Does Health Insurance Cover Paternity Testing?
Does health insurance cover paternity testing? Explore the nuanced criteria for coverage and how to understand your policy.
Paternity testing analyzes DNA to confirm or exclude a genetic relationship, providing definitive answers regarding biological fatherhood. Health insurance plans generally do not cover the cost of these tests unless specific medical circumstances necessitate the procedure. This is because most paternity tests are not considered medically necessary by insurers for diagnosis or treatment.
Types of Paternity Testing and Coverage Considerations
Health insurance coverage for paternity testing is tied to a determination of medical necessity. Insurers define medically necessary services as those required to diagnose, treat, or manage a health condition. A healthcare provider must deem genetic testing, including paternity testing, essential for a patient’s health management for coverage to arise.
A rare instance of medical necessity involves diagnosing or treating a heritable genetic condition in a child. If establishing paternity is crucial for understanding a child’s medical history, identifying risks for inherited diseases, or guiding specific treatment plans, a doctor might consider the test medically necessary. However, these scenarios are uncommon. Tests performed for legal reasons, such as child support, custody disputes, or inheritance claims, are typically not covered. Similarly, tests conducted solely for personal curiosity or peace of mind receive no insurance coverage.
Understanding Insurance Policy Provisions
Health insurance policies cover medically necessary services and explicitly list exclusions. Services deemed medically necessary by a healthcare provider and the insurer are generally covered, while those that do not meet this criterion, like most paternity tests, are excluded. Policy documents detail these benefits and exclusions, often under sections related to laboratory services or genetic testing.
Policies vary significantly across different insurance providers and plan types. However, the core principle remains consistent: coverage is contingent on the service being essential for diagnosing or treating an illness or condition. Many insurance plans require prior approval, known as pre-authorization, for genetic tests to ensure they meet medical necessity criteria before the service is rendered.
Steps to Determine Coverage
To determine if your health insurance policy offers coverage for paternity testing, gather your policy documents, including your member ID card and summary of benefits. Locate the customer service number on your ID card.
Ask if paternity testing is covered under your plan, particularly if there is a documented medical reason from a doctor. You may inquire about coverage for CPT code 86910, which describes “Blood typing, for paternity testing, per individual.” Document the date, time of your call, the representative’s name, and any reference numbers provided. Clarify if pre-authorization is required for the test.
Considering Financial Options
When health insurance does not cover paternity testing, individuals are responsible for the full cost. The expense varies depending on the type of test and the laboratory chosen. At-home paternity test kits, suitable for personal knowledge, typically range from $100 to $300.
Legal paternity tests, which include a chain of custody for court admissibility, generally cost between $300 and $800. Non-invasive prenatal paternity tests, performed before a baby is born, are the most expensive, with costs typically ranging from $1,000 to $2,500. Many laboratories offer payment plans directly to clients. In legal contexts, a court may order one party to pay for the testing, but this is distinct from health insurance coverage. Comparing prices from various accredited laboratories can also help manage the out-of-pocket expense.