Ask the cancer genetics team: insurance coverage


Q: Will my insurance company pay for genetic testing?

A: The short answer to this question is yes; most likely your insurance company will provide coverage for genetic testing.

Patients with private insurance: Most private insurance companies cover the cost of genetic testing. Some insurers have specific criteria in place to determine who is covered for certain types of genetic testing and may or may not require pre-authorization for testing. The tests themselves are billed directly from the laboratory that runs the tests. Many labs will contact patients directly if their out-of-pocket expenses exceed a certain dollar amount (usually over $300-$400) prior to starting the test. You can then choose whether or not you would like to move forward with testing. If you choose to cancel the test, the laboratory will usually not charge you a penalty.

Exclusions on genetic testing: While most group plans do cover genetic testing at some level, some self-insured plans have exclusions on genetic testing.

Patients with Medicare: Medicare will provide coverage for genetic testing to any patient who has had a related cancer diagnosis themselves and meets certain family history criteria. Your health care provider may be able to tell you at the time of your visit whether Medicare is likely to provide coverage.

Patients with Medicaid: Some, but not all genetic tests, are covered by Medicaid plans. This will vary depending on the state from which you receive your insurance benefits, what testing is being ordered, and your personal and/or family history. Some Medicaid plans require a pre-authorization for testing. Your health care provider may be able to tell you whether Medicaid is likely to provide coverage.

If your insurance denies payment, we may be able to assist you in making an appeal. If testing is not covered, is considered medically necessary, and is a financial hardship, there may be other funding sources that could help cover part or all of the cost of testing. However, in some situations, the entire cost of the test will be out of pocket.

We encourage you to contact your insurer to determine what kind of coverage your plan has for genetic testing. The cost of testing can vary from a few hundred dollars to several thousand dollars, so it is important to be aware of your coverage level prior to starting the test.

Insurance terms:

Deductible: The amount you owe for covered health care services before your health insurance or plan begins to pay.

Co-payment: A fixed amount (for example, $15) you pay for a covered health care service. This is usually due at the time you receive care.

Co-insurance: Your share of the costs of a covered health care service. Co-insurance amounts are usually stated as percentages; the most common of which is 80/20. What this means is that your insurance company will cover 80 percent of the medical expenses (cost), while you will be responsible for 20 percent of the medical expenses.

Pre-authorization: Documentation received from the insurance company indicating that a treatment or testing claim will be paid by the company.

Balance billing: In some instances, your insurance company will not reimburse the total cost of a treatment or test ordered by a physician. In this case, the physician or hospital may bill you for the difference between the amount your insurance pays them and the total amount.


 
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  • Ask the Cancer Genetics Team

    • Do you have questions about genetic testing or are you wondering if you or someone in your family is at greater risk of developing cancer? Our cancer genetics team can help answer your questions.