Insurance Coverage for Clinical Trial Participants

ASCO believes that insurance should cover the routine patient costs for people participating in cancer clinical trials. The information below provides resources and highlights ASCO’s policy efforts on the topic.

ACA Requirements for Private Insurance Coverage | Medicare Coverage | State Laws and Cooperative Agreements

Affordable Care Act Requirements for Private Insurance Coverage

The federal health care reform law—the Patient Protection and Affordable Care Act (ACA)—includes the requirement that private insurers cover the routine patient costs associated with participation in approved clinical trials starting in January 2014. The following resources provide further information about the new requirement and ASCO's ongoing work to inform the community about implementation of the law.

Resources:

ASCO Policy Initiatives:

Recommendations for Implementing Regulations:

  • Development of FAQ for Departments (January 2014) - ASCO worked with the American Association for Cancer Research, American Cancer Society Cancer Action Network, American Heart Association, Association of American Cancer Institutes, and the National Coalition for Cancer Research to develop an additional FAQ document for the Departments to release to help clarify key elements of section 2709. The document addresses the most critical questions related to the implementation of the clinical trials coverage provision. The hope is that in the absence of regulations, this FAQ document will provide guidance to help ensure that the intent of the law is adhered to in a consistent fashion.
  • Meeting with CMS on implementation of coverage requirement (April 2012) - ASCO and other leading cancer organizations met with top government regulators to discuss recommendations aimed at ensuring robust implementation of the clinical trials coverage law. 
  • Comments to CMS on implementation of coverage requirement (January 2012) - ASCO and 14 other leading cancer organizations submitted recommendations to the Centers for Medicare & Medicaid Services to influence development of the clinical trials coverage regulation that will implement section 2709 of the Patient Protection and Affordable Care Act.

Medicare Coverage for Clinical Trial Participants

Medicare covers the routine patient costs for qualifying clinical trials. The Medicare National Coverage Determination, passed in the year 2000, clarified clinical trials coverage for beneficiaries enrolled in traditional Medicare fee for services (FFS) coverage.

Coverage of Phase 1 Trials:

The Medicare policy does not specify the phases of trials that are covered but instead states that a trial “must have therapeutic intent.” It is the position of ASCO and other leading cancer organizations that phase 1 cancer clinical trials have therapeutic intent and therefore should be covered by Medicare. In the past, ASCO has worked with other cancer organizations to provide information to assist research sites with coverage denials related to phase 1 participation. For assistance on this issue, please contact ASCO at ResearchPolicy@asco.org.

Coverage for Medicare Advantage (MA) Plan Participants:

A persistent challenge remains for individuals enrolled in Medicare Advantage (MA) or private Medicare managed care plans. The Centers for Medicare and Medicaid Services requires that these beneficiaries revert to FFS coverage if they enroll in a clinical trial. The Medicare Advantage plan is then required to reimburse beneficiaries for the difference in out-of-pocket cost sharing between FFS and their MA plan. ASCO is an opponent of this policy because it serves as a potential financial and bureaucratic disincentive for MA enrollees who want to participate in research.   

Resources:

ASCO Policy Initiatives:

  • NEW! Comments to CMS on 2015 MA Coverage (March 2014) - ASCO teamed up with 19 other health organizations to submit comments to CMS urging the agency to change its long-standing policy that requires MA enrollees to revert to FFS coverage while participating in a clinical trial. This year's comment letter also asks CMS to require MA plans and Medicare contractors to inform MA enrollees of the financial assistance available to them for any difference in cost-sharing between FFS and their MA plan they may encounter. 
  • Comments to CMS on MA Coverage (March 2011) - ASCO and 4 other leading cancer organizations submitted comments to CMS urging the agency to require Medicare Advantage plans to directly cover the routine costs associated with clinical trial participation.


State Laws and Cooperative Agreements

Thirty-eight states and the District of Columbia have laws or cooperative agreements requiring insurers to cover the routine patient costs associated with clinical trials. The components of the laws vary significantly by state.

Resources:

States with Clinical Trials Coverage Laws or Cooperative Agreements
1) Alaska14) Kentucky27) North Carolina
2) Arizona15) Louisiana28) Ohio
3) California16) Maine29) Oregon
4) Colorado17) Maryland30) Rhode Island
5) Connecticut18) Massachusetts31) South Carolina (agreement)
6) Delaware19) Michigan (agreement)32) Tennessee
7) District of Columbia20) Missouri33) Texas
8) Florida (agreement)21) Montana34) Vermont
9) Georgia (agreement)22) Nebraska (agreement)35) Virginia
10) Illinois23) Nevada36) Washington
11) Indiana24) New Hampshire37) West Virginia  
12) Iowa25) New Jersey (agreement)38) Wisconsin
13) Kansas26) New Mexico39) Wyoming