Five-second answer

Claim we investigated

Verifying a girl's sex under I-638 would cost most families little or nothing beyond the sports physical they already need.

Mostly true. A covered checkup costs insured families nothing; lab-test routes are priced from about $21 to $1,310 and likely uncovered. The measure's text lets a provider rely on anatomy at the sports physical students already need, and federal, state and insurer rules make a yearly well-child checkup free to insured and Apple Health families; Medicare and Apple Health payment data, lab price pages and plan rules show the two lab-test routes cost $21 to $1,310 and are unlikely to be covered for this purpose.

Quote or cite this fact-check

FactHub rates the claim “Verifying a girl's sex under I-638 would cost most families little or nothing beyond the sports physical they already need” Mostly true (moderate confidence): A covered checkup costs insured families nothing; lab-test routes are priced from about $21 to $1,310 and likely uncovered. Reviewed October 23, 2026. https://facthub.org/n/article/sex-verification-test-costs/2

One-minute summary

What the evidence establishes

  • Established. The measure requires no lab test. A provider may verify sex from anatomy, genetics or testosterone, as part of the sports physical students already need.
  • Established. A yearly well-child checkup is free to insured families in network under the ACA preventive rule and free under Apple Health; Washington's health department says sports forms can be done at that visit.
  • Established. A testosterone test is paid at $20.65 by Apple Health and $25.19 on average by Medicare; labs bill about $148, and Quest and Labcorp sell it for $69 to $75, to adults only.
  • Established. A chromosome test (karyotype) is paid at $213.65 to $270.16 and billed at about $1,062; the press reported $1,310. No major lab sells one to consumers.
  • Not shown. No insurer or Apple Health has said whether it would pay for a lab test done only for sports eligibility. Plan rules that cover medically necessary care suggest many would not.
  • Context. Before puberty, boys and girls have the same testosterone levels, so a testosterone test cannot verify sex for younger students.
  • Context. In 2024, 3.9 percent of Washington residents under 19 had no health insurance; they pay cash for any physical, which they already need to play.
Important context: Initiative IL26-638 is on Washington's November 3, 2026 ballot. It would require a girl who enters female-only school competition to give, as part of the required sports physical, a form signed by her personal health care provider verifying her biological sex, relying only on her reproductive anatomy, genetic makeup, or normal testosterone levels. Opponents say this means expensive genetic or hormone tests; supporters say it requires no invasive or expensive exams. No official estimate of what families would pay exists: the state's fiscal statement covers only state and school district costs. This article prices each of the three routes.

IL26-638 doesn't require invasive or expensive exams.

Committee for the argument for Initiative IL26-638 (Alesha Perkins and five co-authors), Authors of the official voters' pamphlet argument for IL26-638 2026 Washington voters' pamphlet, Initiative Measure IL26-638, p. 22, argument for: "Rebuttal of argument against" · · Assertion

Context: The Yes reply to the No argument that the measure requires genital examinations.

Source: Washington Secretary of State, 2026 General Election voters' pamphlet (statewide edition) · View in the dataset

Section 2 says doctors must subject girls to invasive examinations of their "reproductive organs," or expensive genetic or hormone tests.

Committee for the argument against Initiative IL26-638 (Justin Gill, APRN, and five co-authors), Authors of the official voters' pamphlet argument against IL26-638 2026 Washington voters' pamphlet, Initiative Measure IL26-638, p. 22, argument against: "Vote No To Protect All Girls" · · Assertion

Context: The No argument's reading of the verification rule, which appears in Section 3(2) of the measure.

Source: Washington Secretary of State, 2026 General Election voters' pamphlet (statewide edition) · View in the dataset

The evidence

The conclusion rests on the combined record. Expand each item to see its role and limitations.

Independence note: This check uses 5 methods across 14 institutions and 2 countries or international groupings.
Evidence map
Method Institution / country Year(s) What it shows Key limitation Primary links
Reading of the measure's text, the Attorney General's explanatory statement and the Office of Financial Management's fiscal impact statement in the official voters' pamphlet. Washington Secretary of State, Washington Attorney General, Washington Office of Financial Management United States 2026 Section 3(2) requires a student entering female-only competition to provide, as part of the required routine sports physical, a form signed by her personal health care provider verifying her biological sex, relying only on one or more of reproductive anatomy, genetic makeup, or normal endogenous testosterone. Any one basis is enough, so no lab test is required. The Attorney General's statement says students would have to undergo some type of medical evaluation. The fiscal statement prices only the state's guidance update (about $21,000) and calls district costs indeterminate. The text does not say how a provider must establish anatomy, genetics or testosterone, whether earlier records qualify, or what a 'normal' testosterone level is; implementing guidance has not been written. The fiscal statement covers state and school district costs only, so there is no official estimate of what families would pay. Washington Secretary of State
Review of federal and Washington coverage rules and an insurer's member guidance for well-child visits and sports physicals, plus Census estimates of how many Washington children lack insurance. U.S. Centers for Medicare & Medicaid Services (HealthCare.gov), Washington State Department of Health, Washington Health Care Authority, Premera Blue Cross, U.S. Census Bureau United States 2024, 2026 HealthCare.gov lists well-child visits among the preventive services Marketplace and many other plans must cover, generally at no cost in network. Washington's health department says children 0-20 can get a free well visit every year, that Apple Health covers it at no cost, and that families can ask the provider to fill out sports forms during the visit; Premera says a sports physical is usually included in the well-child exam. Apple Health expects one checkup a year for ages 5 through 20, with a physical examination at each visit documented in the record. In 2024, 3.9 percent (plus or minus 0.4 points) of Washington residents under 19 were uninsured. MinuteClinic sells sports physicals for cash and does not take insurance for them. $0 applies to covered preventive visits in network; HealthCare.gov warns $0 is not guaranteed in all cases, and a visit billed as diagnostic can carry a copay. Whether a provider would sign from existing records or want an exam at the visit is not settled. Families without insurance pay cash, about $82 at one retail clinic, though the physical is already required. HealthCare.gov (U.S. Centers for Medicare & Medicaid Services) Washington State Department of Health Premera Blue Cross Washington Health Care Authority Washington Health Care Authority (PEBB Program) CVS MinuteClinic FactHub dataset: What sex verification under I-638 would cost, by route
Medicare 2024 claims data on allowed amounts and billed charges for CPT 84403, Washington Apple Health's October 2026 fee schedule, the two largest labs' consumer price pages, and a peer-reviewed review of testosterone levels by age and sex. U.S. Centers for Medicare & Medicaid Services, Washington Health Care Authority, Quest Diagnostics, Labcorp, Endocrine Society (Endocrine Reviews) United States, Australia 2018, 2024, 2026 Apple Health pays $20.65 for a total testosterone test (CPT 84403). Medicare paid $25.19 on average in 2024 ($25.26 in Washington), while labs billed $148.21 on average. Quest sells a testosterone test to consumers for $69 plus a $6 physician fee, and Labcorp OnDemand lists one at $69, but both are for patients 18 and older, and Labcorp says its consumer test is clinically appropriate only for people assigned male at birth. A review in Endocrine Reviews finds no sex difference in circulating testosterone before puberty, so a testosterone level cannot distinguish a younger student's sex. Medicare figures are 2024 averages for mostly older adults, not 2026 rates or children's prices; we did not use the 2026 Medicare lab fee schedule file because CMS serves it only after a license agreement. No published self-pay price for a minor's test was found. Labs price differently for children, who often need a more sensitive mass-spectrometry assay billed under the same code. FactHub dataset: What sex verification under I-638 would cost, by route Quest Diagnostics Labcorp Handelsman DJ, Hirschberg AL, Bermon S. Endocrine Reviews
Sum of the three billing codes for a blood chromosome analysis (CPT 88230 culture, 88262 analysis, 88291 interpretation) from Apple Health's fee schedule and Medicare's 2024 claims data, compared with prices reported in the press and the two largest labs' consumer catalogs. U.S. Centers for Medicare & Medicaid Services, Washington Health Care Authority, The Spokesman-Review United States 2024, 2026 A karyotype costs $213.65 at Apple Health rates and $270.16 at Medicare's 2024 average allowed amounts, while labs billed Medicare $1,062.19 on average for the same three codes. The Spokesman-Review reported chromosome testing at $1,310 and a testosterone test at $162 without insurance; an op-ed by two Spokane family physicians attributed $162.75 and more than $1,300 to Labcorp. Neither Quest nor Labcorp sells a chromosome or SRY test directly to consumers, so a family would need a clinician's order. Medicare volumes for these codes are small because most cytogenetics is billed by hospital labs outside the practitioner file. SRY testing has no single code, and we found no published price for it as a package. The press prices could not be traced to a public Labcorp page. FactHub dataset: What sex verification under I-638 would cost, by route The Spokesman-Review Libby Loft and Luis Manriquez, The Spokesman-Review (opinion)
Reading of the 2026 Uniform Medical Plan certificate of coverage (Washington's largest public-employee plan, administered by Regence), Apple Health's definition of medical necessity, and HCA's testosterone billing criteria. Washington Health Care Authority, Washington State Legislature (Washington Administrative Code) United States 2025, 2026 The Uniform Medical Plan excludes services that are not medically necessary for diagnosing or treating illness or injury and are not covered as preventive care, even if a provider recommends them, and requires preauthorization for genetic tests, covering only medically necessary ones. Apple Health defines medically necessary care as care calculated to prevent, diagnose, correct, cure or alleviate a condition. HCA's billing guide ties its testosterone criteria to conditions such as hypogonadism, while not requiring expedited authorization for girls or anyone 17 and younger. On these rules, a lab test whose only purpose is sports eligibility is unlikely to be covered. No insurer or Apple Health has said how it would treat a lab test ordered for I-638 verification, and we read one commercial plan's terms, not every plan's. Providers sometimes order tests with a diagnosis code, and plans' decisions on individual claims can differ from their written rules. Washington Health Care Authority (PEBB Program) Washington State Legislature Washington Health Care Authority
1. 1. What the measure requires: a provider's signature at the existing sports physical, on any of three bases Reading of the measure's text, the Attorney General's explanatory statement and the Office of Financial Management's fiscal impact statement in the official voters' pamphlet.

Section 3(2) requires a student entering female-only competition to provide, as part of the required routine sports physical, a form signed by her personal health care provider verifying her biological sex, relying only on one or more of reproductive anatomy, genetic makeup, or normal endogenous testosterone. Any one basis is enough, so no lab test is required. The Attorney General's statement says students would have to undergo some type of medical evaluation. The fiscal statement prices only the state's guidance update (about $21,000) and calls district costs indeterminate.

Limit: The text does not say how a provider must establish anatomy, genetics or testosterone, whether earlier records qualify, or what a 'normal' testosterone level is; implementing guidance has not been written. The fiscal statement covers state and school district costs only, so there is no official estimate of what families would pay.

Verify: 2026 General Election Voters' Pamphlet (statewide edition): Initiative Measure IL26-638, explanatory and fiscal statements, arguments, and complete text

2. 2. The checkup route: a covered well-child visit costs insured and Apple Health families nothing Review of federal and Washington coverage rules and an insurer's member guidance for well-child visits and sports physicals, plus Census estimates of how many Washington children lack insurance.

HealthCare.gov lists well-child visits among the preventive services Marketplace and many other plans must cover, generally at no cost in network. Washington's health department says children 0-20 can get a free well visit every year, that Apple Health covers it at no cost, and that families can ask the provider to fill out sports forms during the visit; Premera says a sports physical is usually included in the well-child exam. Apple Health expects one checkup a year for ages 5 through 20, with a physical examination at each visit documented in the record. In 2024, 3.9 percent (plus or minus 0.4 points) of Washington residents under 19 were uninsured. MinuteClinic sells sports physicals for cash and does not take insurance for them.

Limit: $0 applies to covered preventive visits in network; HealthCare.gov warns $0 is not guaranteed in all cases, and a visit billed as diagnostic can carry a copay. Whether a provider would sign from existing records or want an exam at the visit is not settled. Families without insurance pay cash, about $82 at one retail clinic, though the physical is already required.

Verify: Preventive care benefits for children Child and adolescent well-care visits Kids' health (member guidance) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Well-Child Program Billing Guide, July 1, 2026 2026 UMP Classic (PEBB) Certificate of Coverage MinuteClinic price lists Saved analysis: Washington residents under 19 with no health insurance, 2024

3. 3. The testosterone route: about $21 to $25 paid by public payers, $148 billed, adults-only consumer tests Medicare 2024 claims data on allowed amounts and billed charges for CPT 84403, Washington Apple Health's October 2026 fee schedule, the two largest labs' consumer price pages, and a peer-reviewed review of testosterone levels by age and sex.

Apple Health pays $20.65 for a total testosterone test (CPT 84403). Medicare paid $25.19 on average in 2024 ($25.26 in Washington), while labs billed $148.21 on average. Quest sells a testosterone test to consumers for $69 plus a $6 physician fee, and Labcorp OnDemand lists one at $69, but both are for patients 18 and older, and Labcorp says its consumer test is clinically appropriate only for people assigned male at birth. A review in Endocrine Reviews finds no sex difference in circulating testosterone before puberty, so a testosterone level cannot distinguish a younger student's sex.

Limit: Medicare figures are 2024 averages for mostly older adults, not 2026 rates or children's prices; we did not use the 2026 Medicare lab fee schedule file because CMS serves it only after a license agreement. No published self-pay price for a minor's test was found. Labs price differently for children, who often need a more sensitive mass-spectrometry assay billed under the same code.

Verify: Saved analysis: What each verification route costs, by type of price questhealth.com: Testosterone Test Labcorp OnDemand: Total Testosterone Test Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance (2018)

A covered checkup costs families $0; lab tests are priced from $21 to $1,310Prices for each way I-638 lets a provider verify a student's sex, from a covered checkup to a chromosome test, labeled by what kind of price each is.{"width":960,"height":540,"plot":{"left":90,"top":70,"right":926,"bottom":482},"yDomain":[0,1500],"series":[{"name":"Checkup (record or exam)","color":"#176b87"},{"name":"Testosterone test","color":"#b6542c"},{"name":"Chromosome test (karyotype)","color":"#684b9b"}],"points":[{"series":0,"x":124.83,"y":482,"xLabel":"Checkup: Apple Health family cost","yLabel":"$0"},{"series":0,"x":194.5,"y":482,"xLabel":"Checkup: insured family cost, in network","yLabel":"$0"},{"series":0,"x":264.17,"y":459.48,"xLabel":"Checkup: retail sports physical, cash","yLabel":"$82"},{"series":1,"x":333.83,"y":476.33,"xLabel":"Testosterone: Apple Health pays","yLabel":"$21"},{"series":1,"x":403.5,"y":475.08,"xLabel":"Testosterone: Medicare pays (average)","yLabel":"$25"},{"series":1,"x":473.17,"y":461.4,"xLabel":"Testosterone: consumer cash, adults only","yLabel":"$75"},{"series":1,"x":542.83,"y":441.29,"xLabel":"Testosterone: lab billed charge (average)","yLabel":"$148"},{"series":1,"x":612.5,"y":437.5,"xLabel":"Testosterone: press-reported cash price","yLabel":"$162"},{"series":2,"x":682.17,"y":423.32,"xLabel":"Chromosomes: Apple Health pays","yLabel":"$214"},{"series":2,"x":751.83,"y":407.8,"xLabel":"Chromosomes: Medicare pays (average)","yLabel":"$270"},{"series":2,"x":821.5,"y":190.25,"xLabel":"Chromosomes: lab billed charge (average)","yLabel":"$1,062"},{"series":2,"x":891.17,"y":122.19,"xLabel":"Chromosomes: press-reported price","yLabel":"$1,310"}]}A covered checkup costs families $0; lab tests are priced from $21 to $1,310$0$500$1,000$1,500Checkup: Apple Health family costCheckup: retail sports physical, cashTestosterone: Apple Health paysTestosterone: consumer cash, adults onlyTestosterone: lab billed charge (average)Chromosomes: Apple Health paysChromosomes: Medicare pays (average)Chromosomes: press-reported priceRoute and type of priceCheckup (record or exam)Testosterone testChromosome test (karyotype)FactHub · Price (US dollars)
What each route would cost. The checkup bars are $0 because insured and Apple Health families pay nothing for a covered well-child visit. Payer rates and billed charges are not family prices; they bracket what an uninsured family might be charged for a lab test. View source chart
4. 4. The genetic route: a chromosome test is paid at $214 to $270 and billed at about $1,062 Sum of the three billing codes for a blood chromosome analysis (CPT 88230 culture, 88262 analysis, 88291 interpretation) from Apple Health's fee schedule and Medicare's 2024 claims data, compared with prices reported in the press and the two largest labs' consumer catalogs.

A karyotype costs $213.65 at Apple Health rates and $270.16 at Medicare's 2024 average allowed amounts, while labs billed Medicare $1,062.19 on average for the same three codes. The Spokesman-Review reported chromosome testing at $1,310 and a testosterone test at $162 without insurance; an op-ed by two Spokane family physicians attributed $162.75 and more than $1,300 to Labcorp. Neither Quest nor Labcorp sells a chromosome or SRY test directly to consumers, so a family would need a clinician's order.

Limit: Medicare volumes for these codes are small because most cytogenetics is billed by hospital labs outside the practitioner file. SRY testing has no single code, and we found no published price for it as a package. The press prices could not be traced to a public Labcorp page.

Verify: Saved analysis: Chromosome test (karyotype) price, by payer Washington voters to decide whether transgender athletes can continue to compete in K-12 girls sports in I-638 (September 27, 2026) Loft and Manriquez: Beware of I-638 on November's ballot (October 11, 2026)

5. 5. Coverage: plan rules pay for lab tests that diagnose or treat, and none mentions sports eligibility Reading of the 2026 Uniform Medical Plan certificate of coverage (Washington's largest public-employee plan, administered by Regence), Apple Health's definition of medical necessity, and HCA's testosterone billing criteria.

The Uniform Medical Plan excludes services that are not medically necessary for diagnosing or treating illness or injury and are not covered as preventive care, even if a provider recommends them, and requires preauthorization for genetic tests, covering only medically necessary ones. Apple Health defines medically necessary care as care calculated to prevent, diagnose, correct, cure or alleviate a condition. HCA's billing guide ties its testosterone criteria to conditions such as hypogonadism, while not requiring expedited authorization for girls or anyone 17 and younger. On these rules, a lab test whose only purpose is sports eligibility is unlikely to be covered.

Limit: No insurer or Apple Health has said how it would treat a lab test ordered for I-638 verification, and we read one commercial plan's terms, not every plan's. Providers sometimes order tests with a diagnosis code, and plans' decisions on individual claims can differ from their written rules.

Verify: 2026 UMP Classic (PEBB) Certificate of Coverage WAC 182-500-0070, Medical assistance definitions (M) Physician-Related Services/Health Care Professional Services Billing Guide, October 1, 2026

Common questions

“The Yes campaign's rebuttal in the voters' pamphlet: "IL26-638 doesn't require invasive or expensive exams."”

Our rating: Mostly true

The text requires no particular procedure. A provider may rely on anatomy, genetics or testosterone, and the anatomy route can use existing records or an exam at a covered well-child checkup that costs insured and Apple Health families nothing. Our companion fact check finds the measure does not require a genital exam. But the sentence leaves out what the alternatives cost: a family that does not use an anatomy-based check faces a testosterone test (about $21 to $25 at public-payer rates, about $148 billed) that cannot verify sex before puberty, or a chromosome test priced at $214 to $1,310, probably out of pocket. 'Doesn't require' is accurate; the implication that no family would pay much is not true for every family.

“The No campaign's argument: "Section 2 says doctors must subject girls to invasive examinations of their "reproductive organs," or expensive genetic or hormone tests."”

Short answer: Optional, not required

Our companion fact check rates this sentence Misleading: the rule is in Section 3(2), the text says 'reproductive anatomy', and it lists bases a provider may rely on rather than procedures doctors must perform. On cost, the 'expensive' part is fair for the genetic route ($214 to $1,310) and partly fair for the hormone route ($21 to $162), but neither test is required, since a provider may rely on anatomy at a covered checkup.

Related claim: Initiative 638 requires a doctor's sex verification, not a genital exam. — Initiative 638 requires a doctor's sex verification, not a genital exam; the claim that it will require genital exams is rated False. This links to the version that was current when this fact check was written. Read the latest version.

“Opponents wrote in the Spokesman-Review: "According to Labcorp, costs for testosterone hormone testing is $162.75 and for genetic sex chromosome testing, it’s more than $1,300."”

Short answer: Plausible list prices

We could not find these prices on a public Labcorp page, so we cannot confirm them. They fit what labs bill: Medicare data show average billed charges of $148 for a testosterone test and about $1,062 for the three chromosome-test codes. Payers pay far less ($21 to $25, and $214 to $270). An uninsured family ordering a test through a clinician could be charged something near list price unless the lab offers a discount, so the figures are a reasonable warning about the lab routes, but they are not what a family pays at a covered checkup.

“Insurance companies won't pay for these tests.”

Short answer: Likely, for lab tests

This is the opponents' strongest cost point, and the plan rules we read support it for lab tests: coverage turns on medical necessity, defined around diagnosing and treating conditions, and genetic tests need preauthorization. No insurer has said so for I-638, so it remains our reading. It does not apply to the checkup route: a yearly well-child visit is covered preventive care, and the sports form can be completed there.

“A cheap testosterone blood test is an easy way to avoid any physical check.”

Short answer: Not for younger students

A total testosterone test is inexpensive to payers, but the consumer versions from Quest and Labcorp are sold only to adults, so a minor's test needs a clinician's order and may not be covered. Before puberty, boys' and girls' testosterone levels do not differ, so the result cannot verify sex for a younger student. The measure also sets no threshold for a 'normal' level. For older students it may work as an alternative, at a price a family would likely pay itself.

“Girls without a regular doctor would have to pay a stranger for verification.”

Short answer: They already need a physical

Every girl who plays already needs a sports physical, from some provider. A girl without a regular provider can get a covered well-child visit if she has insurance or Apple Health, or pay cash (about $82 at one retail clinic). Whether a retail-clinic or urgent-care clinician counts as her 'personal health care provider' is unsettled, and such a clinician would have no records to rely on, so verification at that visit would likely mean an exam or a lab test. Our companion fact check on pediatric care covers how many girls lack a regular provider.

Related claim: Pediatric checkups already document sex, though many Washington girls lack a regular provider. — Pediatric checkups already document sex, though many Washington girls lack a regular provider.

Conclusion

The measure does not require any lab test. It requires a provider's signed verification, delivered with the sports physical that girls already need, and lets the provider rely on any one of three bases. The first basis, reproductive anatomy, needs no lab work: a provider can rely on what the medical record already shows from routine well-child care or on an exam at the visit. For the roughly 96 percent of Washington children and teens who have health insurance, a yearly well-child checkup is covered as preventive care, generally at $0 in network under the Affordable Care Act rule and at no cost under Apple Health, and Washington's health department and Premera both say sports forms can be completed at that visit. On that route, the added monetary cost of verification is a signature on a form. That is why we rate the claim Mostly true. The claim omits three things. First, the two alternatives to an anatomy-based check carry real prices. A serum testosterone test is paid at $20.65 by Apple Health and $25.19 on average by Medicare, and labs billed Medicare $148 on average; a chromosome test (karyotype) is paid at $213.65 to $270.16 and billed at about $1,062. The press has reported self-pay prices of $162 and $1,310, which we could not trace to a public Labcorp page but which fit the billed charges. Second, these tests are probably not covered for this purpose: the plan and Medicaid rules we read cover lab tests when they diagnose or treat a condition, and none mentions sports eligibility. No insurer or Apple Health has said what it would do, so this is our reading, not a stated policy. Third, the cheap-looking options have limits. Quest and Labcorp sell testosterone tests directly only to adults, and before puberty boys' and girls' testosterone levels do not differ, so a testosterone result cannot verify sex for a younger student. Neither lab sells a chromosome or SRY test to consumers. So the cost burden depends on which route a family uses. A family that accepts verification from records or an exam at a covered checkup pays nothing extra. A family that declines an anatomy-based check, or whose provider will not sign without a lab result, faces costs from about $21 to well over $1,000, likely out of pocket. The 3.9 percent of Washington children with no insurance pay cash for any physical, about $82 at one retail clinic, but they need that physical to play today. The claim's phrase 'most families' is supported by the insurance figures; 'little or nothing' holds for the checkup route and not for the lab routes. What remains unknown: how the Office of Superintendent of Public Instruction and the WIAA would write the forms, whether providers would rely on existing records or want a new exam or a lab result, whether a retail-clinic or urgent-care clinician counts as the student's 'personal health care provider', and how insurers would code a verification. Our confidence is Moderate because coverage for a non-medical lab test is inferred from plan rules, and because the 2026 Medicare lab fee schedule file sits behind a license agreement we did not accept, so Medicare figures are 2024 averages. Whether an anatomy-based check is acceptable to families is a question of privacy and values that prices cannot settle; our companion fact check on the genital-exam claim covers what the text requires on that point.

How we checked

  1. Defined the claim: whether verifying a girl's sex under I-638 would cost most families little or nothing beyond the sports physical they already need, measured by what families pay out of pocket for each route the text allows.
  2. Read Section 3(2) of the measure, the Attorney General's explanatory statement and the fiscal impact statement in the official voters' pamphlet.
  3. Priced each route from payer data rather than a single price quote: Washington Apple Health's October 2026 fee schedules (CPT 84403, 88230, 88262, 88271, 88275, 88291, 99394) and CMS's 2024 Medicare claims data by code, national and Washington.
  4. Checked consumer prices on the Quest and Labcorp consumer storefronts and a retail clinic price list on 2026-10-23, and recorded who may buy each test; searched both labs' catalogs for chromosome and SRY tests.
  5. Read coverage rules from HealthCare.gov, Washington's health department, Apple Health's billing guides and administrative code, a 2026 commercial certificate of coverage, and an insurer's member guidance.
  6. Traced the press-reported prices to their sources; where we could not confirm them, we kept them and said so.
  7. Did not use the CMS 2026 Clinical Laboratory Fee Schedule file because it is served only after accepting a license agreement; used Medicare's 2024 paid amounts instead and recorded this limit.
  8. Recorded every price, its type and its source in a public dataset with the script that builds it.

Editorial note: Scope: what each verification route the measure allows would cost a Washington family, and whether insurance or Apple Health would pay. It does not assess whether verification is a good idea, how comfortable families would be with an anatomy-based check, or how providers will behave; those depend on guidance not yet written. FactHub takes no position on I-638. Prices change; every price is dated in the companion dataset. External specialist review: none recorded.

Expert-review status

No external specialist review has been recorded.

Funding and conflicts

Funding: No external funding for this piece.

Ownership: Published by the FactHub Research Team.

Conflicts: None known.

Sources

Sources are labeled by kind, with what this fact check takes from each, so readers can check the evidence independently.

  1. Government Washington Secretary of State. 2026 General Election Voters' Pamphlet (statewide edition): Initiative Measure IL26-638, explanatory and fiscal statements, arguments, and complete text

    The official pamphlet mailed to voters, with the Attorney General's explanatory statement, OFM's fiscal impact statement and the full text of the measure.

    Reliability: The Secretary of State prints the measure text and the official statements; the campaign arguments in the same pamphlet are advocacy and are cited separately through FactHub's statements dataset.

    • The verification form is delivered as part of the routine sports physical students already need, signed by the student's own provider.

      What the source says
      shall provide, as part of the required routine sports physical examination, a health examination and consent form or other statement signed by the student's personal health care provider that verifies the student's biological sex
      Complete text of the measure, Sec. 3(2), PDF p. 61

    • A provider may rely on any one of three bases, so no lab test is required.

      What the source says
      relying only on one or more of the following: The student's reproductive anatomy, genetic makeup, or normal endogenously produced testosterone levels.
      Complete text of the measure, Sec. 3(2), PDF p. 61

    • Qualifies: The Attorney General's statement says verification means some type of medical evaluation for every girl in female-only competition.

      What the source says
      Students would thus have to undergo some type of medical evaluation of their sex to participate in interschool sports designated for female students only.
      Explanatory Statement, The Effect of the Proposed Measure if Approved, PDF p. 21

    • Qualifies: The official fiscal statement prices only the state's guidance update and says nothing about what families would pay.

      What the source says
      The Office of the Superintendent of Public Instruction would incur a one-time cost of approximately $21,000 in SFY 2026 to update existing guidelines to align with the initiative's requirements.
      Fiscal Impact Statement, Expenditures, PDF p. 21
  2. Government HealthCare.gov (U.S. Centers for Medicare & Medicaid Services). Preventive care benefits for children

    The federal Marketplace's consumer page listing preventive services that plans must cover for children, including well-child visits.

    Reliability: Consumer summary of the Affordable Care Act preventive-services rule by the agency that runs the federal Marketplace.

    • Well-child visits are covered preventive care, generally at no cost in network.

      What the source says
      Generally, these services are covered at no cost to you when provided by an in-network medical provider.
      Notice at top of page; list includes Well-baby and well-child visits

    • Qualifies: The $0 rule has exceptions.

      What the source says
      Coverage may vary. $0 cost isn't guaranteed in all cases.
      Notice at top of page
  3. Government Washington State Department of Health. Child and adolescent well-care visits

    Washington's health department page for families on well-child visits, including coverage and sports forms.

    Reliability: Consumer guidance from the state health department, which promotes well-child visits. It does not address I-638.

    • Washington children 0-20 can get a free well visit each year; most plans, including Apple Health, cover it at no cost.

      What the source says
      Children and youth ages 0–20 in Washington can get a free well visit every year. Most health insurance plans, including Apple Health (Washington’s Medicaid) cover these visits at no cost.
      Most Health Insurance Plans Cover Child and Adolescent Well-Visits

    • Families can have sports forms completed during the well visit.

      What the source says
      Just ask your provider to fill out any needed sports forms during the visit.
      FAQ: Is a well-visit different from a sports physical?
  4. Industry Premera Blue Cross. Kids' health (member guidance)

    Member guidance from one of Washington's largest health insurers on well-child visits and sports physicals.

    Reliability: An insurer describing its own coverage; it tells members to check their benefit booklet for their specific plan.

    • Premera says a sports physical is usually part of the covered well-child exam.

      What the source says
      Yes, this is usually included as part of the well-child exam.
      Frequently asked member questions: Is my child’s sports physical covered?
  5. Government Washington Health Care Authority. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Well-Child Program Billing Guide, July 1, 2026

    Apple Health's rules for well-child checkups for children and youth through age 20.

    Reliability: Official billing rules of Washington's Medicaid agency.

    • Apple Health expects one well-child checkup a year for school-age children and teens.

      What the source says
      One checkup every calendar year for ages 5 through 20 years
      EPSDT Well-Child Checkups, p. 17

    • Each covered checkup includes a physical examination documented in the record, which a provider can later rely on.

      What the source says
      At each visit, an age-appropriate physical examination is required with infants totally unclothed and older children undressed and appropriately draped.
      5. Physical Exam, p. 21
  6. Government Washington Health Care Authority (PEBB Program). 2026 UMP Classic (PEBB) Certificate of Coverage

    The contract terms of the Uniform Medical Plan, the self-insured state employee plan administered by Regence BlueShield.

    Reliability: One plan's terms, typical of commercial coverage language; other plans' wording differs.

    • Covered preventive visits with network providers cost the member $0.

      What the source says
      When you see a preferred or participating provider for these services, you pay $0.
      Preventive care, p. 71

    • The plan excludes services that do not diagnose or treat illness or injury and are not preventive, even when a provider recommends them.

      What the source says
      That are not medically necessary for the diagnosis and treatment of injury or illness or restoration of physiological functions and are not covered as preventive care. This applies even if services are prescribed, recommended, or approved by your provider.
      What the plan does not cover, item 100, p. 115

    • Genetic tests need preauthorization and are covered only when medically necessary.

      What the source says
      Covered genetic tests require preauthorization. With preauthorization, the plan covers medically necessary, evidence-based genetic testing services.
      Genetic services, p. 61
  7. Government Washington State Legislature. WAC 182-500-0070, Medical assistance definitions (M)

    Apple Health's legal definition of medically necessary care.

    Reliability: Administrative rule adopted by the Health Care Authority.

    • Apple Health defines medically necessary care around preventing, diagnosing or treating a condition, not around eligibility paperwork.

      What the source says
      "Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity
      Definition of Medically necessary
  8. Government Washington Health Care Authority. Physician-Related Services/Health Care Professional Services Billing Guide, October 1, 2026

    Apple Health billing rules, including medical necessity criteria for testosterone testing.

    Reliability: Official Medicaid billing rules; criteria based on a state Health Technology Clinical Committee review.

    • Apple Health's testosterone criteria are written around diagnosing conditions such as hypogonadism.

      What the source says
      HCA considers testosterone testing to be medically necessary for clients assigned male at birth who are age 18 and older when at least one of the following conditions are met
      Testosterone testing, p. 179

    • Qualifies: For girls and anyone 17 or younger, Apple Health does not require expedited prior authorization for a testosterone test, so the paperwork barrier is lower than for adult men.

      What the source says
      Note: EPA is not required for clients assigned female at birth of any age or for clients assigned male at birth who are age 17 and younger.
      Testosterone testing, p. 179
  9. Industry Quest Diagnostics. questhealth.com: Testosterone Test

    Quest's direct-to-consumer testosterone test page, read 2026-10-23.

    Reliability: A lab's own retail price page; prices and promotions change.

    • Quest sells a testosterone test to consumers for $69 plus a $6 physician fee.

      What the source says
      $69.00 + $6.00 Physician Service Fee
      Price box

    • Qualifies: The consumer test is not available to students under 18.

      What the source says
      Patient: This test can be performed on patients between 18 and 100 years old.
      Eligibility
  10. Industry Labcorp. Labcorp OnDemand: Total Testosterone Test

    Labcorp's direct-to-consumer testosterone test page, read 2026-10-23 (list price $69).

    Reliability: A lab's own retail page; it showed a sale price of $51.75 on the day we read it.

    • Qualifies: Labcorp's consumer test is limited to ages 18 to 100.

      What the source says
      Age: 18-100
      Test Details

    • Qualifies: Labcorp says its consumer total testosterone test is meant for people assigned male at birth.

      What the source says
      Note: This total testosterone level test is only clinically appropriate for individuals assigned male at birth (AMAB).
      Test description
  11. Peer-reviewed study Handelsman DJ, Hirschberg AL, Bermon S. Endocrine Reviews. Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance (2018) Free copy DOI: 10.1210/er.2018-00020

    Peer-reviewed review of testosterone levels in males and females by age and their role in athletic performance.

    Reliability: Published by the Endocrine Society. One author (Bermon) has worked with World Athletics on eligibility rules; the finding cited here, on prepubertal hormone levels, is not disputed.

    • Qualifies: Before puberty boys and girls have the same circulating testosterone, so a testosterone test cannot verify a younger student's sex.

      What the source says
      Prior to puberty, there is no sex difference in circulating testosterone concentrations or athletic performance
      Abstract
  12. News report The Spokesman-Review. Washington voters to decide whether transgender athletes can continue to compete in K-12 girls sports in I-638 (September 27, 2026)

    A news story by Mitchell Roland that reports self-pay prices for testosterone and chromosome tests.

    Reliability: The prices appear in the reporter's voice next to quotes from a family physician who opposes the measure; the story names no source for them.

    • Qualifies: The press reported a testosterone test at $162 and chromosome testing at $1,310 without insurance.

      What the source says
      A routine blood testosterone test can cost $162 if it’s not covered by insurance, while chromosome testing costs $1,310.
      Body text, after quotes from Dr. Libby Loft
  13. Advocacy group Libby Loft and Luis Manriquez, The Spokesman-Review (opinion). Loft and Manriquez: Beware of I-638 on November's ballot (October 11, 2026)

    An op-ed by two Spokane family physicians who oppose the measure.

    Reliability: Has a stake in this finding. The authors oppose I-638; the prices are attributed to Labcorp without a link.

    • Qualifies: Opponents attribute prices of $162.75 for testosterone testing and more than $1,300 for chromosome testing to Labcorp, and say insurers will not pay.

      What the source says
      Insurance companies surely won’t be footing the bill. According to Labcorp, costs for testosterone hormone testing is $162.75 and for genetic sex chromosome testing, it’s more than $1,300.
      Paragraph on cost
  14. Industry CVS MinuteClinic. MinuteClinic price lists

    A national retail clinic's cash price list, read 2026-10-23, listing sports physicals at $82.

    Reliability: Retail price list; prices may change and may differ by state.

    • Qualifies: A retail clinic sells sports physicals for cash ($82) and does not bill insurance for them.

      What the source says
      We don’t accept insurance for these services.
      Introduction to the price list; Physicals section lists Sports physicals
  15. FactHub record FactHub dataset: What sex verification under I-638 would cost, by route. Saved analysis: What each verification route costs, by type of price

    Prices for the checkup, testosterone and chromosome routes from Apple Health, Medicare, consumer and press sources.

    • A covered checkup costs insured and Apple Health families $0; a testosterone test is paid at $20.65 to $25.19, billed at $148.21, and sold to adults for $69 to $75.

  16. FactHub record FactHub dataset: What sex verification under I-638 would cost, by route. Saved analysis: Chromosome test (karyotype) price, by payer

    Sum of CPT 88230, 88262 and 88291 at Apple Health and Medicare rates and billed charges.

    • Qualifies: A karyotype is paid at $213.65 (Apple Health) or $270.16 (Medicare 2024 average) and billed at $1,062.19 on average.

  17. FactHub record FactHub dataset: What sex verification under I-638 would cost, by route. Saved analysis: Washington residents under 19 with no health insurance, 2024

    American Community Survey 2024 estimate for Washington.

    • 3.9 percent (plus or minus 0.4 points) of Washington residents under 19, about 68,000, had no health insurance in 2024.

  18. FactHub dataset What sex verification under I-638 would cost, by route

    • Tables: prices

      Saved analysis route-price-comparison; prices table

    • Tables: prices

      Saved analysis karyotype-totals

    • Tables: wa-child-coverage

      Saved analysis wa-under19-uninsured

  19. FactHub dataset Initiative 638: the campaigns' claims in their own words
    • IL26-638 doesn't require invasive or expensive exams.
      Committee for the argument for Initiative IL26-638 (Alesha Perkins and five co-authors), Authors of the official voters' pamphlet argument for IL26-638, · In the dataset
    • Section 2 says doctors must subject girls to invasive examinations of their "reproductive organs," or expensive genetic or hormone tests.
      Committee for the argument against Initiative IL26-638 (Justin Gill, APRN, and five co-authors), Authors of the official voters' pamphlet argument against IL26-638, · In the dataset
  20. FactHub chart sex-verification-cost-by-route

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  • Article wa-i638-verification-accuracy — version 2 (published) cites version 2
  • Article wa-i638-verification-accuracy — version 1 (published) cites version 2
  • Article wa-i638-genital-exam-claim — version 9 (published) cites version 2
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  • Briefing wa-i-638 — version 4 (published) cites version 2

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{"@context":"https://schema.org","@type":"ClaimReview","url":"https://facthub.org/n/article/sex-verification-test-costs/2","datePublished":"2026-10-23","dateModified":"2026-10-23","author":{"@type":"Organization","name":"FactHub","url":"https://facthub.org/"},"claimReviewed":"Verifying a girl\u0027s sex under I-638 would cost most families little or nothing beyond the sports physical they already need.","reviewRating":{"@type":"Rating","alternateName":"Mostly true"},"image":"https://facthub.org/node-assets-v2/article/sex-verification-test-costs/2/lab-tubes/social-1200x630.jpg"}

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