Is Genetic Testing Covered By Insurance?
Insurance covers some genetic tests, such as BRCA tests for breast cancer, if you meet certain requirements.
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But there are about 70,000 different genetic tests available, and insurance coverage depends on your plan and specific medical needs. It's always smart to check with your insurance before getting a genetic test, just so you're prepared for the cost if you don't have coverage.
Does insurance cover genetic testing?
Health insurance often covers genetic testing, but it depends on the test, your medical needs and your specific insurance plan.
For example, insurance plans are required to cover genetic counseling and testing for BRCA gene mutations in women, which are associated with a higher risk of several types of cancer, including breast cancer. But not everyone qualifies for coverage. Your doctor has to run you through a screening tool first.
Then, depending on how you score on the screening, you'll have coverage for genetic counseling without having to pay anything. If the counseling confirms that you should be tested for a BRCA mutation, your insurance has to cover a BRCA mutation test at no cost to you.
The best way to find out what your plan covers is to call your insurance company. If your doctor recommends a genetic test, make sure you understand what the test is and why you need it. It could be especially helpful to get the billing code, called a Current Procedural Terminology (CPT) code, associated with the test. Give all the information to your insurance company so they can check the details of your plan to see if you're covered and what you'll have to pay yourself.
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Will insurance cover genetic testing during pregnancy?
Health insurance often covers some prenatal genetic tests. However, just like with testing outside of pregnancy, coverage depends on your plan and medical needs. Talk to your company first if you're concerned about coverage or costs.
- Noninvasive prenatal testing (NIPT): NIPT uses your blood to check the likelihood that your baby has certain chromosomal disorders, such as Down syndrome. Insurance generally covers NIPT.
- Chorionic villus sampling (CVS): CVS testing checks your baby's placenta for signs of genetic conditions such as cystic fibrosis, sickle cell disease and Tay-Sachs disease. Insurance often covers CVS if it's recommended by your doctor because of your age or health.
- Amniocentesis: Amniocentesis uses a sample of your baby's amniotic fluid to check for various genetic conditions, including Duchenne muscular dystrophy and spinal muscular atrophy. Just like with CVS testing, insurance usually covers amniocentesis if your doctor says that it's necessary.
How much does genetic testing cost?
Genetic testing can cost anywhere from $100 to $2,000 or more for each test.
Costs depend on the exact type of test you need and the complexity of the test and analysis. If you have insurance, your cost depends on the specifics of your plan. If a test isn't covered or you haven't yet met your deductible for the year, you'll likely pay the full cost yourself. But your bill might be reduced if you've already hit your deductible or if your insurance company negotiates a discounted rate. In some cases, such as for women who meet the requirements for BRCA gene testing, you may not pay anything.
How to find out if your insurance covers genetic testing
Before you get a genetic test done, it's a good idea to check your insurance coverage, just so you're aware of your coverage specifics and the amount you might have to pay.
Find out why you need a genetic test. Health insurance only pays for things that are "medically necessary." Have a conversation with your doctor about your health, so you understand why they're recommending a genetic test. Having your doctor write a letter to your insurance company explaining why a test is necessary can also be helpful.
Ask your doctor for the billing code, called a CPT code. When your doctor bills medical care to your insurance company, they use a code called a CPT (Current Procedural Terminology) code to show what kind of medical care was provided. Before you get your genetic test, find out what the CPT code is. Your doctor may not have this information, but someone at the medical practice, such as the billing department, should. If you have the code when you call your insurance company, there's a better chance that they'll be able to tell if the test is covered.
Call your insurance company. Now that you have an understanding of why you need a genetic test and the specific CPT code for that test, call your insurance company and ask them to check your coverage. They should be able to check the code against the details of your plan to confirm if you have coverage. They can also look at your plan's features, such as your deductible and out-of-pocket maximum, to estimate how much you could have to pay.
Unfortunately, a conversation with your insurance company doesn't guarantee you'll have coverage. Coverage is officially approved or denied after you get the test and the insurance company gets the bill. But if you document your conversation, you'll have more info in case you need to file an appeal for a denied claim.
What to do if your insurance doesn't cover your test
If insurance doesn't cover the cost of your genetic test, you have to pay for the full cost yourself.
This is why it's so important to check with your insurance before getting a test, even a necessary one. That way, you won't be surprised by the bill and you can prepare.
- Budget and save. If you can, take some time to budget and save for your test. When you have the money ready, you can get your test, knowing you can pay for it without stress.
- Consider a payment plan. If you need your test right away and don't have time to save, or if your test is too expensive to reasonably save for, talk to the billing department at your doctor's office about a payment plan. Many doctors and hospitals offer payment plans and even financing that can help you handle large medical bills. Just make sure you understand the terms of the agreement.
- See if you can order the test yourself. You can order some genetic tests yourself and do them at home. They usually use your saliva or a small amount of blood to check for certain genetic issues. However, these tests do come with some privacy concerns about how the company uses your data. You should also make sure your doctor will accept the results and that you choose a reputable company.
Frequently asked questions
Will my health insurance cover genetic testing?
It depends on the specific test you need, your medical situation and your plan. For example, if you're a woman and have a family history of some cancers, insurance will pay for genetic counseling and testing for BRCA gene mutations if you meet certain other requirements. If you need a genetic test, get the details from your doctor and talk to your insurance company first so you understand your coverage.
Why would insurance deny genetic testing?
Insurance might deny genetic testing if it wasn't considered medically necessary or if the plan specifically says it doesn't include that coverage. For example, insurance has to cover testing for BRCA gene mutations in some women with a family history of certain cancers. But not everyone has coverage
How much does genetic testing cost?
Genetic testing can cost anywhere from $100 to $2,000 or more per test. Your costs will depend on the exact test you need and your insurance plan details. If you don't have insurance coverage and can't afford the test otherwise, talk to your doctor's office about payment plan options or see if you can order an at-home test from a good company.
Sources
Info about genetic testing, costs and legal requirements comes from Cleveland Clinic, KFF, MedlinePlus, the National Human Genome Research Institute and the University of California San Francisco.
Editorial note: The content of this article is based on the author's opinions and recommendations alone. It has not been previewed, commissioned or otherwise endorsed by any of our network partners.
