“My insurance said that the testing would be covered, so how did I end up getting a bill?”
Although I alluded to some of these issues in a previous post on the subject, I figured it would be worthwhile to spend a bit more time discussing some of the ins and outs related to health insurance coverage for genetic testing and genetic services. A Carnegie Mellon University study published in September 2013 found that 86 percent of Americans between the ages of 25 and 64 didn’t understand the fundamental concepts of any kind of health insurance. While I won’t be explaining all concepts related to health insurance, an insurance terminology dictionary can be helpful if you have additional questions which I don’t address here. And remember, insurance companies tend to have many different plans with different terms, so just because your plan is from Aetna or Cigna, you might have different benefits and financial responsibilities than others who use the same insurance company.
When it comes to your health insurance coverage, even though you pay monthly premiums, (ie. your monthly cost to have health insurance), you may still have other financial responsibilities whenever you receive medical services. Some of the most common financial responsibilities are co-pays, coinsurance, and deductibles.
The co-pay is typically the most understood concept, as it is fairly straightforward. Whenever you have a doctor’s visit or other medical service provided, you pay an amount which was previously set by your insurance company. This is usually somewhere between $10 – $50 depending on your specific policy and the type of services being provided.
However, some insurance companies expect you to pay a certain percentage of each visit cost. This is called a co-insurance, and it is typically represented as a percentage, as in, your co-insurance is 20%, which would mean that when you go to the doctor or have other medical services provided, you are responsible to pay 20% of what those services cost, while your insurance will cover the other 80%. Again, the specific percentage co-insurance that you are responsible for will vary based on your insurance company and plan.
Your deductible is basically the amount of money you need to pay towards your medical care before your insurance starts paying. This is often a very confusing concept for people to understand. So basically, you’ve just paid $500 per month for health insurance (for example) and you go to the doctor’s office, and you get a bill for the full cost of the visit! Isn’t that why you paid all that money for health insurance, so that the health insurance would pay for your doctor visits?? The answer is obviously yes, however, depending on your insurance policy, you may have a deductible and sometimes, they can be very high! If for example your deductible is $2,000, that means that you need to pay out of pocket, for the first $2,000 of your medical care (doctors visits, lab tests, etc). Once you pay that $2,000, then your insurance will start paying for your medical services, under the terms of your plan, ie- you may need to pay the $2,000 towards your own medical care, and then once your deductible is met, since you have a 20% co-insurance, so your insurance company will cover only 80% of the cost of services you receive.
So when you come in for genetic testing, and you call your insurance company to find out if your testing will be covered, they might tell you that the testing is a covered service, as in, yes, your insurance covers it in general, but they aren’t necessarily explaining how much you may be responsible for because of your deductible, co-insurance, and co-pays. If you have not yet met your deductible, and your deductible is $5,000, you might get a bill for all of the services provided up until $5,000. If you’ve met your deductible, or you don’t have one, but your co-insurance is 30%, you might still get a hefty bill for your genetic testing, because as I explained before, genetic testing is unfortunately very expensive.
If you are having genetic testing (or really any medical services), it is worthwhile to speak to your insurance company and ask them about the specific terms of your plan. Armed with this new knowledge about co-pays, co-insurance, and deductibles, you are now better informed and capable of having a good understanding about your financial responsibility for genetic testing. Trust me, your medical providers do not want you to end up with large and unexpected bills either.
As boring as it may seem, I actually get asked this question ALL THE TIME. Both by patients and also while giving talks in the community. People get very excited about the possibility of using genetic testing in their own lives, but wonder, how affordable is it really?
Here are a few things that I’ve learned over the years, which may help you navigate that big wide world of insurance coverage for genetic testing. (Use this helpful insurance terminology dictionary to help you through the post!)
Most of the time, genetic testing is treated like any other lab test. When the lab bills your insurance company, most of the time the genetic testing is covered the same way other lab tests would be covered. You may be responsible for your co-insurance and deductible. This differs by insurance policy! You should find out what your insurance’s policy is! Now, when your doctor checks your cholesterol, if that test costs $60, even if you are responsible for 30% of the cost, your “out of pocket” charge is not so significant. Genetic testing on average costs anywhere from a few hundred dollars per test, to thousands of dollars per test. So even if your insurance “covers” the testing, your co-insurance or deductible may leave you responsible for a large amount of money.
Now, there are a few exceptions to this:
Exception 1: Your insurance has a policy whereby it does not cover ANY genetic testing. This is not very common, but some insurance policies state straight out, that they do not cover ANY genetic testing under any circumstances. I have seen these policies before. If you are considering undergoing genetic testing, you should call your insurance company and ask if they have any specific policies about genetic testing. Typically they can direct you to the policy on their website so that you can read through it. Nowadays, as genetic testing becomes more commonplace, more insurance companies are developing genetic testing policies about what they will and will not cover, so it is worthwhile to look into this for your specific insurance plan!
Exception 2: Your insurance will only cover genetic testing if the correct “indication” or “code” is provided. Genetic testing is conducted in a medical model (even if it doesn’t always seem that way!) This means that it is ordered by a medical professional because of a certain indication. So in order for your insurance company to actually agree to covering the genetic test, the correct indication need be provided! For example, if you want to have genetic testing for Marfan syndrome, but you don’t have any of the signs or symptoms of this genetic disease, your insurance company will likely not cover the testing because there is no “indication” for it. For specific tests you may need to meet the “testing criteria” in order for your insurance company to cover the test.
Exception 3: Your insurance will only cover genetic testing if it is done at an “in network lab” Many insurance companies want you to use specific labs when you have your testing done. This may be easy for having your cholesterol checked (as that is a common test) however because genetic tests are unique, there may only be one or two labs in the country who do the testing that you need. So your insurance might cover your testing if it was done at Lab A, but Lab A doesn’t offer that test, it is only offered at Lab Q which is both out of state, and out of your insurance’s network.
Unless you’ve had to muddle through insurance policies and medical bills, a lot of this may seem new to you. The truth is, they don’t even teach us this stuff in school! Insurance issues tend to be one of those things you learn “on the job” as a genetic counselor (and one of the things you keep on learning as the field changes). It is definitely worthwhile for you to research your own health insurance plan’s benefits and your financial responsibilities, so you don’t have any surprises when it comes to your medical bills and insurance coverage.