2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 7. Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage › 27-13-7-20.2. Coverage for Care Related to Cancer Clinical Trials

Sec. 20.2. (a) As used in this section, "care method" means the use of a particular drug or device in a particular manner.
(b) As used in this section, "clinical trial" means a Phase I, II, III, or IV research study:
(1) that is conducted:
(A) using a particular care method to prevent, diagnose, or treat a cancer for which:
(i) there is no clearly superior, noninvestigational alternative care method; and
(ii) available clinical or preclinical data provides a reasonable basis from which to believe that the care method used in the research study is at least as effective as any noninvestigational alternative care method;
(B) in a facility where personnel providing the care method to be followed in the research study have:
(i) received training in providing the care method;
(ii) expertise in providing the type of care required for the research study; and
(iii) experience providing the type of care required for the research study to a sufficient volume of patients to maintain expertise; and
(C) to scientifically determine the best care method to prevent, diagnose, or treat the cancer; and
(2) that is approved or funded by one (1) of the following:
(A) A National Institutes of Health institute.
(B) A cooperative group of research facilities that has an established peer review program that is approved by a National Institutes of Health institute or center.
(C) The federal Food and Drug Administration.
(D) The United States Department of Veterans Affairs.
(E) The United States Department of Defense.
(F) The institutional review board of an institution located in Indiana that has a multiple project assurance contract approved by the National Institutes of Health Office for Protection from Research Risks as provided in 45 CFR 46.103.
(G) A research entity that meets eligibility criteria for a support grant from a National Institutes of Health center.
(c) As used in this section, "nonparticipating provider" means a health care provider that has not entered into an agreement described in IC 27-13-1-24.
(d) As used in this section, "routine care cost" means the cost of medically necessary services related to the care method that is under evaluation in a clinical trial. The term does not include the following:
(1) The health care service, item, or investigational drug that is the subject of the clinical trial.
(2) Any treatment modality that is not part of the usual and customary standard of care required to administer or support the health care service, item, or investigational drug that is the subject of the clinical trial.
(3) Any health care service, item, or drug provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient.
(4) An investigational drug or device that has not been approved for market by the federal Food and Drug Administration.
(5) Transportation, lodging, food, or other expenses for the patient or a family member or companion of the patient that are associated with travel to or from a facility where a clinical trial is conducted.
(6) A service, item, or drug that is provided by a clinical trial sponsor free of charge for any new patient.
(7) A service, item, or drug that is eligible for reimbursement from a source other than an enrollee's individual contract or group contract, including the sponsor of the clinical trial.
(e) An individual contract or a group contract must provide coverage for routine care costs that are incurred in the course of a clinical trial if the individual contract or group contract would provide coverage for the same routine care costs not incurred in a clinical trial.
(f) The coverage that must be provided under this section is subject to the terms, conditions, restrictions, exclusions, and limitations that apply generally under the individual contract or group contract, including terms, conditions, restrictions, exclusions, or limitations that apply to health care services rendered by participating providers and nonparticipating providers.
(g) This section does not do any of the following:
(1) Require a health maintenance organization to provide coverage for clinical trial services rendered by a participating provider.
(2) Prohibit a health maintenance organization from providing coverage for clinical trial services rendered by a participating provider.
(3) Require reimbursement under an individual contract or a group contract for services that are rendered in a clinical trial by a nonparticipating provider at the same rate of reimbursement that would apply to the same services rendered by a participating provider.
(h) This section does not create a cause of action against a person for any harm to an enrollee resulting from a clinical trial.
As added by P.L.109-2009, SEC.4.