Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling
Genet Med. 2011 Dec;13(12):1045-50. doi: 10.1097/GIM.0b013e31822a8113.
Abstract
PURPOSE:
Coverage policies for genetic services for hereditary cancers are of
interest because the services influence cancer risk reduction for both
persons with cancer and their family members. We compared coverage
policies for BRCA genetic testing and genetic counseling among selected
payers in the United States to illuminate eligibility criteria variation
that may explain differential access by insurance type. We compared
these policies with policies for breast cancer screening with magnetic
resonance imaging to consider whether payers apply a unique policy
approach to genetic services.
METHODS:
We conducted a
case study of large private and public payers selected on number of
covered lives. We examined coverage policies for BRCA genetic testing,
genetic counseling, and screening with magnetic resonance imaging and
the eligibility criteria for each. We compared eligibility criteria
against National Comprehensive Cancer Network guidelines.
RESULTS:
Eligibility criteria for BRCA testing were related to personal history
and family history of cancer. Although private payers covered BRCA
testing for persons with and without cancer, the local Medicare carrier
in our study only covered testing for persons with cancer. In contrast,
Arizona's Medicaid program did not cover BRCA testing. Few payers had
detailed eligibility criteria for genetic counseling. Private payers
have more detailed coverage policies for both genetic services and
screening with magnetic resonance imaging in comparison with public
payers.
CONCLUSION:
Despite clinical guidelines
establishing standards for BRCA testing, we found differences in
coverage policies particularly between private and public payers. Future
research and policy discussions can consider how differences in private
and public payer policies influence access to genetic technologies and
health outcomes.
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