Insurance Coverage for Clinical Trials

• It is important to talk with your health care team and your insurance company to find out what insurance coverage you have for participating in a clinical trial and what out-of-pocket costs you might expect to pay. The Patient Protection & Affordable Care Act (ACA) requires most private insurance companies to cover the routine costs of your health care when you participate in a clinical trial. Routine costs include office visits, blood tests, and imaging scans that you would receive if you were getting the standard of care. Insurance companies cannot drop your coverage or refuse to let you take part in the clinical trial.
• Insurance companies are not required to cover the research costs that are specific to the clinical trial, such as extra blood tests or imagining scans. However, most clinical trials will cover those costs. Insurance companies are also not required to cover care that you receive from doctors or hospitals that are outside the insurance companies network, if your plan does not normally cover out-of-network providers. Some insurance companies will cover out-of-network providers, but at a lower rate, meaning that you will have higher out-of-pocket costs when getting care from those providers.
• Some states may have laws that offer additional protections for consumers.
• Different rules apply for government programs such as Medicare, military, and VA plans.
• After 1/1/22, Medicaid will cover routine patient costs associated with clinical trials. Medicaid cannot deny coverage based on the state where the clinical trial is conducted, or whether the provider is in-network for Medicaid. Learn more at Medicaid.gov.