Medicare Expands Cancer Gene Testing and Preventive Surgery Coverage Under New Act

If you or someone in your family has a history that screams "inherited cancer risk," this new legislation, the Reducing Hereditary Cancer Act, is a big deal. It essentially tells Medicare to stop waiting for cancer to show up and start covering the preventative steps needed to catch it early or avoid it altogether. This is about making proactive health management affordable for those covered by Medicare.

The Fine Print on Getting Tested

The most immediate change is that Medicare must now cover germline mutation testing—that’s the genetic testing that looks for inherited cancer risk—if you have a personal or family history that makes a doctor suspicious (Sec. 2). Think of it like this: If your family tree has multiple branches marked by the same type of cancer, Medicare will now pay for the test that tells you if you carry the gene mutation responsible.

Here’s the catch, and it’s a necessary one: the testing has to follow established, evidence-based clinical practice guidelines from major cancer groups. They want to make sure you’re getting the right test, not just any test. Interestingly, if different expert groups have conflicting guidelines, the Medicare contractors are required to use the least restrictive one. This is good news for patients, as it pushes coverage toward the widest possible access. However, be aware that you generally only get one shot at this coverage: the bill states testing will not be covered more than once for the same individual based on the same qualifying history (Sec. 2).

Coverage for Risk-Reducing Surgeries

For those who test positive for a high-risk mutation—like the BRCA genes—the bill addresses a major cost hurdle: preventive surgery. If a doctor determines that a specific surgery will lower your risk of getting cancer, Medicare will now cover it. The bill explicitly changes the rules to consider these risk-reducing surgeries "reasonable and necessary" for treating an illness (Sec. 3). This means procedures like prophylactic mastectomies or oophorectomies, which dramatically reduce cancer risk in high-risk individuals, should now be covered without the bureaucratic fight that often accompanies preventive care.

More Frequent Screening for High-Risk Individuals

Perhaps the most practical relief for people already diagnosed with a hereditary cancer gene mutation is the change to screening frequency. Right now, Medicare often limits how often you can get certain screenings, like mammograms or colonoscopies. If you have a high-risk mutation, those standard limits are often insufficient. This Act requires the Secretary of Health and Human Services to lift those frequency limits for high-risk individuals (Sec. 4).

This means if clinical guidelines recommend you get a screening MRI every six months instead of annually, Medicare has to cover it. The bill specifies that expanded screenings must be done at least once a year, but can be more frequent based on expert guidelines. This is a huge win for cancer surveillance, ensuring that people living with known high risk can monitor their health at the pace science recommends, not the pace bureaucracy dictates.