare is great, but sometimes it can be hard to understand. Even after you sign up, you’ll still have to make some decisions about your health care. Don’t worry about asking questions. Talk to an EZ agent who can tell you what you need to do to sign up and explain everything to you. EZ can help you sign up, buy a Medicare Supplement Plan, or just think about your choices. Our insurance brokers work with the best firms in the country. You can get a free review of all the plans in your area from them. We’ll talk with you about your medical and financial needs and help you find a plan that meets them all. Call one of our certified agents at 877-670-3602 to get started.

CMS Proposes New Medicare Payment Adjustment for Home Healthcare

The U.S. Centers for Medicare & Medicaid Services (CMS) has proposed a permanent payment adjustment to the home healthcare 30-day period payment rate. The change would decrease Medicare payments to home health agencies by $810 million next year. Home healthcare providers have concerns that this will put the stability of home healthcare at risk, and are pushing a new bill to hold off any payment reductions until 2026. Because these pay cuts would mean home healthcare providers would lose a lot of their funding, home healthcare agencies would lose staff and more, which would ultimately affect Medicare beneficiaries’ care.

The New Proposal

CMS is proposing a new Medicare payment adjustment under the Home Health Prospective Payment System. The adjustment would decrease payment rates to home healthcare providers and facilities by 4.2%, or $810 million, compared to 2022 rates.

Providers Not Happy

Home healthcare providers are arguing that the proposal does not take into account multiple factors, such as increased home healthcare labor costs and the high inflation rate.

“We are very disappointed in the CMS proposed rule issued today,” William A. Dombi, the president of the National Association for Home Care & Hospice (NAHC), wrote in a comment shared with Home Health Care News. “The stability of home health care is at risk as a consequence of CMS proposing the application of a fatally flawed methodology for assessing whether the PDGM payment model [Patient-Driven Groupings Model, which uses 30-day periods as a basis for payments] led to budget neutral spending in 2020. That has been made clear to CMS in the 2021 rulemaking and in multiple discussions since.”

blue boxing gloves — *A new bill that would prevent CMS from reducing home health payments until 2026 was introduced in the Senate.*

“With significantly rising costs for staff, transportation, and more, home health agencies across the country cannot withstand the impact of the proposed rate cut,” Dombi said. “Reliable analyses prove that PDGM underpaid home health agencies. We will be taking all steps to protect the home health benefit as this proposed rule advances and have fully prepared for congressional action and more.“

Fighting Back

With pay cuts like this, home health agencies will be underpaid, which could result in fewer workers to help care for Medicare beneficiaries who need home healthcare. But a new bill that would prevent CMS from reducing home health payments this year – and until 2026 – was introduced in the Senate on July 25.

“The bill is set up so that CMS is blocked from reducing payment rates until 2026,” Dombi told Home Health Care News. “And the purpose of that, essentially, is to create what we hope is an opportunity to correct where CMS is at in terms of their methodology. And to deal with even some of the questions around transparency relative to the data that we’ve asked for.”

What Are We Doing about Health Equity in the US?

One of the good things about the Affordable Care Act of 2010 (ACA) is that it has led to a reduction in racial, ethnic, and other disparities in the healthcare system in America. But, unfortunately, it seems that it has not been enough to create health equity for everyone. We are still seeing high rates of uninsured or underinsured people in this country: in a survey released by the Centers for Disease Control and Prevention (CDC), an estimated 9.6% of U.S. residents, or 31.1 million people, lacked health insurance when surveyed in the first six months of 2021, and the numbers have not gotten much better since then.

So now, to reduce uninsured rates and help increase access to healthcare coverage, some states are taking matters into their own hands: California, Connecticut, the District of Columbia, and Massachusetts are implementing strategies in an attempt to improve health equity for all. In addition, the Center for Medicare and Medicaid Services is trying to step up efforts to get everyone equal access to care.

What Is Health Inequity?

black scale with one side lower than the other — *Health inequity is still an issue in America.*

What do we mean when we say health inequity? This term refers to the non-clinical factors (often called the social determinants of health) that can affect health outcomes for people. Some examples of things that can affect health inequity include, but are not limited to:

Redlining, which can still be seen in limited financial, educational, or health resources
Limited career opportunities
Income disparities
Neighborhood safety
Access to nutritious food

According to the Robert Wood Johnson Foundation, “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

And while health inequity is different from health disparity, which refers to differences between health and healthcare between different groups, it is health inequity that leads to health disparities. So how can we address this issue, and are we actually doing so effectively anywhere in the country?

Addressing Health Equity

Researchers have found that health equity goals are similar in every state, but after collecting data, the above-mentioned states are the ones that are taking further steps to apply financial incentives to improve healthcare equity among different racial and ethnic groups. Each state tracked the health equity for underserved populations using the data to identify goals to help insure these populations, and these states came out on top.

But these states and Washington D.C. have come up against federal regulations regarding healthcare that have slowed some of their progress: federal law restricts deviation in plan design to an extent. For example, when the District of Columbia attempted to create an equity-based insurance design, the district was restricted on the changes it could make to cost-sharing due to federal regulations.

CMS Involvement

But, on the other hand, in order to try and create more health equity in the entire country, and not just these four states, the Centers for Medicare and Medicaid Services (CMS) is stepping up their efforts to get healthcare to those who need it most. CMS Administrator Chiquita Brooks-LaSure has charged each CMS office with building health equity into their core work, with the aim of better identifying and responding to inequities in health outcomes, barriers to coverage, and access to care.

According to cms.gov, this includes:

Promoting culturally and linguistically appropriate services to ensure respectful care and services in people’s preferred languages, as well as to promote health literacy.
Building on outreach efforts to enroll eligible people.
Expanding and standardizing the collection and use of data, including race, ethnicity, preferred language, sexual orientation, gender identity, disability, income, geography, and other factors across CMS programs.
Evaluating policies to determine how CMS can support safety net providers caring for underserved communities.
Ensuring engagement with, and accountability to, the communities served by CMS in regards to policy development and the implementation of CMS programs.
Incorporating screening for, and promoting broader access to, health-related social needs, including greater adoption of related quality measures, coordination with community-based organizations, and collection of social needs data in standardized formats.
Ensuring CMS programs serve as a model and catalyst to advance health equity through the nation’s healthcare system, including with states, providers, plans, and other stakeholders.

“Advancing health equity is the core work of the Centers for Medicare & Medicaid Services. We can’t achieve our health system goals until everyone can attain the highest level of health. That’s why I am inviting the healthcare industry to work alongside CMS as we transform the way patients are cared for in our country,” says CMS Administrator Chiquita Brooks-LaSure. “Health equity will be embedded within the DNA of CMS and serve as the lens through which we view all of our work. Our vision is clear and our goal is straightforward — we will not stop until every person has a fair and just opportunity to attain their optimal health.”

Let’s hope that we can achieve those goals!

CMS To Begin Medicare Audits: What This Means For Providers

In order to ensure that hospitals, clinics, and other healthcare providers are not being overpaid for Medicare services, CMS usually conducts on-going audits. However, CMS suspended most fee-for-service claim audits and medical reviews by Medicare Administrative Contractors (MACs) on March 30th of this year due to the coronavirus pandemic. Suspension continued through most of the summer, but the agency resumed auditing providers’ Medicare claims on August 3rd. CMS stated this summer that the audits will continue “regardless of the status of the public health emergency.”

The Audits That Have Been Resumed

CMS has resumed both prepayment and post-payment medical reviews conducted by:

The Medicare Administrative Contractors
The Supplemental Medical Review Contractors (SMRC)
The Recovery Audit Contractor (RAC)
Any contractors under the Targeted Probe and Educate (TPE) program

What This Means For Healthcare Organizations

As states began to reopen this summer, CMS made it clear that they did not expect to extend the enforcement discretion period for audits any longer. At this point, all organizations should be taking the appropriate steps to be prepared for an audit in case it happens, including notifying all staff involved. If an organization is selected for review and they have any hardships related to the pandemic, they can discuss them with their contractors.

doctors dressed head to toe with protective gear seeing an elderly man with a mask on. — *CMS indicated that hospice care providers will most likely be selected for audits.*

CMS noted that “auditors will be applying any waivers and flexibilities in place during the emergency period, otherwise all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements.”

According to CMS, hospices are among the most utilized Medicare services. Because of this, CMS indicated that hospice care providers will most likely be selected for audits. When they are selected, they will have a chance to speak with their contractor about any hardships in replying related to the pandemic.

Many hospice care providers are worried about getting through an audit during this difficult time, especially since being subject to one would redirect focus away from patients, families, and hospice caregivers. “Staff are already being pushed to the limits. We’re operating with constraints in terms of how we can access patients. We’re operating mostly virtually right now, which is cumbersome,” Peter Brunnick, president and CEO of Hospice & Palliative Care Charlotte Region told Hospice News. “To add the audit process, which would require getting staff in-house pulling records and sitting down with auditors, is counter to everything we’re doing now trying to be socially distant and practice safety.”

“We recognize that oversight, even in a pandemic, is important, and we have no patience or tolerance for fraud and abuse. On the other hand, asking a compliant provider to take time out of providing care to their population in the middle of a global pandemic is not the best idea,” said National Hospice & Palliative Care Organization President and CEO Edo Banach. “There is a lot of consternation out there about the possibility that individuals are going to be pulled out of the field into the office and sift through records at a time when really all hands are needed on deck.”

CMS claims that they are taking the pandemic into consideration while doing these audits, so that they will not interfere with healthcare providers providing care to those who really need it.

Beware This Faulty Medicare Tool!

The federal government designed a tool to help seniors navigate through all their possible Medicare choices. This was created for them to be able to choose their best option. There have been some bugs that needed to be fixed, so the Centers for Medicare and Medicaid Services, CMS, updated the Medicare Plan Finder tool in August. However, the tool is still currently giving seniors incorrect price estimates, and wrong coverage information.

older caucasian hands on the keyboard of a leptop — *The Medicare Plan Finder Tool is a tool on the Medicare.gov site that helps consumers navigate through Medicare plans and prices*

The Medicare Finder Tool

The Medicare Plan Finder Tool is a tool on the Medicare.gov site that helps consumers navigate through Medicare plans and prices before signing up. The tool was developed in 2005, but in August of 2019, it was revamped and redesigned.

The Issue With The Tool

Even with the revamp, Medicare beneficiaries have been just as confused as ever. The tool has been showing inaccurate premium estimates. Incorrect prescription drug costs, and inaccurate coverage costs. If a beneficiary chooses the wrong coverage due to the inaccurate information provided, it can cost them a lot of money for the whole year they are stuck with the plan until the next open enrollment.

Per ProPublica, a Medicare consultant in Wisconsin used the tool to research prescription drug plans for a client, and was shocked by the results. The consultant stated that when she searched for them, the comparison page showed all but one of her client’s medications would be covered. So the consultant dug deeper by clicking on “plan details” to find out which medication was left out. She then saw that the plan finder said all of the medications were covered.

She started checking the plans’ websites, and came across two versions of the same high blood pressure medication. One was covered, while the other was not. The difference in price was $2,700 a month.

In Nebraska, an insurance administrator flagged about 100 errors since she began working with the tool in October.

“Millions of people are going to be absolutely affected,” said Ann Kayrish, senior program manager for Medicare at the National Council on Aging. “And you hate to think about millions of people having the wrong plan. That’s kind of crazy.”

red sign with the words "wrong way" on it — *The Medicare Tool has been giving seniors the wrong information on coverage and prices.*

“It’s not like there’s one consistent problem that you can fix and then be addressed,” said David Lipschutz, associate director of the Center for Medicare Advocacy. “It’s really like a game of whack-a-mole.”

What You Can Do

CMS has spent $11 million dollars in order to revamp the tool. But the misinformation it gives is alarming, especially when seniors are struggling as it is to pay for Medicare costs and prescription drugs. Using the tool and enrolling into a plan that ends up costing a medicare beneficiary too much, they will struggle, and possibly end up with major financial issues.

The CMS is currently working on fixing the issues. In the meantime, if you are seeking Medicare advice, it would be best to contact a Medicare agent. A Medicare agent who is familiar with plans and their coverage can help guide you in a better, more accurate direction. EZ.Insure offers highly trained agents in your region that can offer you accurate quotes on plans available. If you would like to speak to an agent, call 888-753-7207 or email us at [email protected]. Or if you would like an instant quote, enter your zip code in the bar above.

Tag: CMS