Reimbursement for Genetic Testing

Genetic testing may be necessary for many reasons, including for preventive, reproductive, or life planning measures.You may be reluctant to have these tests done because your insurance provider might not cover the costs and you don’t want to pay out-of-pocket. Ultimately, genetic testing can be very important in figuring out a health condition, and it’s important for you to do everything that you can to maximize your health.

The Affordable Care Act (ACA), a law that was passed in 2010, defines certain health services as "Essential Health Benefits," which must be covered by all health plans.  What is actually covered may vary by state as some states already require coverage of the federally mandated services. 

Check with your provider to see how this provision may impact coverage of your genetic tests. Even though all necessary and actionable genetic tests might not be covered by every plan, you can learn about what your plan covers or how you can go about the reimbursement process.

Here are some facts about current coverage and reimbursement policies:

• Coverage decision-making is the process that health insurance plans and purchasers go through to figure out which services will be covered and in which situations the providers (such as doctors or genetic counselors) will be reimbursed for the services.
   
• The coverage decision-making process also happens when someone submits a claim for reimbursement or a request for preauthorization for the services is submitted.
   
• Public insurance plans vary from plan to plan on what they cover, however most cover the following:
  • Genetic testing for chromosomal abnormalities
  • Prenatal and neonatal diagnosis
  • In some cases, preimplantation genetic diagnosis (e.g., advanced maternal age, suspected fetal anomaly, or history of miscarriage or developmental problems in prior pregnancies)
• Some plans have specific rules for certain conditions such as:
• • Hereditary cancer testing
  • Cystic fibrosis
  • Tay-Sachs disease
  • Hereditary hemochromatosis
• Evidence-based coverage of genetic tests is when the health insurance plan looks at the test’s accuracy and if there is a treatment in order to determine if it will be cost effective to cover the genetic test.

The most important thing that you can do is to talk to your health insurance company about which tests and counseling they cover or will reimburse, and under what circumstances they will cover these services. Your provider also may be able to help guide you through insurance coverage and reimbursement process.