Whether you are thinking about participating in a clinical study or not, health care costs and insurance coverage are major concerns for many patients and their families. An important factor in deciding to join a clinical study may be whether your health insurance, or Financial Assistance where applicable, will cover the costs.
Fred Hutch Patient Financial Services
A Fred Hutch Patient Financial Services (PFS) coordinator may be able to help you understand your insurance coverage and/or apply for Financial Assistance. You may call them directly or ask your patient care coordinator at Fred Hutch to set up an appointment with your PFS coordinator.
Ask to be transferred to a PFS coordinator.
A common myth is that health insurance won’t cover the cost of treatment provided through a clinical study. Some people might not enroll in a study because of coverage or lack of coverage concerns. In fact, the majority of insured participants in clinical studies do receive at least some reimbursement from their health insurance for routine care, and the study often provides research procedures and the investigational agent for study participants at no cost. But health insurance may not pay all the costs.
To help you make an informed decision about enrolling in a study, review the information in this section, and ask your health insurance company and Fred Hutchinson Cancer Center staff in advance for help in determining what costs are likely to be covered. If you are an uninsured or underinsured Washington state resident, you may also apply for Financial Assistance to help cover these costs.
The costs of care for clinical trial participants fall into two categories — routine care costs and research costs directly related to the clinical trial.
When you take part in a study, you may also incur related personal expenses. For example, you may have extra transportation and childcare costs if you have extra doctor visits that you would not have with standard treatment.
Health insurance coverage for clinical studies is broader than in the past. Routine care costs are usually covered by health insurance. Research costs are usually not covered by health insurance; however, the study sponsor may cover these costs, which would mean you don’t have to pay them. About 80 percent of cancer clinical study participants have health insurance that pays for at least part of their care in the study.
Coverage varies by state, by health insurance company, and even by plan within a health insurance company. Most states have passed legislation requiring health plans to pay the routine care costs for patients in clinical studies; however, Washington state is not among them. Some federal programs, such as Medicare, TRICARE, and Veterans Affairs, help pay the costs of care in clinical studies for their enrollees.
You will still be responsible for any copays and deductibles designated by your insurance coverage while on a clinical trial, just like you would for standard care. The study cannot cover copays and deductibles for you.
If you are enrolled in a Medicare Advantage Plan your participation in a clinical trial requires a change in how research costs are billed. According to Medicare rules, Original Medicare (also known as Medicare Part A and Part B) pays for routine costs in covered research studies. Routine costs related to the study will be billed to Original Medicare and your Medicare Advantage Plan will become the secondary payer. Examples of routine costs include:
When your research-related treatment ends, either at the completion of the study or your withdrawal from the study, billing for services at Fred Hutch will revert to your MedAdvantage Plan. If at any time you are seen for services within UW Medicine (Harborview, UW Medical Center-Northwest) that are not related to the clinical trial, billing for those services will be sent to your MedAdvantage Plan.
These services are often described in the Cost section of the informed consent for the study. They are generally services or items that would be provided to you if you were not involved in the clinical trial. Your study team will also be able to describe these services.
No. Medicare has directed that any additional out of pocket expense associated with billing Original Medicare directly must be paid for by your Medicare Advantage Plan.
Fred Hutch Customer Service can answer questions related to Fred Hutch bills. They can be contacted at 206.606.6226. If your research-related services are provided at the UW Medical Center or other hospitals, you will need to contact their billing departments as identified on the bills you receive.
If you are uninsured or underinsured, you may qualify for Financial Assistance. Financial Assistance can be used to cover the costs of care fully or partially at Fred Hutch, including those related to clinical trials participation.
The federal health care law passed in 2010, known as the Affordable Care Act (ACA), offers a baseline of coverage for clinical study participants in the United States and helps address some of the gaps in existing state laws. For people with cancer, some of the most important provisions of the ACA are those that eliminate lifetime maximums, ensure coverage for pre-existing conditions, and improve access to clinical studies.
The ACA requires all health insurers to pay for routine care for people participating in approved, federally funded clinical studies for cancer and other life-threatening diseases, unless a policy was grandfathered in and is not subject to the reforms. This includes Phase I through Phase IV treatment, prevention, and early-detection studies.
In order to know for sure whether your treatment will be covered, you must be knowledgeable about your health insurance benefits — both now and if your health insurance changes in the future. When you contact your health insurance company to find out more about your benefits, you may want to use the Clinical Study Insurance Coverage Worksheet. It is a good starting point to help ensure you get your questions answered and get all the information you may need.
Your insurance company may consider a number of things in determining whether to cover the cost of a clinical study, including these factors:
According to the ACA, health insurers cannot deny coverage for participating in an approved clinical study for cancer or another life-threatening disease or condition, as long as the individual is eligible to participate according to the study protocol, and is referred to the study by a participating provider (of the insurance company) or provides medical and scientific information that establishes that participation in the study is appropriate. However, the ACA does not apply to Medicaid, and coverage of routine care may vary by state.
If you are denied coverage, in some cases it helps to have your doctor talk to or file a written appeal with the health plan’s representative or medical director. At Fred Hutch, your doctor will discuss this option with you, taking into consideration your current clinical status, treatment alternatives, and how soon you need treatment.