Waiting for answers about your health can already feel stressful. Concerns about cost can make it even harder to move forward with testing. This guide aims to help you understand what to expect and how to get support to keep things moving.
If you come across unfamiliar terms, you can refer to the Insurance Terminology section of our Glossary of Common Terms.
What Insurance Typically Covers During Testing
Most health insurance plans (including employer plans, Marketplace plans, Medicare, and Medicaid) cover diagnostic testing when it is medically necessary.
This often includes:
- Imaging (like X-rays, CT scans, MRIs, ultrasounds)
- Lab work (blood tests, pathology)
- Biopsies and related procedures
- Specialist visits (like seeing a pulmonologist, GI doctor, or surgeon)
A few important notes:
- You may need to use in-network providers for full coverage. It is worth double-checking that both the facility and the doctor are in-network.
- Some tests require insurance approval in advance (prior authorization).
- Depending on your plan, you may need to pay part of the cost.
Common Out-of-Pocket Costs
Even with insurance, you may still have some costs. These vary based on your plan, where the test is done, and whether you have met your deductible. If you have not met your deductible yet, you may be responsible for a larger portion of the cost.
Imaging (CT, MRI, PET scans)
- Copay (fixed fee) or coinsurance (a percentage of the cost)
Biopsies or Procedures
- Often billed as outpatient procedures
- May include:
- Facility fee
- Physician fee
- Pathology/lab fee
Office Visits
- Specialist visits may have higher copays than primary care
You may also receive multiple bills for one test (for example, one from the facility and one from the doctor reading the results). This is normal, but it can feel confusing if you are not expecting it.
Getting an Estimate Before Your Test
If you are concerned about cost, you can ask for an estimate ahead of time. You can ask:
- Your doctor’s office or the scheduling team
“Can you give me a cost estimate for this test?”
- The hospital or imaging center billing office
“Who can I talk to about what this might cost with my insurance?”
- Your insurance company (using the number on your card):
“What would my out-of-pocket cost be for this test?”
Estimates are not exact, but they can help you plan and avoid surprises. If you are having trouble getting a clear estimate, you can ask your provider for the billing code (also called a CPT code) for the test. You can then share that code with your insurance company to get a more specific estimate.
This step is optional, and you do not need to do it on your own. Your care team or a financial counselor can often help with this if needed.
What “Prior Authorization” Means
Prior authorization means your insurance company needs to approve a test before it happens. Urgent tests may be expedited, but routine tests often require this approval step before they can be scheduled.
Why it exists:
- To confirm the test is medically necessary
- To control costs
What this means for you:
- Your doctor’s office usually handles this process.
- It can take a few days to a couple of weeks. This can feel frustrating, especially when you are waiting for answers.
- If it is missing, your test may be delayed or not covered.
What you can do:
- Ask: “Has this been authorized yet?”
- If things feel stuck, call your provider’s office or insurance.
A Quick Note About Your Role
In most cases, your care team will manage prior authorization for you. However, a quick check-in can help prevent delays or unexpected costs.
You might ask:
- “Has this been approved by my insurance yet?”
- “Is there anything I need to do before this test?”
In some cases, if a test is done without prior authorization, insurance may not cover it. A quick check ahead of time can help avoid surprises.
What to Do If You Are Uninsured or Underinsured
If you do not have insurance or your coverage is limited, you still have options, and you do not have to figure them out alone.
Many people face challenges like insurance gaps or financial strain during this time. There are support services designed to help you navigate these issues and keep care moving.
How to Get Connected to Support
Ask Your Care Team Directly.
This is often the fastest path.
- “Is there a financial counselor or patient navigator I can speak with?”
- “Can someone help me understand my insurance or costs before I schedule this?”
Most hospitals and larger clinics have financial counselors, patient navigators, and social workers.
Call the Hospital or Clinic Billing Office.
Ask for financial counseling or patient financial services. They can help you:
- Estimate costs ahead of time
- Screen you for financial assistance programs
- Set up payment plans
Apply for Insurance Coverage or Financial Assistance.
You may be eligible for:
- Medicaid (eligibility can change based on your situation)
- Marketplace plans (you may qualify for a special enrollment period)
- Hospital financial assistance (charity care)
A financial counselor or navigator can walk you through these applications.
Ask About Self-Pay or Discounted Rates.
If you are uninsured, many hospitals offer reduced “self-pay” rates. You can ask:
- “Is there a discounted rate if I am paying out of pocket?”
Look for Community-Based Support.
Some organizations can help with:
- Transportation
- Medication costs
- Basic needs (like food or housing), which can impact your ability to receive care
When to Ask for Help
You do not need to wait until there is a problem to ask for help. It is a good idea to reach out if:
- You are unsure what your insurance will cover.
- You are worried about the cost of a test.
- You do not have insurance.
- You receive a bill you do not understand, or that seems higher than expected.
- You feel hesitant to move forward because of the cost.
Getting support early can help prevent delays and make the process feel more manageable.
