Does Blue Cross Blue Shield of Illinois Cover NIPT Testing?

Blue Cross Blue Shield of Illinois generally covers noninvasive prenatal testing (NIPT) when it is used to screen singleton or twin pregnancies for the three most common chromosomal conditions: trisomy 21 (Down syndrome), trisomy 18, and trisomy 13. The catch is that NIPT is not on the list of no-cost preventive services under BCBSIL plans, so you should expect your normal deductible, copay, or coinsurance to apply. Exact benefits, prior authorization rules, and in-network lab requirements vary by plan, and the surest way to know what you will pay is to call the member services number on the back of your ID card before the blood draw.

What BCBSIL Will and Won’t Cover

Across the Blue Cross Blue Shield system, individual affiliates write their own medical policies, but they lean on a shared evidence document from the Blue Cross Blue Shield Association, so the rules are broadly consistent.¹ Cell-free DNA (cfDNA) screening for trisomies 21, 18, and 13 is treated as medically necessary in singleton and twin pregnancies. Anthem extended that coverage to average-risk pregnancies, not just high-risk ones, back in 2015, and other affiliates have followed.²

Several uses of cfDNA are typically not covered and are classified as investigational:

Screening for microdeletions
Screening for single-gene disorders
Testing for twin zygosity
Screening for rare autosomal trisomies beyond 21, 18, and 13
Any cfDNA testing in pregnancies with three or more fetuses³

Policies also uniformly treat NIPT as a screening test, not a diagnostic one. A positive cfDNA result is expected to be confirmed by diagnostic testing such as amniocentesis or chorionic villus sampling before any clinical decision is made.³

Why You Still Pay Something Out of Pocket

Under the Affordable Care Act, non-grandfathered health plans must cover certain preventive services with no cost-sharing when you use a network provider. BCBSIL’s preventive services document lists the pregnancy-related screenings that qualify: anemia, gestational diabetes, bacteriuria, Rh(D) incompatibility, preeclampsia, and perinatal depression. NIPT is not on that list.⁴

The reason is procedural. The U.S. Preventive Services Task Force has not given cfDNA prenatal screening an “A” or “B” recommendation,⁵ and only services with that designation (or an equivalent from ACIP or HRSA) trigger the zero-cost-sharing mandate under the ACA.⁶ Until that changes, BCBSIL can cover NIPT as a standard medical benefit without waiving your deductible or coinsurance.

BCBSIL’s own preventive services guide notes that Illinois law may add reproductive health benefits beyond the ACA baseline, so it is worth asking member services whether anything on your specific plan goes further.⁴ Grandfathered plans operate under different rules entirely, which is another reason to confirm your plan type before scheduling.

If You Have Blue Cross Community Health Plans (Medicaid)

BCBSIL also runs Illinois Medicaid managed care under the name Blue Cross Community Health Plans (BCCHP). BCCHP’s maternal and infant health benefits cover doctor visits, lab tests, doula support, and care coordination, but the plan’s public materials do not specifically address NIPT or genetic screening.⁷

NIPT coverage under Illinois Medicaid is set by the state Department of Healthcare and Family Services, and managed care organizations have to follow those state rules. A clinical policy used by another Illinois Medicaid plan, Meridian, considers cfDNA medically necessary for singleton and twin pregnancies at ten or more weeks’ gestation, with pretest counseling, for trisomies 21, 18, and 13, while excluding microdeletion screening. That policy also makes clear that state Medicaid rules override the plan’s internal policy if the two conflict.⁸ If you are a BCCHP member, call the number on your ID card or ask your Care Coordinator before the test.

Why NIPT Claims Get Denied

Even when a plan covers NIPT in principle, specific claims still get rejected. The most common reasons:

The test was ordered for an indication that is not covered, such as microdeletions, single-gene disorders, zygosity, or rare trisomies beyond 21, 18, and 13.³
More than one screening approach was used. Payers generally expect one screening modality per pregnancy, so running NIPT alongside a traditional first- or second-trimester serum screen can lead to one being denied.⁹
The blood was drawn too early. Most policies require at least nine or ten weeks of gestation.¹⁰
The pregnancy involves three or more fetuses, which is excluded under most BCBS policies.¹
The testing laboratory was out of network. An NPR investigation documented a case where a NIPT lab billed an insurer $4,480, the insurer paid 45 cents, and the patient was left with the balance.¹¹

Keeping the Bill Down

Even with coverage, your share of the cost can be meaningful. A few things help.

Ask the lab what it charges in cash. Natera, one of the major NIPT labs, lists a self-pay price of $249 to $349 depending on the test and says more than 60 percent of patients who go through insurance pay nothing out of pocket.¹² If the cash price is lower than what you would owe after insurance processes the claim, paying directly can be the better move.

Get a pretest estimate. Labs can often tell you, based on how your specific plan has processed their past claims, roughly what you will owe. That estimate is far more useful than a generic price list.¹²

Check financial assistance. Natera’s financial assistance program can bring the patient cost to $149 or less for those who qualify by income and household size, with interest-free payment plans of up to 12 months.¹²

Confirm the lab is in-network with BCBSIL before the sample is drawn. This is the single biggest cost variable, and it is the easiest to fix in advance.

Appealing a Denied NIPT Claim

If BCBSIL denies your claim, start with the Explanation of Benefits (EOB), which spells out why. Clerical errors, wrong codes, or missing information can often be cleared up with a call from you or your provider’s billing office to member services.¹³

Internal Appeal

For a denial based on medical necessity, you, your doctor, or an authorized representative can file a formal internal appeal. BCBSIL gives you 180 days from the denial to file. A physician reviews medical-necessity appeals, and your ordering doctor can request a peer-to-peer conversation with the BCBSIL reviewer before you file.¹³

Strong appeals include a letter from the ordering physician explaining why the test was warranted, your relevant records and test results, current clinical guidelines or studies supporting NIPT in your situation, and a personal statement. Standard internal appeals are decided in roughly 30 to 60 days depending on the request type. Urgent appeals, used when your health is at risk, are decided within 72 hours.¹³

External Review

If the internal appeal fails, you can ask the Illinois Department of Insurance for an independent external review at no cost. You have four months from the final internal denial to file. Standard external reviews take about 45 days; urgent ones are decided within 72 hours. You can file online through the IDOI Message Center, by email at DOI.externalreview@Illinois.gov, or by fax or mail, and reach the external review staff at 877-850-4740.¹⁴

One important limit: if you are enrolled in a self-insured employer plan, you may not qualify for the state external review process. Self-insured plans fall under federal ERISA rather than Illinois insurance law. Your benefit booklet or a call to member services will confirm which type of plan you have.¹⁴

1
BlueCross BlueShield of Florida. Cell-Free DNA Prenatal Screening Medical Coverage Guideline
2
GenomeWeb. Anthem BCBS Changes Policy, Deems NIPT Medically Necessary for Average/Low-Risk Pregnancies
3
Blue Cross Blue Shield of Michigan. Joint Medical Policy – Cell-Free Fetal DNA
4
Blue Cross Blue Shield of Illinois. Preventive Services
5
U.S. Preventive Services Task Force. USPSTF A and B Recommendations
6
Blue Cross Blue Shield of Illinois. CPCP Preventive Level Services
7
Blue Cross Blue Shield of Illinois. Maternal and Infant Health – BCCHP Benefits and Coverage
8
Meridian Health Plan of Illinois. Clinical Policy – Cell-Free Fetal DNA Testing
9
National Institutes of Health (SEED). Diagnostic Reimbursement Case Study
10
Carelon Medical Benefits Management. Prenatal Screening Using Cell-Free DNA
11
NPR. Prenatal Genetic Test Natera Health Insurance
12
Natera. Pricing and Billing
13
Blue Cross Blue Shield of Illinois. Claim Not Approved
14
Illinois Department of Insurance. File an External Review