Health Insurance and Clinical Studies
For most patients, an important factor in deciding whether to participate in a clinical study is knowing if their health insurance will cover the cost of the treatment. Health insurance coverage for clinical studies is broader than in the past. About 80 percent of patients who participate in cancer clinical trials have health insurance that pays for at least part of their care. For Medicare beneficiaries, Medicare will pay for treatment received in clinical trials, with some restrictions. A number of states have passed legislation
requiring health plans to pay the cost of routine medical care for patients in clinical trials, although Washington state is not among them.
Coverage varies among health insurance companies and even by the type of plans offered within a health insurance company. In order to know for sure whether their treatment will be covered, a patient must be knowledgeable about their health insurance benefits.
To aid in making a fully informed decision about enrolling in a clinical study, patients are encouraged to contact their health plan provider. Here is a worksheet
with questions to ask and information to obtain when contacting a health insurance provider.
It is unfortunately true that some health plans consider treatment received in a clinical study to be “experimental” or “investigational,” and they will deny payment. If a patient’s health plan denies coverage for a clinical study, there may be an option to appeal the health plan’s decision. At SCCA, the patient’s provider will discuss this option with the patient in the context of the patient’s current clinical status, treatment alternatives and how soon the patient needs to be treated.
It is also important for patients to be aware of their coverage benefits if their health insurance changes. Patients should keep this in mind if they need to consider future treatment options, including clinical studies.