FORCE advocates for families facing hereditary breast and ovarian cancer in areas such as access to care, research funding, insurance, and privacy.

Advocacy > Issues > Medicare Coverage of BRCA Testing Significantly Limited by New Policy

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FORCE spearheaded a stakeholder letter to HHS and CMS expressing concern about interpretation of a national policy which places significant limits on hereditary cancer genetic testing in the Medicare population.

FORCE joined 50 other orgs in an advertising campaign to stop the proposed changes to Medicare Part D’s Six Protected Classes.

We submitted comments on the Healthy People 2030 initiative asking that genomics goals are incorporated into the plan.

As a Friends of the Cancer Policy Institute member, FORCE provided comments on the International Pricing Index (IPI) Model for Medicare Part B Drugs.

Success! The EEOC removed the GINA regulations section allowing incentives/penalties to provide personal health information as part of an employer-sponsored wellness program.


Medicare Coverage of BRCA Testing Significantly Limited by New Policy

Genetic Testing & Counseling


January 2019 - A newly implemented Medicare policy is significantly curtailing BRCA genetic testing for cancer survivors. Medicare has discontinued coverage of germline genetic testing for beneficiaries who don’t have "recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer." In other words, people who have earlier stage cancers (stage I or II), those who have no evidence of disease or those who are “cured” no longer qualify for coverage of BRCA testing under Medicare. 

To provide the background, in late 2017 The Centers for Medicare & Medicaid Services (CMS) issued a “Proposed Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer.” We submitted comments in January and the National Coverage Determination (NCD) was finalized in March 2018. All indications were that the policy only applied to genomic tumor (somatic) testing, which is very different from hereditary (germline) testing. However, on November 30, 2018, CMS released a guidance which clarifies the rule, ultimately eliminating coverage of BRCA tests except in advanced cancer settings where the patient is seeking further treatment. Medicare is comprised of about a dozen local regions managed by Medicare Area Contractors (MACs); these tests have historically been covered by local coverage determinations (LCDs). The guidance indicates that the new NCD takes precedence over these local policies.

Restriction of hereditary cancer genetic test coverage to only Medicare beneficiaries with advanced cancer is short-sighted, and a step backward. We are actively exploring options to get a policy revision or clarification stating that hereditary/germline genetic testing is not included in the NCD. 

On January 31, 2019, we coordinated a stakeholder letter to Seema Verma, Administrator Centers for Medicare & Medicaid Services, signed by over 60 patient advocacy groups, health professional organizations, labs and other industry explaining why this interpretation of the NCD is faulty. A press statement on the issue was released on February 1.

Beyond that, FORCE supports BRCA counseling and testing for all Medicare beneficiaries who have a known BRCA mutation in their family or meet established guidelines for hereditary cancer risk assessment. Beneficiaries without a personal history of cancer have never qualified for coverage of BRCA testing under Medicare because the program is very specific about the preventive services it provides. We would like to change this. 

FORCE is working to introduce federal legislation that will change the Medicare statutes to allow for BRCA counseling, testing, and related evidence-based preventive and risk-reducing services for anyone who meets national guidelines—survivors and previvors.  

Check back frequently for updates on our efforts around this important coverage issue...

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