Which lab tests are covered by insurance—and which aren’t
Get the breakdown to get the tests you want while avoiding unexpected bills.
Laboratory tests of blood and urine are some of the most basic tools that physicians use to screen for and diagnose diseases. Providers also use these labs to spot risk factors—like high cholesterol or elevated organ-health markers—that can otherwise be difficult to detect and to help monitor some chronic conditions.
Yet despite their role in monitoring your health, not all tests are covered by insurance. Health insurance companies generally cover labs that the medical establishment has deemed necessary. But health plans vary, and even if a test is considered "necessary" by a medical provider, you may have to pay some money out of pocket, depending on your coinsurance or deductible.
But you’re not limited to the handful of common insurance-covered tests. If you want to learn your values for a different biomarker, you have options. First, you can talk to your doctor about ordering the test; in some cases, a physician’s order may be enough to get insurance coverage for a lab. You can also use a direct-to-consumer testing company (including Quest and Labcorp, which both sell direct). You simply order the test online, and the testing company facilitates a remote physician’s order if needed. Then the lab sends your results directly to you. You may have to pay out of pocket, but some tests are surprisingly inexpensive (think: ~$20).
This guide will help you understand which tests insurance typically pays for, instances where plans may cover other tests, and why some people prefer the direct-to-consumer route.
Do you have metabolic syndrome?
Answer a few quick questions to see whether your results suggest elevated risk of Type 2 diabetes, heart disease, and more.
Metabolic syndrome is defined by five common health markers: waist circumference, triglycerides, HDL cholesterol, blood pressure, and fasting glucose. If three or more are out of range, your long-term risk rises. The good news: for many people, these markers can improve meaningfully with consistent lifestyle changes.
What tests are free for nearly everyone
The 2010 Affordable Care Act (ACA) mandates that insurance (including Medicare and Medicaid) cover specific screening tests for everyone, and some only for people of a particular age or risk group.
Four expert medical and scientific bodies recommend which tests should be covered. These bodies include the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, and the HRSA-sponsored Women’s Preventive Services Initiative (WPSI).
The screening recommendations are based on scientific evidence that a test positively impacts health for the broadest portion of the population. In other words, covered tests are meant to assess the most common health concerns, not your specific condition.
Lab tests covered through the ACA include:
- Lipid screening (cholesterol and triglycerides)
- Diabetes screening, including blood sugar tests, for people aged 40 to 70 with risk factors
- Cervical cancer screening (Pap test)
- Colorectal cancer screening (colonoscopy and PSA tests)
- Certain sexually transmitted infections (STIs) in high-risk people
- HIV screening
- Hepatitis screening in high-risk people
- Tuberculosis screening for high-risk people
What other lab tests are typically covered by insurance?
Along with offering the mandatory coverage of preventive screenings, many health insurance plans cover, at least in part, additional laboratory tests. These include labs that medical professional groups have determined are medically necessary for preventing, managing, and treating diseases. But what you pay and what insurance covers will vary depending on your plan.
Below are some examples of the types of tests that insurance plans typically cover:
- Annual routine tests (complete blood count and comprehensive metabolic panel)
- Diagnostic tests ordered to investigate specific symptoms (like thyroid tests or vitamin D)
- Tests required to monitor chronic conditions (such as HbA1c for diabetes, and liver function tests)
- Prenatal testing
- Some hormonal tests deemed medically necessary
How often can you get lab tests?
Most plans offer coverage for preventive screening once a year (under ACA requirements), but for some tests, your plan may only cover tests performed at longer intervals, such as every other year.
If you have a condition that requires you to monitor specific markers, such as diabetes or high cholesterol, plans usually cover more frequent testing. That may also be true if you’re starting or stopping a medication or other treatment. However, in some cases, to receive coverage for more frequent testing, your doctor may need to demonstrate that shorter intervals are medically necessary.
When do you need prior authorization for lab tests?
Sometimes, insurance plans require prior authorization for some tests. This is a request your healthcare provider makes, asking your insurer to approve—and therefore cover—the test before it’s performed. Certain genetic tests, molecular diagnostics, and some cancer testing commonly need prior authorization.
To get prior authorization, your healthcare provider has to submit information to your insurance company about your symptoms or diagnosis and why the test is medically necessary. If your plan denies the request and won’t cover specific tests, you can appeal the decision. However, your doctor must provide additional proof that the test is medically necessary.
What lab tests may not be covered by insurance?
Insurance plans may not cover tests that are not considered medically necessary. This situation may apply to tests that are useful for health optimization or improvement but not necessarily diagnostic, or to tests that are more individually useful but may not apply to a larger percentage of the population.
Below are some examples of tests that may not be covered:
- Genetic testing without a clear medical necessity
- Micronutrient (vitamin and mineral) level testing (except in specific circumstances)
- Food sensitivity or intolerance panels
- Some functional medicine tests, such as saliva analysis, hair analysis, heavy metal panels, gastrointestinal health panels, and cortisol stress tests
- Tests for conditions if someone isn’t currently showing symptoms
- Multiple tests for the same condition in a timeframe shorter than medically warranted
- Hormone testing for things like fertility, infertility, and menopause
- Tests that aren’t FDA-cleared or approved, or aren’t performed in a credentialed and certified laboratory
In some cases, if your healthcare provider can show that a test is medically necessary, they can request that your insurance cover it, but their request may be denied.
How much do blood tests cost without insurance?
If you don’t have insurance or want a test that your insurance plan doesn’t cover, you may have to pay for lab tests out of pocket. However, if you have a high-deductible health plan (HDHP), which is required to have a health savings account (HSA), you can typically use your HSA dollars to cover these medical expenses. Likewise, if you have a flexible spending account (FSA), which you can only get through an employer, you can generally use your FSA dollars to pay for labs. The cost for lab work may vary, depending on how routine or specialized the tests are. For example, standard tests for cholesterol or a complete blood count may cost $20 to $40, whereas a food allergy test may cost $200.
Where you get tested can also affect the cost. Hospital outpatient departments (HOPDs) typically charge the most for lab services. Stand-alone labs, like Labcorp or Quest, charge less and allow you to order specific tests. Direct-to-consumer testing companies (like Levels or Function Health) get bundled pricing from the lab companies and can typically offer testing packages at a lower cost than if you were to go directly to a lab. For example, the Levels comprehensive panel includes 100+ markers for $498 (including membership), whereas purchasing these tests individually would total several thousand dollars. Lastly, you can look into getting free or low-cost tests at community health centers.
Does insurance cover at-home or online lab tests?
Direct-to-consumer testing (meaning tests you order yourself) may or may not be covered by insurance. Some of the tests or packages you can order focus on expanded screening by offering hormone, metabolic, or genetic testing. Other tests or packages include traditional labs and routine tests.
In-network health plans don’t cover many of these direct-to-consumer tests, so most people must pay out of pocket up front. Depending on your health insurance plan and the tests you’re ordering, you may be able to apply for reimbursement as an out-of-network expense. Or if you have an FSA or HSA account, you can withdraw money to reimburse yourself for these costs as long as they are considered qualifying medical expenses.
Some testing companies also offer in-home blood collection if you can’t get to a laboratory. In this case, you’ll have to pay for the in-home collection service, but your insurance plan may cover the actual tests.
A few tests, such as the colon cancer screening test Cologuard, are covered by insurance if you fit the eligibility criteria for preventive screening. So read the fine print about insurance coverage and confirm anything with your health plan if you’re considering these services.
Check with the testing company and with your insurance company to understand your particular situation.
How to avoid unexpected bills
Unfortunately, determining what’s covered and what isn’t involves doing the legwork with your insurer, and, if you’re using one, the third-party testing company. Insurance covers many laboratory tests, but coverage varies by the test, provider, and your specific plan. For some preventive tests, you may owe nothing out of pocket, but for diagnostic tests or those used to monitor chronic illnesses, you may have a deductible or coinsurance cost. And some specialized or alternative testing may not be covered at all.
Doing the legwork—as frustrating as it may be— is worth your time to avoid unexpected costs. Doctors may not always know what’s covered and may order tests that end up costing you hundreds of dollars. You also can’t assume that the $500 you spent with a direct-to-consumer company is always eligible for FSA or HSA reimbursement. Check with your insurance provider to confirm your lab test coverage and what you may owe for specific tests. They can also verify which laboratories are in your plan’s network and will cost you less.
Blood testing is an incredibly valuable tool for understanding your health, and everyone should take advantage of covered preventive tests to get an annual baseline. If you want labs beyond that, you can ask your doctor to order them for you or obtain testing on your own, but you may have to do some research to understand the costs.
Get lab testing and guidance with Levels
Levels offers all members a free 28-marker labs panel with membership, and the chance to upgrade to a comprehensive 100+ marker panel for $299 more. Plus the Levels app helps you track your meals and habits so you can make meaningful improvements in your lab markers. Click here to learn more about Levels.
