Massachusetts Insurance Information*

 

Fully Insured or Managed Plans

 

·        Are health plans fully-insured when purchased from an insurance company or other underwriter that assumes full risk for medical expenses.1

 

·        These types of plans that have been issued or renewed after January 1, 2003 are required by MA State Mandate, Massachusetts (2002) Chap 176A Sec 8X to cover all phases of cancer treatment trials. All other types of cancer clinical trials are not required to be covered.  These trials must be peer-reviewed and approved by the federal government or a qualified non government research entity.1,2

 

·        If you have further questions about these types of plans, check with your employer group plan or the benefits administrator of the employer to find out what benefits are covered.3

 

Self insured or Non-Managed Plans

 

·        Are self-funded or self-insured health plans based on the employer assuming the financial risk of covering its employees and paying medical claims from its own resources.1

 

·        These types of plans are exempt from the MA State Mandate, Massachusetts (2002) Chap 176A Sec 8X. Federal laws and regulations govern self-funded plans and the federal Employee Retirement Income Security Act (ERISA) of 1974 exempts these plans from complying with state laws and regulations.1

 

·        If you have further questions about these types of plans, check with your employer rather than the plan administrator because exceptions to ERISA of 1974 could be decided on a case-by-case basis on whether or not you can receive clinical trial coverage.4

 

Medicare

 

·        Is a federal government program that gives health coverage to those who are 65 or older or those with a disability, no matter what your income.5

 

·        This type of plan will pay for all routine costs of a clinical trial.6

 

These services include:

·        Visits to a doctor’s office

·        All tests necessary for medical care

·        Hospital stay(s), if needed

·        Surgery if necessary

·        Tests and treatments for side effects, if needed

·        If you have any further questions you can contact Medicare at 1-800-633-4227 or visit them at http://www.medicare.gov

 

Veterans Affairs Medical Benefits

 

·        A standard health benefits plan available to veterans of the United States military.

 

·        This type of plan will cover the costs of National Cancer Institute (NCI) sponsored cancer clinical trials such as prevention, diagnostic, or treatment cancer clinical trials at Veterans Affairs (VA) facilities and their costs at non-VA facilities in certain cases.7

 

·        If you have further questions you can call Veterans Affairs at 1-877-222-8387 or visit them at www.va.gov/

 

TRICARE

 

·        Is a health program provided by the United States Department of Defense for members of the uniformed services and their families and survivors

 

·        This type of plan pays for medical costs during participation in Phase II and Phase III cancer prevention and treatment trials.7

 

·        If you have further questions you can call them at 1-877-363-6337 or visit them at http://www.military.com/benefits/tricare/understanding-your-tricare-benefits

 

Other options

 

·        Check to see if you are eligible for MassHealth, Commonwealth Care, or contact the trial coordinator(s) at the institution(s) sponsoring the cancer clinical trial to see if you could obtain coverage for treatment and other associated medical costs involved with the trial

 

·        If you have MassHealth and wish to participate in a cancer clinical trial it must be considered medically necessary by your primary care provider and they would need to obtain proper authorization from your health insurance in order for certain costs to be covered

 

·        If you have Commonwealth Care and wish to participate in a cancer clinical trial you would need to contact your health plan and ask them if they offer coverage or under what circumstances they will cover certain costs associated with the trial

 

·        If none of the above options exist you could contact the trial coordinator(s) involved in the cancer clinical trial and ask who you could talk to about obtaining coverage for treatment and other associated medical costs involved with the trial (e.g. a financial counselor).

 

·        Additionally, you could contact the American Cancer Society to see what local resources could help with costs outside of treatment (e.g. transportation)

 

·        For further information you can contact:

 

MassHealth

      At 1-800-841-2900 or visit them at www.mass.gov/masshealth

 

      Commonwealth Care

      At 1-877-623-6765 or visit them at www.mahealthconnector.org

 

      American Cancer Society

      At 1-800-227-2345 or visit them at www.cancer.org

 

Sources:

1Self-funded and Fully-Insured Health Plans: How Do They Differ? Massachusetts Division of Health Care Finance and Policy February 19, 2003 http://www.mass.gov/hrsa/pages/pdf/selffund.pdf

 

2 http://www.cancer.gov/clinicaltrials/developments/laws-about-clinical-trial-costs-massachusetts

 

3 http://www.medicare.gov/Publications/Pubs/pdf/02226.pdf

 

4 Section on “While Policies Generally Exclude Coverage, Insurers Claim to Review     and Approve Some Trial Services” http:// www.gao.gov/archive/1999/he99182.pdf

 

5 http://www.medicarerights.org/maincontentwhatismedicare.html

 

6 http://www.cancer.gov/clinicaltrials/resources/medicare-and-cancer-trials/page3

 

7 http://www.cancer.gov/clinicaltrials/digestpage/VA-DOD/page3

 

 

*Information accessed 10/18/07