42 U.S.C. § 300gg–8: Coverage for individuals…

Summary

Health plans and insurance companies must let people in the plan join approved clinical trials for cancer or other life‑threatening conditions. They cannot stop someone from joining, refuse to pay for the usual care related to the trial, or treat them worse because they are in the trial. "Routine patient costs" means the regular items and services the plan normally covers for someone not in a trial. It does not include the experimental drug, device, or service itself, items used only to collect research data, or services that clearly go against accepted medical care. A "qualified individual" is someone in the plan who is eligible for a trial under the trial rules and who either has a participating doctor saying the trial is right for them or can show medical evidence that it is appropriate. Plans may require using participating (in‑network) trial providers if those providers will accept the patient. Plans do not have to pay for out‑of‑network trial care unless they normally cover out‑of‑network care. An "approved clinical trial" is a phase I, II, III, or IV trial for cancer or a life‑threatening condition that is funded or approved by agencies like the National Institutes of Health, CDC, AHRQ, CMS, certain cooperative groups or qualified non‑government research entities, or by the Department of Veterans Affairs, Department of Defense, or Department of Energy if the study passed peer review like the NIH process; it also includes trials under an FDA investigational new drug application or FDA‑exempt drug trials. Plans may offer more coverage, this applies to federal employee plans, and state laws that give greater protections still apply.

Title 42, §300gg–8

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Coverage

(1)In general

If a group health plan or a health insurance issuer offering group or individual health insurance coverage provides coverage to a qualified individual, then such plan or issuer—

(A)may not deny the individual participation in the clinical trial referred to in subsection (b)(2);

(B)subject to subsection (c), may not deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial; and

(C)may not discriminate against the individual on the basis of the individual’s participation in such trial.

(2)Routine patient costs

(A)Inclusion

For purposes of paragraph (1)(B), subject to subparagraph (B), routine patient costs include 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.

(B)Exclusion

For purposes of paragraph (1)(B), routine patient costs does not include—

(i)the investigational item, device, or service, itself;

(ii)items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; or

(iii)a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.

(3)Use of in-network providers

If one or more participating providers is participating in a clinical trial, nothing in paragraph (1) shall be construed as preventing a plan or issuer from requiring that a qualified individual participate in the trial through such a participating provider if the provider will accept the individual as a participant in the trial.

(4)Use of out-of-network

Notwithstanding paragraph (3), paragraph (1) shall apply to a qualified individual participating in an approved clinical trial that is conducted outside the State in which the qualified individual resides.

(b)Qualified individual defined

For purposes of subsection (a), the term “qualified individual” means an individual who is a participant or beneficiary in a health plan or with coverage described in subsection (a)(1) and who meets the following conditions:

(1)The individual is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of cancer or other life-threatening disease or condition.

(2)Either—

(A)the referring health care professional is a participating health care provider and has concluded that the individual’s participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1); or

(B)the participant or beneficiary provides medical and scientific information establishing that the individual’s participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1).

(c)Limitations on coverage

This section shall not be construed to require a group health plan, or a health insurance issuer offering group or individual health insurance coverage, to provide benefits for routine patient care services provided outside of the plan’s (or coverage’s) health care provider network unless out-of-network benefits are otherwise provided under the plan (or coverage).

(d)Approved clinical trial defined

(1)In general

In this section, the term “approved clinical trial” means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is described in any of the following subparagraphs: (A) Federally funded trials.—

(B)The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration.

(C)The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

(2)Conditions for departments

The conditions described in this paragraph, for a study or investigation conducted by a Department, are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary determines—

(A)to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and

(B)assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.

(e)Life-threatening condition defined

In this section, the term “life-threatening condition” means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

(f)Construction

Nothing in this section shall be construed to limit a plan’s or issuer’s coverage with respect to clinical trials.

(g)Application to FEHBP

Notwithstanding any provision of chapter 89 of title 5, this section shall apply to health plans offered under the program under such chapter.

(h)Preemption

Notwithstanding any other provision of this chapter, nothing in this section shall preempt State laws that require a clinical trials policy for State regulated health insurance plans that is in addition to the policy required under this section.

Editorial Notes

Codification Another section 2709 of act July 1, 1944, is classified to section 300gg–9 of this title.

Prior Provisions

A prior section 2709 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see section 238h of this title.

§300gg–8 Coverage for Individuals Participating in Approved Clinical Trials

Summary

Title 42, §300gg–8

Notes & Related Subsidiaries

Editorial Notes

Prior Provisions

Citations & Metadata