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Advocacy > Issues > Medicare Expands Genetic Services Coverage in Some Regions

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Medicare Expands Genetic Services Coverage in Some Regions

Insurance Coverage & Barriers

Overview

Medicare operates on a regional system in which Medicare Area Contractors (MACs) manage the provision of health services for a specific jurisdiction. In the spring of 2015, four MACs--Palmetto, Noridian (Area JF), Noridian (Area JE), and CGS--proposed Local Coverage Determinations (LCDs) that expand and better align their services with National Comprehensive Cancer Network (NCCN) guidelines in a number of important areas, including:

  • Expanding coverage of genetic testing for individuals who have or had cancer consistent with hereditary cancer syndromes, including men and those who are affected by prostate and pancreatic cancer,
  • Coverage of multigene testing panels if more than one mutation may be indicated, and
  • Clarification of the BRCA testing policy for use of the targeted therapy, Lynparza (olaparib).

The draft LCDs were identical so FORCE submitted indistinguishable comments to each of the MACs. Read FORCE's comments submitted to Palmetto in July 2015. The majority of changes were accepted and made final. The LCDs apply to services performed on or after October 5, 2015.

It is important to note that these policy changes apply only to states covered by these MACs:
Arkansas, Arizona, California, Hawaii, Idaho, Kentucky, Montana, Nevada, North Carolina, North Dakota, Ohio, Oregon, South Carolina, South Dakota, Utah, Virginia, Washington, West Virginia and Wyoming

FORCE is encouraging other Medicare Area Contractors to follow suit, bringing all Medicare recipients improved access to genetic services. Two key Medicare coverage issues remain unaddressed:

  • Coverage of genetic counseling and testing for unaffected carriers/previvors. The Centers for Medicaid & Medicare Services (CMS) maintains that its mandate does not permit coverage of genetic testing for individuals who have not had cancer
  • Medicare recognition of genetic counselors as providers. While medical doctors such as oncologists and geneticists are approved Medicare providers, CMS indicated that recognition of genetic counselors as providers would require statutory change

FORCE continues to advocate for these issues to be addressed and will provide updates as they become available.

Advanced Reading

  • Medicare Rights Center, a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.
  • Center for Medicare Advocacy, a national nonprofit, nonpartisan law organization that provides education, advocacy and legal assistance to help older people and people with disabilities obtain fair access to Medicare and quality health care.
  • Medicare – What is a MAC? 
  • Medicare Jurisdiction Map 

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