Understanding Insurance Coverage
for Genetic Counseling and Genetic Testing

Understanding Insurance Coverage
for Genetic Counseling and Genetic Testing

What is the difference between genetic counseling and genetic testing?

Genetic counseling is a type of healthcare performed by a genetic counselor, a healthcare provider with training in genetics and counseling. The role of a genetic counselor is to evaluate the risk of a hereditary, or genetic, condition in a family and provide information and support to those affected by or at risk for a genetic disorder. In addition, they often discuss the option of genetic testing and help patients determine what testing option is right for them. Genetic counseling appointments may be covered by insurance but you may have an out of pocket cost for the appointment if you have an unmet deductible or there is a co-pay.

Genome Medical provides genetic counseling sessions for a variety of indications. These may include a personal or family history of cancer, neurologic or cardiac conditions, preconception or prenatal testing, a pediatric patient with a concern for an underlying syndrome, individuals interested in proactive/healthy screening, an individual wanting or recommended to undergo pharmacogenetic testing, or a personal or family history of other genetic conditions. Genome Medical is not a genetic testing laboratory but rather a medical practice which may recommend and/or order tests from various laboratories depending on a patient’s unique medical history.

For more information on Genome Medical’s specific billing policy, visit https://www.genomemedical.com/payment-options-for-a-genetic-counseling-session/.

Genetic testing is a type of medical test that can identify changes, also called variants, in your DNA. It is done by qualified laboratories and is ordered by a healthcare provider. Examples of genetic testing laboratories include Ambry, Invitae, and Myriad.

The costs of genetic testing are not included in a genetic counseling appointment. Once a genetic testing laboratory receives the order, they will bill your insurance provider. Many insurance companies cover the costs of genetic testing, especially if you meet their criteria for genetic testing. However, as with genetic counseling, you may have out-of-pocket expenses if you have not met your deductible or if there is a co-pay.

deductible

  • The amount of money a patient is responsible for paying for healthcare services before insurance will begin to cover these costs.

co-pay (copayment)

  • An amount paid by a patient for a healthcare service which is covered by insurance. Co-pay amounts are determined by insurance companies.

CPT code

  • CPT stands for “Current Procedural Terminology.” These are codes which describe a healthcare procedure or service, such as a visit to a medical provider, a laboratory test, or a procedure such as surgery.

ICD-10 code

  • ICD-10 stands for “International Classification of Diseases, 10th edition.” These are codes which describe a patient’s diagnosis or symptoms.

benefit investigation

  • A benefits investigation is a process by which a medical provider determines if a medical service will be covered by your insurance plan.

in-network

  • In-network providers have a contract with your insurance company to accept your insurance and provide services at specific rates.

out-of-network

  • Out-of-network providers have no pre-existing contract with your insurance company. If you see an out-of-network provider or use an out-of-network laboratory, you may be responsible for paying the full cost of the services or a higher amount than you would have with an in-network provider.

prior authorization

  • Prior authorization is a requirement that your health insurance approves a medical service before it takes place. Prior authorization for genetic testing may involve meeting with a genetic counselor to determine if you meet testing criteria or to make sure that the appropriate genetic test was ordered. Prior authorization is also called preauthorization, precertification, or prior approval.

explanation of benefits (EOB)

  • An explanation of benefits is a document your insurance company sends summarizing the total cost of a medical service, the amount covered by insurance, and an estimation of the amount you will need to pay. An EOB is not a bill! Bills will be sent by the medical provider or testing laboratory after they have billed your insurance.

What is the difference between genetic counseling and genetic testing?

Genetic counseling is a type of healthcare performed by a genetic counselor, a healthcare provider with training in genetics and counseling. The role of a genetic counselor is to evaluate the risk of a hereditary, or genetic, condition in a family and provide information and support to those affected by or at risk for a genetic disorder. In addition, they often discuss the option of genetic testing and help patients determine what testing option is right for them. Genetic counseling appointments may be covered by insurance but you may have an out of pocket cost for the appointment if you have an unmet deductible or there is a co-pay.

Genome Medical provides genetic counseling sessions for a variety of indications. These may include a personal or family history of cancer, neurologic or cardiac conditions, preconception or prenatal testing, a pediatric patient with a concern for an underlying syndrome, individuals interested in proactive/healthy screening, an individual wanting or recommended to undergo pharmacogenetic testing, or a personal or family history of other genetic conditions. Genome Medical is not a genetic testing laboratory but rather a medical practice which may recommend and/or order tests from various laboratories depending on a patient’s unique medical history.

For more information on Genome Medical’s specific billing policy, visit https://www.genomemedical.com/payment-options-for-a-genetic-counseling-session/.

Genetic testing is a type of medical test that can identify changes, also called variants, in your DNA. It is done by qualified laboratories and is ordered by a healthcare provider. Examples of genetic testing laboratories include Ambry, Invitae, and Myriad.

The costs of genetic testing are not included in a genetic counseling appointment. Once a genetic testing laboratory receives the order, they will bill your insurance provider. Many insurance companies cover the costs of genetic testing, especially if you meet their criteria for genetic testing. However, as with genetic counseling, you may have out-of-pocket expenses if you have not met your deductible or if there is a co-pay.

deductible

  • The amount of money a patient is responsible for paying for healthcare services before insurance will begin to cover these costs.

co-pay (copayment)

  • An amount paid by a patient for a healthcare service which is covered by insurance. Co-pay amounts are determined by insurance companies.

CPT code

  • CPT stands for “Current Procedural Terminology.” These are codes which describe a healthcare procedure or service, such as a visit to a medical provider, a laboratory test, or a procedure such as surgery.

ICD-10 code

  • ICD-10 stands for “International Classification of Diseases, 10th edition.” These are codes which describe a patient’s diagnosis or symptoms.

benefit investigation

  • A benefits investigation is a process by which a medical provider determines if a medical service will be covered by your insurance plan.

in-network

  • In-network providers have a contract with your insurance company to accept your insurance and provide services at specific rates.

out-of-network

  • Out-of-network providers have no pre-existing contract with your insurance company. If you see an out-of-network provider or use an out-of-network laboratory, you may be responsible for paying the full cost of the services or a higher amount than you would have with an in-network provider.

prior authorization

  • Prior authorization is a requirement that your health insurance approves a medical service before it takes place. Prior authorization for genetic testing may involve meeting with a genetic counselor to determine if you meet testing criteria or to make sure that the appropriate genetic test was ordered. Prior authorization is also called preauthorization, precertification, or prior approval.

explanation of benefits (EOB)

  • An explanation of benefits is a document your insurance company sends summarizing the total cost of a medical service, the amount covered by insurance, and an estimation of the amount you will need to pay. An EOB is not a bill! Bills will be sent by the medical provider or testing laboratory after they have billed your insurance.

How do I know if my insurer will pay for genetic counseling or genetic testing?

It is always advisable to contact your insurance provider directly for details about potential coverage of both genetic counseling and genetic testing or with questions regarding your specific plan’s deductibles or co-pays as each insurance company has its own policies regarding their covered benefits. Your insurance company should be able to explain if a given service, be it genetic counseling or genetic testing, will be paid for by your insurance or if the cost of it will be applied to your deductible.

When you contact your insurance company, you may need to provide CPT and ICD-10 codes. These are codes which describe medical procedures and symptoms. Insurers look for the correct combination of ICD-10 and CPT codes to determine if they will cover a medical procedure or not. All medical providers and insurance companies use the same ICD-10 codes and CPT codes. However, there are many different CPT codes for genetic testing and different testing laboratories will use different codes. If you need the CPT codes associated with genetic counseling, please contact Genome Medical.

Another option is to ask that the testing laboratory verify your health insurance coverage by doing a benefit investigation. This is a process to determine if your health insurance will cover a medical service, in this case genetic testing, and if you will have any out-of-pocket costs. Some testing laboratories do this automatically while others may do it if asked.

It is important to check if the provider or laboratory is in-network with your insurance provider. In-network providers have an agreement with an insurance company to provide services to its members at a specific rate. While you can still get medical services from an out-of-network provider, your insurance plan may not cover the costs of the service or you may have out of pocket costs. You can contact your health insurer to find in-network genetic counselors in your area and to learn which testing laboratories they partner with.

For a list of insurance companies Genome Medical is in-network with, see https://www.genomemedical.com/insurance-coverage/. Please note that Genome Medical does not currently accept Medicaid or Medicare as a primary insurance at this time.

How do I know if my insurer will pay for genetic counseling or genetic testing?

It is always advisable to contact your insurance provider directly for details about potential coverage of both genetic counseling and genetic testing or with questions regarding your specific plan’s deductibles or co-pays as each insurance company has its own policies regarding their covered benefits. Your insurance company should be able to explain if a given service, be it genetic counseling or genetic testing, will be paid for by your insurance or if the cost of it will be applied to your deductible.

When you contact your insurance company, you may need to provide CPT and ICD-10 codes. These are codes which describe medical procedures and symptoms. Insurers look for the correct combination of ICD-10 and CPT codes to determine if they will cover a medical procedure or not. All medical providers and insurance companies use the same ICD-10 codes and CPT codes. However, there are many different CPT codes for genetic testing and different testing laboratories will use different codes. If you need the CPT codes associated with genetic counseling, please contact Genome Medical.

Another option is to ask that the testing laboratory verify your health insurance coverage by doing a benefit investigation. This is a process to determine if your health insurance will cover a medical service, in this case genetic testing, and if you will have any out-of-pocket costs. Some testing laboratories do this automatically while others may do it if asked.

It is important to check if the provider or laboratory is in-network with your insurance provider. In-network providers have an agreement with an insurance company to provide services to its members at a specific rate. While you can still get medical services from an out-of-network provider, your insurance plan may not cover the costs of the service or you may have out of pocket costs. You can contact your health insurer to find in-network genetic counselors in your area and to learn which testing laboratories they partner with.

For a list of insurance companies Genome Medical is in-network with, see https://www.genomemedical.com/insurance-coverage/. Please note that Genome Medical does not currently accept Medicaid or Medicare as a primary insurance at this time.

What happens after a genetic test is ordered?

Once the genetic testing laboratory receives your order, the laboratory’s billing department will contact your health insurance. Again, many testing laboratories will conduct a benefit investigation to verify insurance coverage automatically and will contact you if they determine you will have to pay for all or part of the test. These laboratories may offer a self-pay price and allow you to switch to this option if your costs through insurance are too high.

Your insurer may require prior authorization before they will approve the test. Prior authorization is a process by which an insurance company verifies that a drug, test, or procedure is medically necessary. If a genetic test was ordered by a non-genetics provider, your insurance company may require you to meet with a genetic counselor as part of prior authorization.

Once the test is run, the testing laboratory will send an insurance claim to your insurer. This is a request to the insurer to pay for the test. If the test is covered, the insurance company will pay for the test and will also send an explanation of benefits or EOB to you. An EOB is not a bill! It is a summary of the total cost of a medical service, the amount paid by the healthcare insurer, and an estimation of the cost to the patient. The actual bill will be sent by the testing laboratory directly to you and may be different from the amount listed on the EOB.

What happens after a genetic test is ordered?

Once the genetic testing laboratory receives your order, the laboratory’s billing department will contact your health insurance. Again, many testing laboratories will conduct a benefit investigation to verify insurance coverage automatically and will contact you if they determine you will have to pay for all or part of the test. These laboratories may offer a self-pay price and allow you to switch to this option if your costs through insurance are too high.

Your insurer may require prior authorization before they will approve the test. Prior authorization is a process by which an insurance company verifies that a drug, test, or procedure is medically necessary. If a genetic test was ordered by a non-genetics provider, your insurance company may require you to meet with a genetic counselor as part of prior authorization.

Once the test is run, the testing laboratory will send an insurance claim to your insurer. This is a request to the insurer to pay for the test. If the test is covered, the insurance company will pay for the test and will also send an explanation of benefits or EOB to you. An EOB is not a bill! It is a summary of the total cost of a medical service, the amount paid by the healthcare insurer, and an estimation of the cost to the patient. The actual bill will be sent by the testing laboratory directly to you and may be different from the amount listed on the EOB.

Does having genetic testing affect my insurance?

The Genetic Information Nondiscrimination Act (GINA) is a federal law which helps to protect against health insurance and employment discrimination based on genetic test results. However, GINA does not protect against discrimination for other types of insurance, such as life, long-term care, and disability insurance. GINA also does not apply to the military or to businesses with fewer than 15 employees. Some states have laws which provide additional protections against genetic discrimination. See http://www.ginahelp.org/GINA_you.pdf for more information on GINA.

Does having genetic testing affect my insurance?

The Genetic Information Nondiscrimination Act (GINA) is a federal law which helps to protect against health insurance and employment discrimination based on genetic test results. However, GINA does not protect against discrimination for other types of insurance, such as life, long-term care, and disability insurance. GINA also does not apply to the military or to businesses with fewer than 15 employees. Some states have laws which provide additional protections against genetic discrimination. See http://www.ginahelp.org/GINA_you.pdf for more information on GINA.

Terms

Benefit Investigation:
A benefits investigation is a process by which a medical provider determines if a medical service will be covered by your insurance plan.
Co-Pay (copayment):
An amount paid by a patient for a healthcare service which is covered by insurance. Co-pay amounts are determined by insurance companies.
CPT Code:
CPT stands for “Current Procedural Terminology.” These are codes which describe a healthcare procedure or service, such as a visit to a medical provider, a laboratory test, or a procedure such as surgery.
Deductible:
The amount of money a patient is responsible for paying for healthcare services before insurance will begin to cover these costs.
Explanation of Benefits (EOB):
An explanation of benefits is a document your insurance company sends summarizing the total cost of a medical service, the amount covered by insurance, and an estimation of the amount you will need to pay. An EOB is not a bill! Bills will be sent by the medical provider or testing laboratory after they have billed your insurance.
ICD-10 Code:
ICD-10 stands for “International Classification of Diseases, 10th edition.” These are codes which describe a patient’s diagnosis or symptoms.
In-Network:
In-network providers have a contract with your insurance company to accept your insurance and provide services at specific rates.
Out-of-Network:
Out-of-network providers have no pre-existing contract with your insurance company. If you see an out-of-network provider or use an out-of-network laboratory, you may be responsible for paying the full cost of the services or a higher amount than you would have with an in-network provider.
Prior Authorization:
Prior authorization is a requirement that your health insurance approves a medical service before it takes place. Prior authorization for genetic testing may involve meeting with a genetic counselor to determine if you meet testing criteria or to make sure that the appropriate genetic test was ordered. Prior authorization is also called preauthorization, precertification, or prior approval.

Terms

Benefit Investigation:
A benefits investigation is a process by which a medical provider determines if a medical service will be covered by your insurance plan.
Co-Pay (copayment):
An amount paid by a patient for a healthcare service which is covered by insurance. Co-pay amounts are determined by insurance companies.
CPT Code:
CPT stands for “Current Procedural Terminology.” These are codes which describe a healthcare procedure or service, such as a visit to a medical provider, a laboratory test, or a procedure such as surgery.
Deductible:
The amount of money a patient is responsible for paying for healthcare services before insurance will begin to cover these costs.
Explanation of Benefits (EOB):
An explanation of benefits is a document your insurance company sends summarizing the total cost of a medical service, the amount covered by insurance, and an estimation of the amount you will need to pay. An EOB is not a bill! Bills will be sent by the medical provider or testing laboratory after they have billed your insurance.
ICD-10 Code:
ICD-10 stands for “International Classification of Diseases, 10th edition.” These are codes which describe a patient’s diagnosis or symptoms.
In-Network:
In-network providers have a contract with your insurance company to accept your insurance and provide services at specific rates.
Out-of-Network:
Out-of-network providers have no pre-existing contract with your insurance company. If you see an out-of-network provider or use an out-of-network laboratory, you may be responsible for paying the full cost of the services or a higher amount than you would have with an in-network provider.
Prior Authorization:
Prior authorization is a requirement that your health insurance approves a medical service before it takes place. Prior authorization for genetic testing may involve meeting with a genetic counselor to determine if you meet testing criteria or to make sure that the appropriate genetic test was ordered. Prior authorization is also called preauthorization, precertification, or prior approval.