Billing and Insurance

Genetic testing for common high-risk hereditary cancer genes is covered by most insurance plans; however, most insurance plans do have family history criteria (as is the case currently for BRCA, Lynch, and FAP testing). The criteria are typically modeled after national guidelines (NCCN) although it might not be up to date with current guidelines and each insurance company is different. A patient must meet his or her insurance's criteria for a given gene for that test to be covered.

Other aspects of billing and insurance to consider include:

  • Most insurance companies do not yet have criteria to determine coverage for genes besides BRCA, Lynch, and FAP. This includes other hereditary cancer syndromes and moderate-risk cancer genes.
  • Individuals may have coverage for NGS panel testing if they meet criteria for multiple genes on the panel. Other insurance companies have genetic testing exclusions or limits on the number of genetic tests in a lifetime.
  • Some of the genetic testing laboratories offer financial assistance programs that have income and family history criteria. Genetic counselors may have access to grants or other sources of funding that may help patients who would not otherwise qualify for testing.
  • Some insurance companies may be capitated to certain genetic testing laboratories, which could dictate which tests may be available to the patient.

The nuances of insurance and billing are continuously changing. Part of the genetic counselor’s job is to stay apprised of current criteria and updates with regard to available testing and insurance. Genetic counselors discuss billing and insurance with patients during the pre-test appointment.

To learn more about the genetic counseling process, please visit our Genetic Counseling section.