Does Medicare Cover Genetic Counseling?

By Gina Coniglario 

Currently, the answer is yes… but ironically, not when provided by the healthcare providers who are specifically trained and certified in clinical genetics!

Passage of H.R. 3235 would mean Medicare recognition of certified genetic counselors as healthcare providers and reimbursement for their services. 

Decreasing costs of genetic testing have led to an expanding number of genetic testing options and greater accessibility to genetic testing for many individuals. With increased availability of genetic testing comes increased demand for affordable and accessible genetic counseling. Many of those in need of genetic counseling services rely on insurance to cover the cost, just as most of us rely on insurance to cover the cost of other healthcare services. 

Medicare currently covers 44 million Americans, and this number is projected to grow to 79 million by 2030. Although genetic counseling is a covered benefit under Medicare, The Centers for Medicare and Medicaid Services (CMS) does not currently recognize certified genetic counselors as healthcare providers. This means that currently, certified genetic counselors cannot independently bill for and be reimbursed for counseling Medicare beneficiaries, unlike physicians who are able to bill and be reimbursed for genetic counseling services. H.R. 3235 would change this. 

In October of 2018, two members of the House of Representatives introduced H.R. 7083, the “Access to Genetic Counselor Services Act of 2018.” This act would have authorized CMS to recognize certified genetic counselors as healthcare providers. While this bill never made it past the House floor, the introduction of this bill was still seen as progress. In June of 2019, the same representatives re-introduced the amendment, this time under H.R. 3235, the “Access to Genetic Counselor Services Act of 2019. H.R. 3235 would allow genetic counselors to receive 85 percent of what physicians receive for providing genetic counseling services, includes updated CPT codes for billing purposes, and has an effective date of January 1, 2020.

What qualifications does a certified genetic counselor have?

Genetic counselors are healthcare professionals with training in both human medical genetics and counseling. Genetic Counselors have Masters of Science degrees in Human Genetics and pass a national board exam to become Certified Genetic Counselors (CGC). Programs in the U.S. and Canada are accredited by the Accreditation Council for Genetic Counseling (ACGC).  

Similar to other healthcare providers, genetic counselors are required to maintain their certification through continuing education. Knowledge of clinical genetics among physicians and other ordering-level healthcare providers, on the other hand, varies widely, and many physicians who can bill and be reimbursed for genetic counseling services may not have the knowledge base to effectively provide genetic counseling services to their patients. Physicians who would like to refer their Medicare patients to a genetic counselor, however, run into the problem of lack of reimbursement by Medicare for these services. 

Are genetic counselors licensed healthcare providers?

Twenty-two states currently issue licenses for genetic counselors. Seven other states have passed bills to license genetic counselors which are currently in rulemaking. There are ongoing efforts in most other states to lobby for licensure of genetic counselors. The NSGC website provides information about the status of licensure of genetic counselors in different states

Licensure requirements generally include both a master’s degree from an ACGC-accredited program and certification by the American Board of Genetic Counseling, usually obtained by passing the national ABGC certification exam. While most genetic counselors are certified by ABGC, in the absence of a state licensure requirement, certification is not legally required to practice as a genetic counselor. 

H.R. 3235 would provide reimbursement of services provided by licensed genetic counselors or, in states where there is not currently licensure of genetic counselors, by certified genetic counselors.

Expanding access to genetic counselors is estimated to Lower healthcare costs

Many studies have shown that the involvement of genetic counselors significantly lowers healthcare spending, helping to avoid unnecessary genetic testing and related medical expenses. Genetic counselors are more likely than non-genetics professionals to recommend more appropriate and targeted genetic testing. By some estimates, the involvement of certified genetic counselors in ordering genetic testing could lead to a projected $4 billion in potential Medicare savings over a decade.

As genetic counselor licensure laws have continued to pass in recent years, the trend has been for a licensed genetic counselor’s scope of practice to include ordering genetic testing. In many states with genetic counselor licensure laws, however, this is a gray area. (Only one state, Pennsylvania, specifically disallows ordering of genetic tests by genetic counselors, without the involvement of another healthcare provider.) This means that even when a physician would like to refer their patients to a genetic counselor and defer to them regarding genetic testing recommendations, genetic testing may still need to be ordered under the name of the referring physician, or under the name or another physician. Depending on the state, genetic testing may also be ordered by a nurse practitioner or a physician’s assistant. Many genetic counselors working in hospital settings routinely order genetic testing under a physician’s name who may have no involvement with genetic counseling of the patient or lab or test selection.

H.R. 3235 is only one step in recognizing genetic counselors as independent healthcare providers, but it has the potential to meaningful impact millions of Medicare beneficiaries. 

What Can You Do To Help?

Contact your Congressional Representative to voice your support for H.R. 3235! 

Not sure who your representative is or how to contact them? NSGC has created draft emails that can be personalized to make this as easy as possible. Entering your address will automatically address your email to the correct representative. 

Further Reading & Quality News Coverage

H.R.3235 – Access to Genetic Counselor Services Act of 2019. Bill introduced to the house June 12, 2019.
“National Society of Genetic Counselors Supports Access to Genetic Counselor Services Act.” June 14, 2019. Press Release. National Society of Genetic Counselors.
NSGC FAQ on CMS Recognition of Genetic Counselors
Genetic Counseling Medicare Payment Bill Introduced in Congress.” Genome Web. June 17, 2019. 
Sturm, Amy. “Improving Access to Genetic Counselors under H.R. 3235, the ‘Access to Genetic Counselor Services Act’ of 2019.” June 27, 2019. Guest blog post. American Society of Human Genetics.
Gustafson, Shanna.Support for the Genetic Counselor Services Act of 2019. June 27, 2019. Blog post, Informed DNA.
Sutphen, Rebecca. “How Medicare coverage of genetic counseling could decrease care costs and improve quality.” Medical Economics. December 26, 2018. 
Richardson, John. H.R. 7083, the ‘Access to Genetic Counselor Services Act.’” October 26, 2018. Advocate Newsletter
“Projecting the Supply and Demand for Certified Genetic Counselors: A Workforce Study.” September 7, 2016. 
More general information on genetic counseling

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