How to find out more about your health plan’s clinical trial coverage
Living in a state that does not require clinical trials coverage doesn’t mean your insurance provider will not offer coverage. It’s always a good idea to contact your insurer first to find out what they will cover before you get involved in a clinical trial. If you disagree with their decision, you can submit an appeal. (For more on this, see Health Insurance and Financial Assistance for the Cancer Patient.)
If you are thinking about entering a clinical trial and your insurance doesn’t want to cover it, contact your state insurance department to learn the details of any laws specific to your state. State insurance departments can give you the most up-to-date information about what your insurance company must pay for. You can find your state’s insurance department contact information in the blue pages of your local phone book, or visit the Web site of the National Association of Insurance Commissioners at www.naic.org/state_web_map.htm.
If you have more questions, contact your American Cancer Society’s Clinical Trials Matching Service at 1-800-303-5691.
The Affordable Care Act: 2014 brings change
The Affordable Care Act (ACA), passed in 2010, changes health care in many ways that help people with cancer. As of January 1, 2014, it will ensure health insurance coverage for the routine patient costs of people taking part in clinical trials. Insurers will not be allowed to drop or limit coverage because a person chooses to take part in a clinical trial. This will apply to all clinical trials that treat cancer or other life-threatening diseases.
The ACA describes the clinical trial-related “routine patient costs” that health insurers must cover as “all items and services consistent with the coverage provided in the plan (or coverage) that is typically covered for a qualified individual who is not enrolled in a clinical trial.” This includes items such as hospital visits, imaging or laboratory tests, and medicines.
According to the ACA, insurers do not need to pay for:
- The treatment, device, or service that is being studied and is usually covered by the trial’s sponsor
- Items and services only needed for data collection and analysis and are not used in direct patient care
- Any service that is clearly not in line with widely accepted and established standards of care for a certain diagnosis
To learn more, please read our document called The Affordable Care Act: How It Helps People With Cancer and Their Families. You can also get up-to-date information online from the US Department of Health & Human Services at www.healthcare.gov.
Last Medical Review: 02/25/2013
Last Revised: 02/25/2013